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OBJECTIVES: Mississippi recorded the first case of coronavirus disease 2019 (COVID-19) on March 11, 2020. This report describes the initial COVID-19 experience of the single healthcare system serving Jackson County, Mississippi. The intent of this retrospective review of COVID-19 hospitalized patients was to identify any characteristics or interventions amenable to improving care management and clinical outcomes for patients within our community hospital. METHODS: All hospitalized patients 18 years of age and older in our health system with positive tests for COVID-19 (severe acute respiratory syndrome-coronavirus-2 [SARS CoV-2]) by reverse transcriptase-polymerase chain reaction between March 15 and April 10, 2020 are included in this retrospective observational report. RESULTS: During the study period, 158 patients of the 1384 tested (11.4%) were positive for COVID-19 infection. Of the 158 patients, 41 (26%) were hospitalized, with 17 (41%) admitted to the intensive care unit (ICU). The remaining 24 patients did not require ICU admission. The mean age of the 158 COVID-19-positive patients was 55 years (range 2-103). Obesity was noted in 68% of the hospitalized patients, including 13 (54%) of the non-ICU patients and 15 (88%) of the ICU patients. All 9 deceased patients were obese. Twelve of 17 patients received invasive mechanical ventilation (IMV) and 3 patients received only high-flow nasal cannula oxygen. Only 25% (3 of 12) of the IMV patients were successfully extubated during the study period. The median duration on IMV was 17 days (range 4-35). The mortality in the 158 COVID-19-positive patients was 5.7% (9 of 158). None of the 24 non-ICU patients died. The ICU mortality rate was 53% (9 of 17). CONCLUSIONS: This report describes a community hospital experience with COVID-19. Patient outcome was comparable to that reported at larger centers. Obesity was a major comorbidity and correlated with adverse outcomes. Amidst the initial wave of COVID-19 with high demand for inpatient treatment, it is reassuring that appropriate care can be provided in a community health system.

Uncertainty surrounding the COVID-19 epidemic exists, partly driven by the difficulty in prognostication and understanding risk factors that portend worse outcomes. This study examines whether differences in clinical characteristics on admission result in the need for intensive care unit (ICU)–level care and demonstrates few differences among patients needing ICU care and those that did not. Furthermore, patients admitted to the ICU generally have poor outcomes., Objectives The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) epidemic is characterized by a global sense of uncertainty, partly driven by the paucity of real-life clinical data. This study assessed whether admission patient characteristics were associated with need for intensive care unit (ICU) care. Methods The observational study included consecutive patients admitted to a large community teaching hospital with a diagnosis of SARS-CoV-2 between March 6, 2020 and March 31, 2020. Comparisons were made based on the need for ICU admission. Results A total of 156 patients were admitted, 42 of whom (26.9%) required ICU admission and 114 (73.1%) did not. No difference in age (61.9 years vs 60.5 years, P = 0.67), race/ethnicity, or comorbidities were noted, except that patients requiring ICU care had lower serum albumin levels and lymphocyte counts and higher liver function tests, white blood cell count, and absolute neutrophil count on admission. The average time from admission to death was similar (10 days in an ICU subset vs 9.2 days in a non-ICU subset, P = 0.78), yet patients necessitating ICU care had longer hospital lengths of stay (10.2 vs 5.1 days, P = 0.0002). At the time of data extraction, 15 patients in the ICU had died, 7 were discharged from the hospital, and 20 were still admitted while 5 patients died in the non-ICU cohort with 97 discharged and 12 patients admitted. Conclusions This is the largest study assessing clinical differences based on the need for ICU admission in inpatients with SARS-CoV-2. It found few major differences in clinical variables between subsets. Among patients admitted to the ICU, outcomes were generally poor.

Objectives The data from temperate regions indicate increases in pediatric traumatic injuries during the spring and summer months with anticipated admission spikes on warm weather holidays; hospitals in southern subtropical regions should not anticipate the same trends. The objectives of this study were to identify holiday-specific spikes in pediatric traumatic injury admissions at a community hospital in South Florida and report injury patterns in age, mechanism of injury, and surgical consults. Methods A 5-year retrospective review of pediatric traumatic injuries during holiday periods was conducted; patterns in age, mechanism of injury, and surgical consults were described. A ratio of the mean number of patients seen per day for holiday periods versus nonholiday days of the same month was calculated for each holiday. Results The most notable spikes in injury volume were for autumn and winter holidays; average volume doubled during the holiday periods for New Year's Day, Super Bowl weekend, Valentine's Day, St Patrick's Day, and Halloween. Holiday periods had increases in the proportion of injuries related to motorcycle crashes. Conclusions Hospitals located in southern subtropical climates should consider increasing staffing as necessary during select autumn and winter holidays.

OBJECTIVES Patient throughput and early discharges are important for decreasing emergency department wait times and creating available beds for new hospital admissions. The educational schedule of internal medicine trainees can interfere with timely discharges, but targeted interventions can help residents meet the hospital's patient flow needs. Our training program instituted daily morning discharge rounds on the inpatient service, requiring each team to prepare potential discharges 1 day ahead and prioritizing these discharges the next day. METHODS We conducted a retrospective, pre-post analysis 1 month before and 3 months after implementation in August 2013 to assess discharge order entry times, the proportion of discharges before 11:00 am, and hospital departure times. RESULTS One month post-implementation, discharge orders were entered 59 minutes earlier (from 1:07 pm to 12:08 pm; P = 0.001), the percentage of pre-11:00 am discharges increased from 21% to 39% (P

Patients are 30% less likely to be readmitted or visit the emergency department if they have a clear understanding of their discharge instructions. A standardized approach to a hospital discharge plan has not been universally implemented, however. Our goal was to increase patients' comprehension of discharge instructions by implementing a standardized patient-centered discharge planning protocol that uses a physician team member to explain these plans.This was a prospective study that included all of the patients discharged from an inpatient medical teaching service in a community-based hospital during the study period. We used two 4-week periods separated by 4 months in which training and practice with the study intervention took place. Patients' understanding of discharge instructions was assessed via a follow-up telephone call from a physician co-investigator within 1 week of each patient's discharge. Differences in patients' understanding between groups were analyzed.A total of 181 patients were enrolled, with 9 lost to follow-up. After implementation of the discharge planning protocol, a statistically significant improvement in patients' understanding was found in study subjects' knowledge of their diagnosis, the adverse effects of their medications, whom to call after discharge, and follow-up appointments.Institution of a standardized patient-centered discharge planning protocol can improve patients' understanding of several key components of their discharge process, which may lead to improved compliance with instructions and outcomes.

Objectives Total annual costs for syncope-related hospitalizations were $2.4 billion in 2000. The aim of this study was to examine the type and number of tests ordered for patients admitted with syncope and whether these tests helped establish the cause. Methods We studied the records of 1038 patients coded as "syncope" in billing records, and 167 fulfilled the eligibility criteria. The main outcome measures were the diagnostic yield of the ordered tests, the incremental cost/incremental benefit, and the number of admissions that can be averted if risk stratification were used in the evaluation. Results The etiology of the syncope was identified in 48.3% of the patients. Postural blood pressure measurement has the highest diagnostic yield at 58.7%, whereas history taking diagnosed 19.7% of cases. The diagnostic yields of telemetry, electrocardiogram, radionuclide stress test, echocardiography, and troponin measurement were 4.76%, 4.24%, 3.44%, 0.94%, and 0.62%, respectively. Chest x-ray, carotid ultrasonography, 24-hour Holter monitoring, brain computed tomography, and brain magnetic resonance imaging did not yield the diagnosis in any of the patients. Only 1.9% of the money spent in the evaluation of syncope was effective in leading to a definitive diagnosis. The orthostatic blood pressure measurement was ranked first in the incremental cost/incremental benefit ratio and the radionuclide stress test was ranked last (17.03 vs 42,369.0, respectively). Approximately 6% of the patients did not meet the admission criteria. Conclusions Physicians ordered unnecessary tests that have a low yield and are not cost-effective. A standardized algorithmic approach should be the cornerstone in the evaluation of syncope.

OBJECTIVE To demonstrate that the application of therapeutic hypothermia is technically feasible in a community-based setting. BACKGROUND Implementation of therapeutic hypothermia for survivors of cardiac arrest in the United States has been slow, at least partially because of the perception that this therapy is technically difficult, especially at the community level. STUDY DESIGN Retrospective cohort study with historical controls. METHODS At our three community hospitals and after return of spontaneous circulation (ROSC), survivors of cardiac arrest were treated with therapeutic hypothermia using ice and cooling blankets or suits in order to cool patients to 32 degrees C-34 degrees C within 4 hours to achieve goal temperature within 8 hours and to maintain goal temperature for 24 hours. RESULTS Beginning in 2004, 44 survivors of cardiac arrest were managed with therapeutic hypothermia. The mean time from ROSC to initiation of therapeutic hypothermia was 2.8 hours (range, 0.2-7.8 hours), the mean time from ROSC to goal temperature was 7.2 hours (range, 0.8-15.1 hours), and the mean time maintained at goal temperature was 24.5 hours (range, 9-28 hours). Once patients achieved goal temperature, 4.4% of the temperature readings were above 34 degrees C, reflecting undercooling, while 16.4% of the readings were below 32 degrees C, indicative of overcooling. Overall survival until hospital discharge with good neurologic outcome was 43%, compared to only 13% (P < 0.001) among selected controls. There were no major complications directly attributable to the induction of hypothermia or rewarming. CONCLUSION A simple protocol of mild therapeutic hypothermia using locally available resources is technically feasible and safe in a community-based setting.

Background Lack of health insurance can adversely affect access to medical care which leads to poor disease outcome. Few studies examine the effects of no insurance on the development of diabetes complications. The objective of this study was to determine if there is an association between health insurance status and the outcome of complications among a group of diabetic patients admitted to a teaching hospital on the Texas-Mexico border. Methods A retrospective case-control study was conducted over a one-year period. Multiple imputations were used to address missing values. We examined 82 diabetics who had one or more complications and 83 diabetic controls without complications. A complication was defined as a current skin or soft-tissue infection or a limb amputation. The main exposure was health insurance status, a three-level variable: no health insurance, Medicaid, and other insurance (referent). Logistic regression was used to calculate health insurance odds ratios (OR) adjusted for age, sex, and a history of recent trauma. Results Patients with no health insurance were twice as likely to have a diabetic complication as patients in the referent category: adjusted OR = 2.22, P = 0.03. An association between Medicaid status and complications was not detected (adjusted OR = 1.16, P = 0.78). Conclusions Not having health insurance was a risk factor for developing diabetic complications in a group of predominantly Hispanic patients.

OBJECTIVES The number and types of inpatients given inadequate prophylaxis for venous thromboembolism (VTE) are not known; patients receive less than appropriate prophylaxis with some frequency. METHODS Initially we evaluated VTE prophylaxis at a community hospital by comparing prophylaxis patterns in adult inpatients for whom some prophylaxis was indicated. Patients were categorized as medical, general surgery, and orthopedic, then categorized as "appropriate," "suboptimal," or "none" in terms of VTE prophylaxis. After initial data collection, we performed an intervention on medical patients using a VTE risk assessment tool; a printed evaluation containing the VTE risk assessment score with related VTE prophylaxis regimens was placed in the patients' charts, after which prophylaxis patterns were compared between preintervention and postintervention medical patients. RESULTS Initial data collected from 116 medical, 110 general surgery, and 72 orthopedic patients (n = 298) showed that there was a significant association between diagnosis category and level of observed appropriate VTE prophylaxis (P < 0.0001). Fifty-six medical patients (48%) received no prophylaxis, compared to 40 (36%) general surgery patients and 12 (17%) orthopedic patients. In the second phase, 74 medical patients on whom the intervention was performed were compared to 116 preintervention medical patients (n = 190). The findings showed that intervention status had a significant association with level of appropriate VTE prophylaxis (P < 0.0001). CONCLUSION An increase in appropriate VTE prophylaxis was observed after a system-level intervention.

Background: Many studies have documented the fact that outcomes and survival are improved when major surgical oncology cases are performed at high-volume centers. Consolidation of such cases in tertiary centers, however, is often not possible or practical, due to a number of factors. Methods: A retrospective review was performed of the operative experience of a single surgical oncologist at a community hospital in Mississippi during a noncontinuous 36-month period. Data were obtained regarding all major inpatient cancer operations, as well as complication and death rates. This review was limited to major inpatient procedures and resections performed with intent to cure. Results: A total of 171 major cancer cases were performed during the study period. This represented 23.7% of the total inpatient procedures performed and 47.5% of all major inpatient procedures. Distribution of surgical sites was as follows: liver-9; stomach-8; esophagus-3; pancreas-4; colon and rectum-76; breast-33; lung-13; intra-abdominal (sarcoma)-9; and thyroid-16. There were 5 complications within this group (2.9%); two of these resulted in death (1.2%). Conclusions: In the hands of a single surgeon operating at a community institution, major resections for cancer and major surgical oncology cases could be done safely with acceptable complication rates and results. Whether or not such major cancer cases should be done at the community level, however, depends on a number of factors and requires further evaluation of both surgeon and hospital capabilities.

Objective: The Centers for Disease Control (CDC) recommends trivalent influenza (TIV) and pneumococcal (PPV) vaccination for eligible hospitalized patients. We conducted a retrospective study comparing two different methods of assessment and its impact on TIV and PPV vaccination in hospitalized patients. Design: Two sequential models were compared in a community hospital for assessing patients' vaccination status and eligibility for TIV and PPV in an inpatient setting. In the first model (Model I), physicians were responsible for assessing eligibility and ordering TIV and/or PPV. In the second model (Model II), nurses were responsible for assessment and vaccination of eligible patients. Charts of hospitalized patients were randomly analyzed for completion rates of the assessment form, rate of vaccination, and documentation of the reason for not vaccinating eligible patients. Results: A total of 138 charts were analyzed for Model I and 168 charts were analyzed for Model II. A significantly higher completion rate for assessment was noted for Model II compared with Model I (79.16% versus 34.78%, P < 0.001 for TIV; 72.02% versus 33.33%, P < 0.001 for PPV). Hospital vaccination rates were not significantly different between the two models for TIV (P = 0.625) and PPV (P = 0.689). A significant percentage of patients refused PPV in Model II [8.03% versus Model I at 3.2% (P = 0.04)]. Conclusion: A standing order protocol for assessing hospitalized patients' vaccination status by nursing staff and allowing them to vaccinate eligible patients without depending upon a physician order significantly improved the assessment compliance rate, but not the vaccination rates. Our findings suggest that a system-based method with nursing assessing the need for vaccination and a physician ordering the vaccination would probably have a higher potential for success.

Group B streptococcal bacteremia in nonpregnant adults continues to be a significant infection.We reviewed medical records of nonpregnant adult patients with group B streptococcal bacteremia from 1995 to 1999 and compared the findings with data from a similar study in our institution between 1980 and 1984.There were 36 episodes of group B streptococcal bacteremia. The mean age was 70 years. Most of the cases (94%) were community-acquired. The most common underlying disease was diabetes mellitus (49%). The most common sources of group B streptococcal bacteremia were pneumonia and soft tissue infections. The overall mortality rate was 16.7%.Group B streptococcal bacteremia is still found mainly in the elderly, with significant underlying disease, particularly diabetes mellitus. The spectrum of infection has included lymphadenitis, ascending cholangitis, mastitis, prostatitis, and toxic shock syndrome. The mortality has decreased significantly during the past 15 years (16.7% vs 67.9%).

We sought to determine whether elderly patients with a serum albumin level3.4 g/dL on admission to community hospitals have a longer duration of hospitalization than those with an admission serum albumin levelor =3.4 g/dL.A total of 144 patients, 60 years of age or older, were consecutively admitted to our medical service for a variety of health problems. Within 4 hours of their admission, we measured serum albumin level and recorded subsequent length of hospital stay.Length of hospital stay was inversely related to admission serum albumin level. The mean length of hospitalization was 3.85 +/- 2.55 days (+/- SD) for patients with an admission serum albumin levelor =3.4 g/dL and 6.74 +/- 4.79 days for those with an admission serum albumin level3.4 g/dL. Three patients (6%) with admission serum albumin levels3.4 g/dL died, but no deaths occurred in patients with an albumin levelor =3.4 g/dL.A serum albumin level3.4 g/dL obtained within 4 hours of hospital admission is a reliable predictor of prolonged hospital stay and death in patients 60 years of age or older.

Background We investigated whether a recently restructured pediatric intensive care unit (PICU) had a decrease in the cost of patient care over the years. Methods We retrospectively studied 89 previously healthy patients admitted to the PICU of a community-based, university-affiliated teaching hospital over a 4-year period (1991 to 1994) for treatment of lower airway disease. Data collected were patient age, severity of illness, length of stay in both PICU and hospital, prorated hospital bill, year of admission, and patient-specific PICU-originated costs (POC). Results There was a decrease of POC over the 4-year period, though two factors were associated with a cost increase in this group of patients: an increase in the severity of illness and intubation. The decrease over the years remained present even when excluding intubated patients and adjusting for severity of illness. A decline of 58% below the initial cost for diagnostic tests was the most prominent of all the individual areas studied. Decreases in POC correlated with decreases in the prorated hospital bill. Conclusions The costs of management for these previously healthy patients treated for lower airway disease decreased over the study period. We speculate that the time related decrease in costs is a reflection of the learning curve of the pediatric critical care team. The decrease in POC did not shift costs to other areas of the hospital.

This retrospective study reviewed the hospital and professional costs, charges, and reimbursements for laparoscopic cholecystectomy (lap chole) and open cholecystectomy (open chole) and compared the two procedures. There was no significant difference in hospital costs between lap and open chole procedures; however, there were marked differences in the categories of costs for each procedure. The mean total (hospital and professional) charge was 8% greater for lap chole. The mean total (hospital and professional) reimbursement for patients with private insurance was 23% greater for lap chole, but no significant difference was seen for patients on Medicare or Medicaid. Lap chole patients returned to work 11 days sooner than open chole patients; this can result in a 69% decrease in short-term disability costs to employers. The clinical variables that significantly affect total charges and reimbursement are discussed.

Acute services to older citizens often require health care professionals to manage problems that are difficult to assess and treat. Age-related complications such as physical decline and the presence of psychiatric and medical illness together can produce an array of confusing symptoms for the physician. This study examines the diagnostic outcomes of the first 100 patients admitted to an acute care-based geropsychiatric unit. Assessment protocols and treatment interventions are described and results of patient progress are discussed.

In the past, chronic daily headaches have been attributed to many possible causes, including "tension," excessive contraction of pericranial muscles, and depression. A careful history reveals that many patients start out with fairly typical intermittent migraine attacks that evolve over the years into a pattern of daily or almost daily head pain. Overuse of analgesics is usually a part of this clinical picture, which has been termed "analgesic rebound headache." Fifty-three of the first 100 patients admitted to a community hospital's inpatient headache treatment program had chronic daily headaches and were overusing analgesics or other headache relief medications. We report our retrospective review of these patients and describe treatment of this difficult and sometimes unrecognized syndrome, primarily with intravenous dihydroergotamine (DHE). Results at hospital discharge and at follow-up several months later showed significant reduction of pain.

We describe the convalescent care of 169 back-transported (to community hospitals) and 285 eligible but not back-transported very low birth weight (VLBW) infants. Eligible infants who were not back transported to a level I or II community hospital were transferred to a level II nursery within the Medical University of South Carolina (MUSC) for convalescent care. Study infants were admitted to the neonatal intensive care unit (NICU) at MUSC from July 1985 through June 1989. They were admitted after maternal transport to MUSC for imminent delivery (N = 159), out-born community delivery (N = 55), or in-born MUSC delivery (N = 240). The mean +/- SD birth weight and gestational age and the NICU admission diagnoses for the back-transported and non-back-transported neonates were similar. The mean +/- SD weight of neonates at the time they were back transported was significantly greater than the weight of neonates at the time of intrahospital transfer. In contrast, the discharge weight to home and total days hospitalized were significantly less in the back-transported infants. Five back-transported neonates (3%) and 12 non-back-transported neonates (4%) were readmitted to the NICU. The back-transported infants used more than 3,800 bed days at community hospitals that would otherwise have been spent in the regional center, thus facilitating increased parental and primary physician involvement in their care.

Objectives To detect the readmission rates of a hospitalist group at a community hospital, to identify probable causes of rehospitalizations, and to propose solutions to decrease the rate of readmissions. Methods We conducted a retrospective medical chart review on patients who were rehospitalized with the same diagnosis within 30 days over a period of one year. Results Among 5,206 patients who were admitted to the hospitalist service over one year, 85 (1.6%) were rehospitalized within 30 days due to the same condition. Of the 85 readmitted patients, 47% were male and 82% were Caucasian, with a mean age of 58 ± 17 years. The top diagnoses were pneumonia, sepsis, and chronic obstructive pulmonary disease (COPD). Follow-up appointments were made for only 27% of patients at first admission. Ninety percent of patients received an accurate medication list at discharge. Mortality within three months was higher in patients with sepsis, more comorbidities, longer length of stay at first hospitalization, and those discharged to a nursing home after readmission. Only 4.7% of readmissions were concluded to be preventable. Conclusion Our readmission rate (1.6%) is significantly lower than that of previous studies (23.2%), as we included the readmissions only due to the same diagnosis. Patient education, family involvement in discharge process, and scheduling follow-up appointments could potentially reduce readmissions, despite multiple unmodifiable factors. We suspect all-cause readmissions have room for more improvement, which should be the focus of intervention.

Cardiovascular magnetic resonance imaging (CMR or cardiac MRI) has advanced dramatically in the last ten years and has been proven a reliable and flexible method for cardiac diagnosis. Stress perfusion MRI is a new technique that accurately detects coronary heart disease with high sensitivity and specificity. The role of CMR is also increasing for the evaluation of congestive heart failure and cardiomyopathy. Late gadolinium enhancement highlights areas of myocardial scar and helps predict prognosis. CMR usually complements, but does not fully replace, other diagnostic modalities. Careful patient selection is required to ensure safety in the presence of this powerful magnetic field. MRI gives unique tissue characterization without ionizing radiation. No longer used just for esoteric conditions, CMR is becoming common in the community hospital.

Objectives: Described here is the clinical presentation and etiology of community-acquired meningitis in adult patients in a Baltimore community hospital from 1997 to 2006. Method: A retrospective chart review was performed. Data were collected regarding demographics, presenting symptoms, cerebrospinal fluid findings, and outcome. Results: Of 80 patients identified, 17 were diagnosed with bacterial meningitis, 18 with viral meningitis, 39 with aseptic meningitis of unclear etiology, and 6 with other noninfectious causes. Streptococcus pneumoniae was the most common bacterial pathogen. Herpes simplex virus, enteroviruses and West Nile encephalitis virus were the most common viral pathogens. The classic triad of fever, neck stiffness and change of mental status was less common than previously reported, found in 5.0% of all the patients and 21.4% of the patients with bacterial meningitis. Conclusion: Meningitis should be suspected with any suggestion of central nervous system complaint, even in the absence of the classic triad of symptoms and signs.

Intensity of hospital services is often estimated by length of stay (LOS). Increasing demands for documentation in the medical record suggested to us an alternate method: weighing the chart. In a retrospective study, we compared LOS and chart weight as predictors of actual hospital costs at a community teaching hospital. We reviewed a sample of 123 patients randomly chosen from the medical service and stratified by phase of the academic year. Both least-squares regression and a multiple sampling/validating technique were used to derive mean cost per ounce of chart and per day of stay. Costs estimated from weight were within 7% and from LOS within 14% of measured actual costs among patients not used to derive the formulae. We conclude that the intensity of paper documentation closely reflects actual costs; the same may be true of bytes or key-strokes for electronic records.

Objectives: Previous studies evaluating the use of CT in the diagnosis of appendicitis have taken place at university-based institutions where surgical bedside consultation seems prudent before radiological study. In the private hospital setting, the emergency department (ED) physician is responsible for diagnosis. We attempt to assess if this process is detrimental to patient care. Methods: Retrospective review of 150 patient's records admitted through the ED was performed with the discharge diagnosis of appendicitis between March 1998 and May 2000. Data was stratified for analysis based on age ( 50) and gender. Using Graph Pad Prism software the groups were compared for complications based on whether or not CT was obtained. Chi-square, number needed to treat (NNT), absolute risk reduction (ARR), relative risk reduction (RRR) and respective confidence intervals were calculated for each group. Results: No significant differences overall were obtained between CT and no CT groups at P < 0.05. A significant benefit is demonstrated at P = 0.017 in females of childbearing age while a detrimental trend is found for those over the age of 50 years. Conclusions: Contrary to our initial hypothesis, no increased incidence of appendiceal perforation or abscess was demonstrated based on the ED physician's decision to perform CT without surgical consultation.

Objective: We sought to determine predictors of coronary events (cardiac death, acute myocardial infarction, and urgent revascularization) within 30 days after admission. Methods: We prospectively collected data on 400 patients admitted through our emergency room for unstable angina and acute coronary syndromes. Patients with ST-segment elevation myocardial infarction and those who required thrombolysis were excluded. Results: Of 383 patients who were eligible, 120 patients had coronary events within 30 days. Statistically significant variables associated with coronary events were advanced age, male sex, family history of premature coronary artery disease (CAD), diabetes mellitus, tobacco abuse, prior congestive heart failure, prior myocardial infarction, and history of CAD. Symptoms at presentation associated with cardiac events were typical angina and shortness of breath. Objective measures of ischemia associated with cardiac events were elevated troponin T, elevated creatine kinase MB, and ischemic electrocardiographic changes. Using forward stepwise regression analysis, we generated a model to predict 30-day major adverse cardiac events. The strongest predicting variable was serum troponin T (accounting for 33% of predicting r 2 , P < 0.001) followed by typical angina (r 2 increasing to 37%), ischemic electrocardiographic changes (40%), prior CAD (42%), family history of premature CAD (44%), shortness of breath (46%), and positive creatine kinase MB (48%). The positive predictive power of the complete model was r 2 = 48%, P < 0.001. Conclusion: Our model incorporating elements from the patient's demographic, medical history, presentation, and ischemic assessment identified 48% of patients presenting with unstable angina and acute coronary syndromes who will suffer a major adverse cardiac event within 30 days of admission. Although the strongest predictor was identified as serum troponin T, other clinical criteria offered improvement in our predictive abilities. Therefore, good initial clinical evaluation in addition to simple tests such as serum cardiac markers and electrocardiography are valuable in risk stratification of patients presenting with acute coronary syndromes and cardiac chest pain. Additional testing may be necessary to improve the positive predictive value of the model. Cardiac enzymes and electrocardiographic changes have the highest negative predictive value for occurrence of major adverse cardiac events. Identification of high-risk patients is essential to direct resources toward these patients and to avoid unnecessary costs and risk to the low-risk population.

BACKGROUND: The prevalence of congestive heart failure (CHF) in the United States is approximately 4 million, with associated annual health care expenditures exceeding dollar 8 billion. Clinical pathways for CHF have been developed, but they have not been rigorously evaluated regarding efficacy and improvement in the quality of care. We sought to evaluate the effect of a CHF clinical pathway on hospital charges, length of stay, and use of angiotensin-converting enzyme (ACE) inhibitors in patients with CHF in a retrospective cohort study. METHODS: We studied 371 patients (age range, 44-92 yr) with discharge diagnoses of CHF in a 376-bed community hospital between July 1996 and December 1997. We conducted chart reviews to determine length of stay, hospital charges, and use of ACE inhibitors. RESULTS: Of the 371 patients, 174 were assigned to the clinical pathway and 197 were not. Baseline characteristics of the two groups were similar. The benchmark of less than 4 days' in-hospital stay was achieved in 65% of patients on the pathway and 42% who were not on the pathway (odds ratio, 2.6; 95% confidence interval, 1.67-4.05; P < 0.001). The median hospital charges were lower in the group on the clinical pathway (dollar 3,000 versus dollar 5,500, P < 0.001). In addition, 81% of the patients on the clinical pathway were administered ACE inhibitors, compared with 48% of equally eligible patients from the nonpathway group (odds ratio, 4.68; 95% confidence interval, 2.85-7.72; P < 0.001). CONCLUSION: The clinical pathway for CHF was associated with increased use of ACE inhibitors as well as reduced length of stay and hospital charges.

We reviewed 51 consecutive parotidectomies done at a general community hospital and gathered data on age and sex of the patients, length of stay in the hospital, perioperative outcome, complications, and surgical pathology. Statistical method included logistic regression and ANOVA to determine relationship and dependence of the variables. There were 24 male and 27 female patients. Thirty-six (70.6%) of the parotid tumors were benign. There were no major complications. Treatment of parotid tumors in the community hospital is feasible and safe if basic guidelines are implemented. The epidemiology of parotid tumors in the relatively smaller hospital should resemble that reported in the literature. Our data suggest that parotid malignancy may occur more frequently in elderly men and that length of stay in the hospital may be longer for patients having surgery for malignant than for benign parotid tumors.

Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). The purposes of this study are to evaluate the safety of PDT in a non-university hospital setting and to compare our results with those published in the literature.The study was done by retrospective chart review.Over a 6-year period, 300 PDTs were done in two community hospitals in Tyler, Texas. There was one death and 12 complications. Comparison of our results and those reported in five recently published articles in the literature showed no significant difference in mortality rate, pneumothorax, bleeding, paratracheal placement, dislodgement, or cellulitis. There was a trend toward a significantly lower incidence of paratracheal placement using bronchoscopic guidance.Bedside PDT with bronchoscopic guidance can be safely done in a community hospital setting.

People older than 90 years represent an increasing segment of the US population, but little information exists on their hospitalization for acute illness.We retrospectively analyzed the clinical characteristics of patients aged 95 through 99 years admitted during 1 year to a large teaching hospital.Of 43 patients admitted at least once, 14 were admitted twice, 6 were admitted three times, and 1 was admitted four times; 35 (81%) were women, and 8 (19%) were men. Patients admitted more than once took a mean of 6.8 +/- 3.3 drugs compared with 4.4 +/- 2.6 drugs for patients admitted only once. Routine laboratory values were typically normal or mildly abnormal. Mean hospitalization was 5.6 +/- 3.5 days. Only 2 patients (5%) died. All 11 patients with a recent fall were discharged to a long-term nursing facility, compared with only 18 of 30 patients without a recent fall.Patients aged 95 through 99 years generally have a favorable prognosis when hospitalized for an acute medical condition. However, patients with a recent fall are more likely to require placement in a long-term nursing facility, and patients taking six or more drugs on admission are more likely to be rehospitalized within 12 months.

Several studies in recent years have addressed the accuracy of the clinical diagnosis of Alzheimer's disease (AD). However, most large studies have been done in university centers specializing in dementia. The purpose of this study was to assess the diagnostic accuracy of dementia in a community-based brain bank program, using data from the Central Florida component of the State of Florida's Brain Bank Program. Since 1987, 261 cases of dementia have been assessed at antopsy, and the clinical and pathologic diagnoses were compared. Of 234 patients with a clinical diagnosis of AD, 181 (77%) had a pathologic diagnosis of AD, with or without other contributing disorders. Of 27 patients with a clinical diagnosis of non-AD dementia, 14 (52%) had a pathologic diagnosis of AD, with or without other contributing diagnoses. These findings are similar to those previously reported and emphasize the importance of autopsy for the accurate diagnosis of dementia for genetic counseling, assessment of diagnostic techniques or drug therapy, and epidemiologic studies.

We reviewed cases of Providencia stuartii bacteremia at a large community teaching hospital during a 12-year period (1981 to 1992). None of the infections were hospital-acquired. Of the 49 patients, 47 (96%) came from a nursing home, and 45 (92%) had a long-term indwelling Foley catheter. The urinary tract was definitely proven to be the source of bacteremia in 35 patients (71%) and was the probable source in another 5 patients (11%). Polymicrobial bacteremia occurred in 25 patients (51%). The overall mortality rate during hospitalization was 25%.

Gram's stain (GS) and culture of sputum are used routinely for diagnosis of lung infection. We prospectively studied physicians' use of sputum GS and culture for management of lung infection, the correlation between GS and culture in 224 adequate sputum specimens from patients admitted to our hospital over a 15-month period, and its impact on the antibiotic used. GS correlated with sputum culture in one third of the cases in the most predictive group. Gram-negative rods including Haemophilus influenzae formed the majority of the positive cultures and were also the most poorly predicted by GS. Physicians used broad spectrum antibiotics empirically in most cases. These choices were not altered by the culture results in most instances. It may be reasonable to use broad spectrum antibiotics empirically for lung infection. Sputum GS and culture may be helpful in patients at risk for high morbidity and mortality.

Gastrostomy can be a valuable adjunct to patient care, and percutaneous endoscopic gastrostomy is often considered the method of choice for gastrostomy placement. As with all surgical procedures, however, patient selection is important no matter how the gastrostomy is placed. In a retrospective review of 125 randomly selected patients having gastrostomy tube placement, there were certain groups of patients who received virtually no benefit from gastrostomy and may even have died sooner due to gastrostomy placement. The leading indication for gastrostomy placement was neurologic debilitation; the procedural mortality rate for these patients was 28%. However, patients with pulmonary cachexia or metastatic cachexia had much higher mortality rates: 90% and 37%, respectively. We believe patient selection has been imperfect and that certain patients should not have a gastrostomy tube. These patients suffer the moral indignation of persistent intervention and often die without receiving any real benefit.

We prospectively tabulated all isolates of Haemophilus influenzae at DeKalb Medical Center from 1987 through 1989 to assess the occurrence of antibiotic resistance in patients of different ages. Of 325 total strains isolated, 24% produced beta-lactamase, rendering them resistant to ampicillin and amoxicillin. Antibiotic resistance was as common in patients older than age 60 (24%) as in younger patients (23%). Sensitivity testing by disk diffusion and microdilution techniques on 71 isolates (37 beta-lactamase-positive) showed uniform susceptibility to cefuroxime, cefotaxime, amoxicillin/clavulanate, cefaclor, and chloramphenicol, but three beta-lactamase-positive isolates were resistant to trimethoprim/sulfamethoxazole. The high rate of ampicillin resistance noted in elderly patients has implications for the choice of antimicrobial therapy for these infections.

Transrectal ultrasonography (TRUS) was used to guide 277 biopsies of the prostate in 182 patients. The Bard Biopty system was used. Of these 182 patients, 107 (59%) had benign changes, and 75 (41%) had malignant lesions. Of those with cancer, 40% (30/75) had negative results of digital rectal examination (DRE). The cancer detection rate by TRUS was 40.7%, and by DRE alone it was 24.2%. Use of TRUS before transurethral resection of the prostate (TURP) in 47 patients with negative findings on DRE yielded 22 cancerous lesions (47%). We advocate this method in patients with abnormalities detected on DRE or with elevated levels of prostate-specific antigen or prostatic acid phosphatase, and as preoperative screening in patients having TURP because of the potential impact of a preoperative diagnosis of cancer upon the choice of treatment.

Current hospital policies controlling original diagnostic radiographs do not serve the best interests of either the patients or the institutions. A survey of 200 randomly selected hospitals shows that approximately 40% of the hospitals would not release the original radiograph directly to the patient. Even more important, hospitals will destroy original radiographs without prior notification of the patient. Although statutes and case law support the institutional ownership of the x-ray film, there is a strong legal trend allowing the patient the use of the film. There are potential problems with patient control of the original radiographic image, but there is no evidence that these problems would develop if current hospital policies were changed to allow the patient physical possession of the films. Because there are economic incentives for hospitals to destroy the original radiographs, hospital policies should be liberalized to allow patients to acquire and maintain possession of their own original radiographic images.

Forty-four patients with undifferentiated small cell carcinoma of the lung (SCCL) were diagnosed and treated at community hospitals. Patients with limited disease were treated with surgical resection or primary radiation therapy (RT) followed by chemotherapy; those with extensive disease received chemotherapy followed by RT if there was not a complete primary response. The chemotherapy used was a combination of methotrexate, doxorubicin, cyclophosphamide, and lomustine. Median survival for patients with both limited and extensive disease was 12 months, with a six-month survival of 89%. Half of the patients had recurrence in the lung. The toxicity was moderate and tolerable. We conclude that this combination chemotherapy plus radiation therapy carries acceptable toxicity and can be used in a community hospital to achieve response rates and survival of SCCL equivalent to that obtained in large cancer centers.

We reviewed charts of total hip arthroplasties from a ten-year period (January 1973 through December 1982) to determine the rate of infection at the Birmingham Veterans Administration Medical Center. Of 321 procedures, 296 were reviewed (92%). Overall, there were 24 infections (8.1%), 13 of which (4.4%) were deep infections. Seven of the deep infections were due to Serratia marcescens, resulting in six implant removals. These figures are compared to the 1.1% deep infection rate after total hip arthroplasty at the adjoining University Hospital, University of Alabama at Birmingham. The main determinants for risk of infection at the VA Hospital were length of procedure and previous procedures on the affected joint.

We reviewed the records of patients with infectious endocarditis from three hospitals in the same city from 1970 to 1972 and from 1980 to 1982. A total of 43 episodes of infectious endocarditis occurred in 42 patients. The clientele of these hospitals differ in that one is a teaching hospital which treats principally indigent tertiary care patients, one treats principally private patients, and one provides care for military veterans. In our study we noted that changes in the frequency and etiology of endocarditis observed at our teaching hospital were not seen in either of the other hospitals. We also noted that the predilection for men and mitral valve involvement observed in some retrospective reviews of endocarditis from large metropolitan centers could not be extended to our city's hospitals. Although some interhospital variations in epidemiologic and microbiologic parameters in infectious endocarditis may be explained by different patient populations, others, such as local variations in the frequency of valvular involvement, cannot be reliably predicted from published series. We conclude that a larger data base founded on statewide reporting of infectious endocarditis would lead to a better understanding of the microbiology, anatomy, and demography of infectious endocarditis.

To determine whether intravenous streptokinase can be delivered safely and effectively in a community hospital without acute angiography, we treated 120 patients with intravenous infusion of 1.5 million units of streptokinase shortly after arrival in the emergency room. Average time from onset of pain to treatment was 2.7 hours. Therapy was well tolerated without significant complication. Reperfusion was clinically suspected in 78% of patients. Coronary angiography was done at referral hospitals in 94% of the surviving patients two to ten days after treatment. The infarcted vessel was patent in 74% of these patients. Of these, coronary angioplasty was performed in 36%, and 32% had bypass grafting. We conclude that intravenous streptokinase can be safely and effectively used in community hospitals without acute angiography in carefully selected patients with acute myocardial infarction.

We analyzed population-based data from the Georgia Neonatal Surveillance Network from 1974 to 1978 to determine the effect of the hospital of delivery on the neonatal mortality rate (NMR) of infants later admitted to neonatal intensive case units (NICUs). The NMR of 3,524 infants transported from primary centers to NICUs was significantly higher [relative risk (RR) = 2.1; 95% CL = 1.9 to 2.3] than that of 10,764 infants born in tertiary centers and admitted directly to an NICU. This effect persisted even after adjustment for birth-weight differences (RR = 1.6; 95% CL = 1.5 to 1.8). The relative risk in favor of delivery in a tertiary center increased with increasing birth weight. However, the proportion of infants of less than 1,000 gm surviving was higher for transported infants and increased with distance transported. This finding suggests that, at these very low birth weights, the hardiest infants were selectively transported. A surprising finding was the very low proportion of low-birth-weight infants delivered in primary centers and transported to NICUs (eg, 32% of infants weighing between 1,001 and 1,200 gm). Our findings support previous reports that delivery in a hospital with an NICU is preferable to later neonatal transport and suggest that efforts to increase the rate of maternal transport in high-risk pregnancies can lead to a substantial reduction in infant deaths.