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Background The electroencephalogram (EEG) is a common diagnostic tool used to investigate patients for various indications including seizure disorders. In our study we investigate factors that predict the presence of epileptiform abnormalities on EEG and review the common indications for ordering an EEG. Methods We retrospectively reviewed all routine adult EEGs performed in a hospital over a six-month period. Data collated included patient demographics, clinical indication for EEG, setting in which EEG was performed, activation procedures utilised, history of epilepsy, and whether the patient was on antiepileptic medication. Our primary objective was to evaluate the factors that were predictive of an EEG with epileptiform abnormalities. Results 239 routine EEGs were included with indications including first seizure (25.9%), known epilepsy (25.1%), cognitive change (15.9%), syncope (15.0%), movement disorder (6.7%), psychogenic non-epileptic events (5.4%), unresponsiveness/ICU (4.6%), and psychiatric presentation (1.3%). Most EEGs were normal (48.1%). 8.9% of EEGs demonstrated epileptiform abnormalities. Using multivariate logistic regression, three variables proved significant in predicting an EEG with epileptiform abnormalities. Any seizure as an indication (first seizure or seizure in known epileptic), increasing patient age, and EEGs conducted in an inpatient setting and within 48 hours of seizure event were all statistically more likely to yield epileptiform abnormalities on EEG. Conclusions Our findings suggest that careful selection of patients based on appropriate indications for EEG referral would likely improve the yield of an EEG. Depending on the indication, a normal EEG result can be of similar usefulness to an abnormal EEG demonstrating epileptiform abnormalities. This article is protected by copyright. All rights reserved.

Background Internationally, clinical and economic advantages of low-risk penicillin delabeling have been explored, supporting changes to healthcare delivery systems where penicillin delabeling is embedded into inpatient usual care. Aim To determine if economic advantages of low-risk inpatient penicillin delabeling, described in the international literature, are realised in the Australian context. Methods This explorative economic evaluation had prospective patient data collection between January and August 2019, across two Australian health services. Part-1: Determine the cost per effectively delabeled patient for Penicillin Allergy Delabeling Program inpatients (PADP cohort) compared to Outpatient Antibiotic Allergy Testing Service outpatients (OAATS cohort). Part-2: A cost analysis to compare hospital costs for inpatients with low-risk penicillin allergy who did (PADP cohort) and did not (usual care cohort) undergo PADP delabeling. Results Part-1: The PADP (n=350) and OAATS (n=27 patients, n=36 individual visits) cohorts were comparable. In PADP, costs/proportion delabeled was $20.10/0.98, equating to $20.51 per effectively delabeled patient; in OAATS, it was $181.24/0.50, equating to $362. Compared to OAATS, PADP was associated with savings of $341.97 per effectively delabeled patient; indicating the outpatient testing was the dominated strategy, being more costly and less effective. Part-2: The PADP (n=218) and usual care (n=32) cohorts were comparable. Significantly favouring the delabeled PADP cohort, mean difference per patient was -4.41 days (95%CI -7.64, -1.18) and -$9,467.72 (95%CI -$15,419.98, -$3,515.46). Conclusions Consistent with international literature, delabeling low-risk penicillin allergies in the inpatient setting had economic advantages in the Australian context. Fully powered economic evaluations are urgently required to consolidate these findings. This article is protected by copyright. All rights reserved.

Aim This study aimed to identify and compare age stereotypes of registered nurses and supervisors in clinical inpatient settings. Design Generic qualitative study using half‐standardized interviews. Method Nineteen face‐to‐face interviews and five focus groups (N = 50) were conducted with nurses of varying levels at a hospital of maximum medical care in Germany between August and November 2018 and were subjected to structured qualitative content analysis. Results Reflecting the ageing process and cooperation in mixed‐age teams, nursing staff and supervisors defined similar age stereotypes towards older and younger nurses reminiscent of common generational labels ‘Baby Boomers’ and Generations X. Their evaluation created an inconsistent and contradictory pattern differing to the respective work context and goals. Age stereotypes were described as both potentially beneficial and detrimental for the individual and the cooperation in the team. If a successfully implemented diversity management focuses age stereotypes, negative assumptions can be reduced and cooperation in mixed‐age teams can be considered beneficial. Conclusion Diversity management as measures against age stereotypes and for mutual acceptance and understanding should include staff from various hierarchical levels of the inpatient setting., publishedVersion

BACKGROUND Neurology is often perceived as a difficult discipline by medical students, yet it is an essential part of medical training. While the most common disorders of the nervous system can be observed in the outpatient setting, positive neurological signs are more likely to be found in neurology wards. We aimed to compare the impact of a neurology outpatient versus inpatient rotation setting on the grades obtained by medical students as a proxy measure of the learning outcomes. METHODS We compared the results obtained by fourth year medical students in practical (OSCE) and multiple choice question (MCQ) exams in neurology, between students whose main (total of 24 h contact) teaching allocation was either the outpatient or inpatient setting, controlling for students' gender, teacher, academic year and student' previous achievement (measured by their scores on practical evaluation). RESULTS A total of 1127 students were included, of whom 644 (57.14%) were allocated mainly to the neurology ward and 483 (42.86%) to the outpatient clinic. Students assigned to the ward obtained significantly higher grades in the OSCE and MCQ exams than those placed in the outpatient clinic. Teaching setting was an independent predictor of both classifications after adjustment. CONCLUSIONS The teaching setting had a significant impact on the learning outcomes. This may be due to a higher likelihood of observing abnormal neurological signs or to more student-centered teaching on the ward. These results highlight the importance of a balanced distribution of students by different clinical settings.

Background We sought to describe the burden of arrhythmias and their impact on in‐hospital outcomes in transgender patients who underwent gender re‐assignment surgery. Methods The study utilized data from the National Inpatient Sample from January 2012 to September 2015. Results 16 555 adult transgender patients were included in this study. A total of 610 adults developed arrhythmia out of which atrial fibrillation (N = 475, 2.87%) was the most frequent arrhythmia. In‐hospital mortality increased substantially with arrhythmias. Conclusions New‐onset arrythmias, while infrequent in the inpatient setting is associated with significantly higher in‐hospital mortality and resource utilization., New‐onset arrhythmias were not frequent in patients undergoing gender‐affirming surgeries in the inpatient setting. Atrial fibrillation was the most common arrhythmia noted in this population. These arrhythmias, when developed, increases the risk of in‐hospital mortality and resource utilizations.

Aims To examine the delirium point prevalence studies conducted in different inpatient settings and to discuss the implication of the findings for delirium screening, assessment, prevention and management. Background Delirium-a common and distressing condition manifesting as an acute decline of attention and cognition-is frequently overlooked, misdiagnosed or treated inappropriately. This neuropsychiatric syndrome manifests as changes in attention, cognition and awareness, with resultant impact on behaviour, function and emotions. Delirium is recognised as a patient management challenge in the inpatient setting, and there is a need to understand the current point prevalence and assessment practices of delirium. Design A systematic review and meta-analysis. Methods A systematic review of published delirium prevalence studies in inpatient settings was conducted and the implications of findings for delirium screening, assessment, prevention and management identified. The random-effects meta-analysis was conducted among studies measuring delirium point prevalence. The PRISMA statement was used to report systematic review and meta-analysis. Results Nine studies were included in the review, with sample sizes ranging from 47-1867. Delirium point prevalence ranged from 9%-32%. Hypoactive delirium was the most common subtype, ranging from 23%-78%. Fifteen delirium screening tools or assessment or diagnostic methods were used. Comorbid dementia was present in up to 50% of inpatients. Conclusions Gaining a consensus on effective delirium instruments, the time windows for assessment and measurement will be crucial in driving benchmarking and quality improvement studies. Relevance to clinical practice Consistent identification of high-risk patients and treatment settings with elevated risk, accompanied by the implementation of effective preventive and management strategies, are critical to addressing delirium-a frequent and burdensome condition, that adversely affects patient outcomes.

Objectives To describe patient behaviour related to mobility in a rehabilitation inpatient setting and compare intensive and Transition Care Program (TCP, slow-stream rehabilitation) models. Methods Prospective cross-sectional design including weekday and weekend sampling in two rehabilitation wards (one intensive and one TCP) in a publicly funded facility. A single trained observer undertook behavioural mapping, observing patient location, mobility, activity and company on all inpatients 8 am-4 pm using a structured 2-minute observation protocol. Observations were summarised and compared between wards. Results We observed 74 inpatients on a Tuesday and 77 on a Sunday. Participants spent 7% (median) of daytime standing or walking. They spent 62%-87% in their room, 22%-40% sleeping or resting and 74%-86% alone. The only significant difference between wards was time spent off ward on Tuesday. Activity was lower on Sunday. Conclusions Time spent in physical, cognitive and social activities is low in inpatient rehabilitation and TCP wards.

Background and objectives Buprenorphine/naloxone has been shown to be effective in the treatment of opioid use disorder. Due to its pharmacological properties, induction can be challenging, time-consuming, and result in sudden onset of withdrawal symptoms. Methods Retrospective case series (n = 2). Results Two patients with opioid use disorder were successfully started on buprenorphine/naloxone using a rapid micro-induction technique that did not cause precipitated withdrawal or require preceding cessation of other opioids. Discussion and conclusions These cases provide an alternative method for starting buprenorphine/naloxone that offers unique benefits compared to protocols previously described in the literature. Scientific significance This method can be used to minimize barriers to opioid agonist therapy. (Am J Addict 2019;28:262-265).

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.

The use of teledermatology in an inpatient setting is not well-established, with limited data published compared to the outpatient setting. It has, however, been demonstrated that teledermatology may be effective for managing inpatient dermatologic disease, leading to highly concordant diagnostic and management decisions(1,2). Involvement of dermatologists in the care of hospitalized patients has been found to improve patient outcomes(3) with inpatient teledermatology reducing response times(4).

BACKGROUND: As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience. METHODS: We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures. RESULTS: Our synthesis of the literature characterizes contributors to hospitalists’ procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists. CONCLUSION: We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.

BACKGROUND Single-center reports of central line-associated bloodstream infection (CLABSI) and the subcategory of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) in pediatric hematology oncology transplant (PHO) patients have focused on the inpatient setting. Characterization of MBI-LCBI across PHO centers and management settings (inpatient and ambulatory) is urgently needed to inform surveillance and prevention strategies. METHODS Prospectively collected data from August 1, 2013, to December 31, 2015, on CLABSI (including MBI-LCBI) from a US PHO multicenter quality improvement network database was analyzed. CDC National Healthcare Safety Network definitions were applied for inpatient events and adapted for ambulatory events. RESULTS Thirty-five PHO centers reported 401 ambulatory and 416 inpatient MBI-LCBI events. Ambulatory and inpatient MBI-LCBI rates were 0.085 and 1.01 per 1000 line days, respectively. Fifty-three percent of inpatient CLABSIs were MBI-LCBIs versus 32% in the ambulatory setting (P

BACKGROUND AND OBJECTIVES Although buprenorphine/naloxone is widely recognized as first-line therapy for opioid use disorder, the requirement for moderate withdrawal prior to initiation in efforts to avoid precipitated withdrawal can be a barrier to its initiation. METHODS We present a case utilizing transdermal fentanyl as a bridging treatment to eliminate withdrawal during the transition from methadone to buprenorphine/naloxone in a patient who had ongoing significant intravenous heroin use while on methadone. RESULTS Patient was successfully transitioned from methadone to buprenorphine/naloxone without a period of withdrawal utilizing transdermal fentanyl as a bridge in an inpatient setting. DISCUSSION AND CONCLUSIONS Our experience indicates a transdermal depot of fentanyl allows for slow release and elimination while buprenorphine doses are introduced during an induction without presence of withdrawal, as quantified by serial clinical opiate withdrawal score. SCIENTIFIC SIGNIFICANCE This case report highlights ways to minimize barriers to induction of first-line opioid substitution therapy, buprenorphine/naloxone, by eliminating withdrawal during induction phase utilizing a fentanyl bridge within the limitations of a transdermal fentanyl bridge in an inpatient setting. (Am J Addict 2018;XX:1-4).

Objectives Psychologists routinely work in psychiatric inpatient settings and it is acknowledged that they cannot work in isolation from the multidisciplinary team. The aim of this study was to examine the multidisciplinary team's perspective on the role of psychology within the acute psychiatric inpatient setting. Design A qualitative approach was taken utilizing semi-structured interviews for data collection. Methods Interviews were undertaken with 12 multidisciplinary team members (occupational therapists, psychiatric nurses, psychiatrists, and clinical managers) examining their perspectives on the role of psychology within the acute psychiatric inpatient setting. Thematic analysis was used to analyse data. Results The analysis identified two key themes 'psychological treatments', which describes the perceived function of psychology on the ward, and 'integrated psychological working' outlining key issues that psychologists should consider when working in multidisciplinary teams. Conclusions Psychology is seen by multidisciplinary team members as an integral, but not first line, treatment option in the psychiatric inpatient setting. Both direct work and indirect work were valued by multidisciplinary staff participants. The multidisciplinary team do not have a clear understanding of the role of psychology. Education dialogue about the role are required. Practitioner points The role of psychology in the psychiatric inpatient setting is valued by the multidisciplinary team. Psychology was not viewed as a first-line treatment option in the psychiatric inpatient setting but an 'add-on' to medical treatment. Psychology was a valued source of support for skilling-up and offering reflective space to the multidisciplinary team. Psychologists need to better promote their role and their skills to the multidisciplinary team.

AIM The introduction of an electronic system for recording and displaying growth measurements replaces multiple paper growth charts and theoretically improves the availability and consistency of information to support clinical decision-making. Introducing this in a single New Zealand District Health Board provided the opportunity to evaluate usage in hospital settings and determine the uptake of growth recording in a defined population. METHODS All records between 2010 and 2015 in the Southern District Health Board (SDHB) anthropometry database were downloaded and examined in a retrospective cohort analysis. Records were extracted after matching to demographic and clinical setting data from the hospital patient management system. RESULTS Analysis included 30 670 data entry points, representing 8551 children. Data entry increased over time to a maximum of 8407 observations in 2015. By the fifth year of use, up to 67% of available clinical encounters had anthropometry recorded in the outpatient department. Rates were lower in the inpatient setting, where only up to 18.4% had anthropometry recorded. The errors identified were low (0.2% of all data). Weight was the most commonly recorded measurement (98.2% of anthropometry entries, 35.1% of available clinical presentations). Height was available for 82.6% of entries and 29.5% of presentations. A body mass index z-score was available for 81.5% of entries and 29.1% of presentations. A head circumference was available for 50.2% of children

Medical students and residents often have little experience in placing or responding to dermatologic consults in the inpatient setting when they first begin training. Trainees often learn what and how to communicate through observation or trial and error. We propose that dermatologists can play an active role in facilitating interspecialty education and improving patient outcomes by teaching in a systematic fashion.

INTRODUCTION: Research on treatments for young people (YP) with anorexia nervosa (AN) is scarce. Evidence supports the use of cognitive remediation therapy (CRT) to improve central coherence and set-shifting, inefficiencies that can negatively impact on prognosis.OBJECTIVE: The study aims to evaluate the feasibility of individual CRT in an inpatient setting for YP aged 10-18 years with AN and to qualitatively examine YP's and their parents experiences.METHOD: In a single-centre, pilot, randomised controlled trial, 80 patients aged 10-18 years with AN will be randomly allocated to the immediate or delayed CRT group, in addition to standard treatment. A repeated measures design will be conducted across 3 time points.DISCUSSION: The data will provide evidence regarding the feasibility of individual CRT in YP with AN, informing directions of further development of CRT. The study is in preparation for a definitive randomised controlled trial. The aim of this manuscript is to describe the study protocol.

Prior investigation has suggested a positive association between increased colonic propionate production and circulating odd-chain fatty acids [(OCFAs; pentadecanoic acid (C15:0), heptadecanoic acid (C17:0)]. As the major source of propionate in humans is the microbial fermentation of dietary fiber, OCFAs have been proposed as candidate biomarkers of dietary fiber. The objective of this study is to critically assess the plausibility, robustness, reliability, dose-response, time-response aspects of OCFAs as potential biomarkers of fermentable fibers in two independent studies using a validated analytical method. OCFAs were first assessed in a fiber supplementation study, where 21 participants received 10g dietary fiber supplementation for 7 days with blood samples collected on the final day at a 420 minute study visit. OCFAs were then assessed in a highly controlled inpatient setting, which 19 participants consumed a high fiber (45.1g/day) and a low fiber diet (13.6g/day) for 4 days. Collectively in both studies, dietary intakes of fiber as fiber supplementations or having consumed a high fiber diet did not increase circulating levels of OCFAs. The dose and temporal relations were not observed. Current study has generated new insight on the utility of OCFAs as fiber biomarkers and highlighted the importance of critical assessment of candidate dietary biomarkers before application.

BACKGROUND: Individual provider performance drives group metrics, and increasingly, individual providers are held accountable for these metrics. However, appropriate attribution can be challenging, particularly when multiple providers care for a single patient. OBJECTIVE: We sought to develop and operationalize individual provider scorecards that fairly attribute patient-level metrics, such as length of stay and patient satisfaction, to individual hospitalists involved in each patient’s care. DESIGN: Using patients cared for by hospitalists from July 2010 through June 2014, we linked billing data across each hospitalization to assign “ownership” of patient care based on the type, timing, and number of charges associated with each hospitalization (referred to as “provider day weighted”). These metrics were presented to providers via a dashboard that was updated quarterly with their performance (relative to their peers). For the purposes of this article, we compared the method we used to the traditional method of attribution, in which an entire hospitalization is attributed to 1 provider, based on the attending of record as labeled in the administrative data. RESULTS: Provider performance in the 2 methods was concordant 56% to 75% of the time for top half versus bottom half performance (which would be expected to occur by chance 50% of the time). While provider percentile differences between the 2 methods were modest for most providers, there were some providers for whom the methods yielded dramatically different results for 1 or more metrics. CONCLUSION: We found potentially meaningful discrepancies in how well providers scored (relative to their peers) based on the method used for attribution. We demonstrate that it is possible to generate meaningful provider-level metrics from administrative data by using billing data even when multiple providers care for 1 patient over the course of a hospitalization.

Hospitalisation of a parent with acute mental health problems impacts the consumer, their extended family/carers and children. Mental health nurses are at the forefront of promoting recovery for consumers in an acute inpatient setting. Recovery-oriented care can include provision of family-focused care which supports recovery of the parent-consumer and their family members and contributes to prevention of intergenerational mental illness. The aim of this narrative literature review was to explore existing knowledge regarding the experiences, care and support needs of parent-consumers, their family members/carers and children during the parent's acute mental health hospitalisation. It also aims to explore existing knowledge about the practices of mental health nurses providing care to this consumer group, to inform future healthcare practice and strengthen parent, child and family outcomes. Nineteen published studies addressed the review questions. In the context of hospitalisation, the majority of research regarding parenting with a mental illness is focused on mothers. Parents reported experiencing stigma during their hospitalisation. Separation from children was a concern for parents and their extended family, but admission provided an opportunity for the parent to receive treatment and for the family to receive support. Mental health nurses did not always identify parental status on admission. When parental status was identified, nurses reported issues regarding logistics and practicalities of using family rooms, children visiting the unit, and their own professional knowledge and organisational support regarding familyfocused care. Implications for practice are identified, highlighting how mental health nurses can develop their practice to support the recovery of parent-consumers.

Background When families transition from the neonatal intensive care unit (NICU) to the home, they become responsible for their infant's daily medical needs. Though neonatology physicians prepare families for hospital discharge, it is unclear how much clinicians understand about how their teaching and instructions translate into home care. The goal of this study was to evaluate the influence of a home visiting program on neonatology fellows’ understanding of family needs soon after hospital discharge. Methods Neonatology fellows conducted a home visit for an infant recently discharged. Before the visit, fellows reviewed their original discharge instructions, along with information about the family's neighborhood. During the home visit, fellows reviewed their discharge planning with families and discussed any challenges experienced. Afterwards, fellows completed a semi-structured interview; these transcriptions were manually coded for themes. Results Fellows identified several common women/family discharge challenges. These challenges fall into four domains: (1) inadequate discharge preparation, (2) medicalization of the home, (3) family adjustment to new “normal,” and (4) the relevance of social context to discharge planning. Most (90%) fellows reported the home visit experience would affect their future NICU discharge practices and all agreed that home visits should be a part of neonatology training. Conclusions Home visits allowed neonatology fellows to examine how their discharge preparation did, or did not, meet the family's needs. Incorporating home visits into neonatology training could help fellows learn about the relevance of social and community factors that are difficult to assess in the inpatient setting.

Background Vocal fold movement impairment (VFMI), a known complication following thoracic aortic surgery, has been associated with poorer surgical outcomes, including higher pulmonary complications and longer length of stay (LOS). Awake transcervical injection laryngoplasty in the inpatient setting serves to augment pulmonary toilet function for affected patients. This study investigates clinical outcomes of patients who underwent early versus late injection laryngoplasty following aortic surgery. Methods A 5-year review (2011–2016) of 35 patients who underwent inpatient injection laryngoplasty for VFMI following aortic repair was conducted. Data included demographics, surgery parameters, laryngologic evaluation, pulmonary complications, LOS, and mortality. Early injection was defined as within 5 days from extubation. Statistical analyses were performed using SPSS, version 17.0 (IBM Corp., Armonk, NY). Results All 35 patients (mean age 56, 77% male) underwent left vocal-fold injection laryngoplasty without complication. There were 15 (43%) early procedures and 20 (57%) late procedures. Mean LOS for early and late injection groups (13 vs. 20 days, respectively) significantly differed (P = 0.04, 95% confidence interval (CI) 0.3 to 14.4). Early laryngoplasty cohorts experienced less pulmonary complications (20%) than those who had late medialization (50%), but this did not reach significance (P = 0.06, 95% CI −0.3 to 8.1). The most common complication type in both groups was therapeutic bronchoscopy. Conclusion Early awake injection laryngoplasty within 5 days from extubation is feasible and may improve clinical outcomes for patients with VFMI following aortic repair. Further prospective studies on this approach for VFMI after thoracic surgery are needed. Level of Evidence 4. Laryngoscope, 00:000–000, 2017

Aim Practitioners often avoid administering iron dextran in parenteral nutrition (PN) for hospitalised children because of the concern for anaphylaxis. The primary aim of the present study was to determine the risk of anaphylaxis associated with exposure to PN containing iron dextran in the inpatient setting. Methods Charts were reviewed for all children admitted to The Children's Hospital of Philadelphia from January 1, 2011 to December 30, 2013 who received PN containing low molecular weight (LMW) iron dextran. Subject characteristics, primary diagnoses and PN orders were evaluated. The pharmacy adverse events database was queried for adverse drug reactions. Results Over three years, 89 subjects received PN containing a maintenance dose of LMW iron dextran with a total of 2774 days of exposure. Subjects ranged from two months to 21 years of age and received between 1 and 196 days of PN containing iron dextran. The mean dose of iron dextran in children decreased as the weight category increased from

Objective: To assess the validity of using ICD-9-CM code 710.3 to identify adult patients with dermatomyositis in outpatient and inpatient settings. Methods: Electronic medical records were examined for adult patients with ICD-9 code 710.3 between January 2001 and November 2014 (n=511). Physician diagnosis, clinical findings and diagnostic testing results were recorded. A dermatomyositis rating scale was assigned based on classic cutaneous findings and at least 2 additional clinical and diagnostic findings from the Bohan criteria. Sensitivity and positive predictive values (PPV) were determined. Sensitivity analyses were performed to evaluate the accuracy of multiple ICD-9 codes in the outpatient setting, as well as primary and secondary inpatient codes. Results: The sensitivity and PPV for multiple ICD-9 codes of 710.3 in the outpatient setting was 0.89 and 0.35, respectively. The PPV for primary and secondary inpatient codes of 710.3 was 0.95 and as high as 0.8. However, the sensitivity of ICD-9 code 710.3 was poor in the inpatient setting (primary: 0.23; secondary: 0.26). Miscoding as diabetes mellitus (32%) was the most common reason for failure to meet appropriate dermatomyositis criteria followed by diagnosis at an outside institution (19%), dermatomyositis as a rule out diagnosis (10%), cutaneous dermatomyositis (8%), and juvenile dermatomyositis (6%). Conclusion: One or more occurrences of ICD-9 code 710.3 are insufficient to support diagnosis of dermatomyositis in the outpatient setting. However, ICD-9 codes of 710.3 appear to be valid in the inpatient setting. This article is protected by copyright. All rights reserved.

BACKGROUND Obesity prevalence is increasing in Australia, particularly in non-metropolitan areas. The effect of obesity on acute surgical outcomes is not known. We aimed to record waist circumference (WC) (surrogate for obesity) amongst acute surgical unit (ASU) patients in a New South Wales regional hospital, and compare outcome measures (length of stay (LOS), unplanned return to theatre, readmission rates, intensive care unit (ICU) admission and mortality). METHODS Retrospective cohort study of 4 months of consecutive ASU admissions, excluding age

Mental health inpatient milieus have repeatedly been found to be associated with passivity, social disengagement, and low levels of interaction with staff. However, little is known about patients' experiences related to different ward activities. In the present study, we aimed to study the reports of activities and associated experiences of patients admitted to acute psychiatric inpatient wards. Disengaged, inactive, and solitary activities were hypothesized to be associated with less reward and more distress than their counterparts. We also aimed to investigate if such activities predicted distress, and if they were associated with clinical severity. Participants (n = 102) recorded their activities along with concurrent ratings of reward and distress in a structured 1-day diary, and nurses provided clinical severity ratings. On average, 3.74 of the 11 hours assessed (34%) were spent doing nothing, only 0.88 hours (8%) were spent with staff, and most of the time was spent in solitude. Doing nothing, being alone, and passivity were associated with the greatest levels of distress and lowest levels of reward, whereas informal socializing demonstrated the opposite pattern. Distress was not predicted by activity or reward when adjusting for baseline distress. Clinical severity was not associated with the amount of time spent alone or the experience of reward during activity. In conclusion, the risk for passivity and social disengagement during admission prevails. This activity pattern could have detrimental emotional consequences and warrants action, but more studies are needed to determine if activity actually precedes emotional experience.

Objective To evaluate the impact of incorporating a standardized ward round (SWR) tool including checklists for communication, safety, and efficiency into ward rounds. Methods A prospective non-randomized, before-and-after observational study was conducted at a tertiary maternity hospital in Brisbane, Australia, between October 1, 2014, and October 1, 2015. Obstetric team members performing prenatal ward rounds used role-specific lanyards prompting the structure of each consultation. Rounds were audited before and after the introduction of the SWR for safety checks, hand hygiene, the duration of patient encounters, and plan congruity. Patients completed a paper-based satisfaction survey. Results from before and after the introduction of the SWR were compared. Results There were 71 conventional ward rounds and 79 SWRs audited, and no difference was found in the mean duration of patient encounters (P=0.566). SWRs were associated with increased rates of each of the five safety checks being performed and of hand hygiene being observed correctly (all P

Drug-reward cues trigger motivational circuitry, a response linked to drug-seeking in animals and in humans. Adverse life events have been reported to increase sensitivity to drug rewards and to bolster drug reward signaling. Therefore, we hypothesized that cocaine-dependent individuals with prior emotional, physical and sexual abuse might have a heightened mesolimbic brain response to cues for drug reward in a new brief-cue probe. Cocaine-dependent human individuals (N = 68) were stabilized in an inpatient setting and then completed an event-related blood-oxygen-level dependent functional magnetic resonance imaging task featuring 500-ms evocative (cocaine, sexual, aversive) and comparator (neutral) cues. Responses to three questions about emotional, physical and sexual abuse from the Addiction Severity Index were used to divide the patients into subgroups (history of Abuse [n = 40] versus No Abuse [n = 28]). When subjects were grouped by the historical presence or absence of emotional, physical or sexual abuse, the Abuse group showed a heightened midbrain, thalamic, caudate, and caudal orbitofrontal cortex response to cocaine cues; a similar result was found in other evocative cues, as well. These findings are the first reported for a 500-ms cocaine-cue probe, and they highlight the ability of very brief evocative cues to activate the brain's motivational circuitry. Although all participants had severe cocaine use disorders, individuals reporting prior abuse had a heightened mesolimbic response to evocative cues. To our knowledge, this is the first study in humans linking a history of abuse to a brain vulnerability (heightened mesolimbic response to drug cues) previously shown to contribute to drug-seeking.

Very little research exists on inpatient psychiatric treatment for youth, and hardly any information on the types of interventions used on inpatient units or the efficacy of inpatient therapies has been published in the past 20 years. With the increase in managed care, length of hospital stay has decreased, though readmission rates have increased (Blader, 2004; Pottick, McAlpine, & Andelman, 2000; Wickizer, Lessler, & Boyd-Wickizer, 1999). From 1990 to 2000, inpatient length of stay for youth dropped by 63% from approximately 12 days to 4.5 days despite higher rates of self-injury and serious mental illness and decreased transfers to intermediate care facilities (Case et al., 2007).

Evidence about the treatment of hospitalized type 2 diabetes patients with incretin‐based therapy has emerged in the past 15 years. Based on this evidence, dipeptidyl peptidase‐4 inhibitors should be considered for hospitalized patients with type 2 diabetes and an algorithm for this is proposed. In relation to use of glucagon‐like peptide‐1 and glucagon‐like peptide‐1 receptor agonist, further research is required to help define their role in the inpatient setting.

Objective We explored the effect of autonomous and controlled motivation on outcomes for patients undergoing inpatient treatment for Anorexia Nervosa (AN). Method Data on 80 patients with AN were available for the start of treatment, and for 49 at end of treatment. Patients completed measures of autonomous and controlled motivation, eating disorder symptoms and attitudes, and comorbid psychopathology at the start and end of treatment. Results Patients showed significant improvements on eating symptoms and comorbid psychopathology over the course of treatment. Autonomous motivation was a significant predictor of change in severity of eating symptoms and attitudes such that patients with higher pre-treatment levels of autonomous motivation showed larger post-treatment reductions on these indices. No such effects were associated with controlled motivation. Discussion This study highlights a relationship between autonomous motivation and outcome in an inpatient setting. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016)

Objectives To determine whether acute hospitalization is associated with a change in potentially inappropriate medication (PIM) use and whether use varies across geographic region. Design Observational. Setting Continental United States. Participants Medicare beneficiaries aged 65 and older hospitalized for acute myocardial infarction (AMI) during 2007–08. Measurements Potentially inappropriate medication use was defined according to the High-Risk Medications in Elderly Adults quality indicator from the Healthcare Effectiveness Data and Information Set. Prevalence of outpatient PIM use was determined at admission and discharge and then used to identify medications discontinued during hospitalization and incident medications started during this period. Results Of 124,051 older adults hospitalized for AMI, 9,607 (7.7%) were outpatient PIM users at admission, which increased to 8.6% at discharge (P

Rationale, aims and objectives The aim of this study was to examine the validity of the Health of the Nation Outcome Scales (HoNOS) in terms of change in relation to sex, clinical characteristics and level of clinical change as assessed using other measures. Methods The sample consisted of N = 690 admissions from one Swiss psychiatric hospital who were assessed at admission and discharge using the HoNOS and the clinical global impression (CGI) scale. Repeated measures analyses of variance were conducted to compare changes in HoNOS scores over time stratified by sex, diagnostic category and CGI level of change, controlled for age and previous hospitalizations. Two-way interactions between time and these factors were calculated and post hoc t-tests were conducted to compare changes in HoNOS scores between admission and discharge at factor levels. Results HoNOS scores significantly decreased from admission to discharge in bivariate analyses although no main effect of time was found in multivariate models. Sex was found to moderate change in HoNOS behavioural subscale scores; primary diagnosis at admission moderated change in HoNOS total scores, the behavioural subscale and the social subscale; and CGI level of change moderated the change in all HoNOS scales. Conclusions Our findings confirmed the sensitivity to change of the HoNOS in psychiatric settings from admission to discharge. Furthermore, we found that this change reflected similar changes in the CGI, a well-established measure for the evaluation of clinical outcomes, which, in turn supports the validity of the HoNOS.

Non-adherence to medication remains a major barrier to recovery from mental illnesses. Identification of those patients likely to experience adherence difficulties is best undertaken during inpatient treatment, prior to discharge into the community. More objective assessments of adherence behaviours might assist staff to more effectively target support to those patients most in need. This study investigated the interrater reliability of an inpatient behavioural observation scale of patient engagement with medication: the Observer Rating of Medication Taking (ORMT) scale. Eight mental health nurses working in a psychiatric hospital inpatient setting were trained in the use of the ORMT using video-based vignettes. Working in pairs, staff then independently rated adherence behaviours of 13 inpatients in a rehabilitation unit (total of 160 ratings) over a 1-week period. Concurrently, two expert raters also undertook independent ratings of patient medication-taking behaviour using the ORMT. Interrater reliability was assessed across both staff and expert raters. The results indicated that the ORMT has satisfactory interrater reliability, and can be appropriately used in an inpatient setting. The observational location of raters on the ward influenced the range of medication-taking behaviours observed, and thus the extent of concordance between raters. Further research to determine if the ORMT predicts adherence in the community is warranted.

The link between alliance and treatment outcome is robust. Nevertheless, few, if any, self-report measures exist to assess the alliance between hospitalized adolescents and their treatment team as a whole. The present study looks to extend the use of a brief self-report measure of inpatient treatment alliance designed for adult inpatients to be used with adolescents. The scale is designed incorporating items that tap the three factors of alliance (bond, goals and collaboration) to assess the alliance that the patient has with his or her treatment team. Our results show that the Inpatient-Treatment Alliance Scale is unifactoral, shows good psychometrics and is linked in theoretically meaningful ways to global clinician ratings of engagement in individual psychotherapy. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message Inpatient treatment of adolescents requires the assessment of alliance to be between the patient and his or her treatment team rather than an individual clinician. Assessment of the alliance can benefit clinicians treating hospitalized adolescents especially because these patients are difficult to engage with in treatment. This study shows that the Inpatient-Treatment Alliance Scale is a promising measure for assessing treatment alliance on an adolescent inpatient setting.

Objectives/Hypothesis To develop and assess the feasibility of a new standardized protocol to guide tracheostomy decannulation. Study Design Descriptive review of quality improvement project. Methods A quality improvement project was conducted in the inpatient setting of a tertiary urban academic hospital. Adult patients who had received a tracheostomy and for whom the indication for tracheostomy had resolved were included. A multidisciplinary task force reviewed input from clinicians caring for tracheostomy patients and developed a protocol for screening, capping, and decannulation. The primary outcome measured was successful decannulation. Results Fifty-seven patients were screened for a capping trial over a 12-month period; 54 were capped. Six patients were lost to follow-up. Fifty patients passed the capping trial, and all 50 were decannulated successfully. When decannulation was pursued in one patient who had twice failed the screening criteria and subsequent capping trials, the patient failed decannulation and ultimately required reintubation for the management of secretions. The screening tool had high sensitivity (90%) and positive predictive value (100%) for successful decannulation. Additionally, the number of reported patient safety concerns decreased from seven in the 6 months preceding implementation of the program to one report in the 6 months after implementation. Conclusion The new tracheostomy capping and decannulation protocol assisted in predicting both successful and failed decannulation. Although several patients failed certain capping criteria initially, the protocol stipulated modifications of care that enabled successful decannulation. The screening tool had high sensitivity and promoted communication, standardization of practice, and patient safety. Level of Evidence 2b. Laryngoscope, 124:1794–1800, 2014

Background and Objectives Errors in sample identification contribute to patient mismanagement and erroneous administration of blood and blood products. This report describes the rate of sample identification errors over 2 years in a multispecialty hospital in India and possible measures to decrease these errors. Materials and Methods Various measures were taken to reduce the risk of identification errors during sample collection, laboratory processing and administration of blood. The bedside blood grouping method by the slide agglutination technique was also introduced along with other measures in December 2011 as a risk mitigation step to prevent an ABO incompatible transfusion, as well as to provide a method of surveillance for possible errors during transfusion. Results The rate of sample identification errors was 48 and 45 per 1 000 000 among the total tests billed in 2011 and 2012, respectively. In the blood bank alone, the sample identification error rate was 0·96 in 2011 and 0·46 in 2012 per 1000 bags of blood and blood components issued after the various steps to prevent such errors in the blood bank were introduced. 81% of these errors (26 out of 32) have been reported in the inpatient setting. 15·6% (5 out of 32) were repeat errors made by the same technicians. Conclusions Among the various measures used to reduce sample identification errors, bedside blood grouping allows prevention of ABO incompatible transfusions when performed by trained technicians and may also be used as a method of active surveillance for sample identification errors in hospitals.