Single-bed wards: pros and cons

Single-bed wards are popular with patients, but hospital staff have concerns about visibility, surveillance, teamwork, monitoring and keeping patients safe in single rooms, a UK study finds. The researchers conducted a study of patient and staff experiences and safety outcomes around the 2011 opening of the first English NHS hospital to have 100% single inpatient rooms in all wards.
			Nurses felt ill-prepared for working on single-bed wards and had to adapt their working practices significantly, the study found. The move to single rooms also resulted in staff walking distances increasing

Popular with patients

Two-thirds of patients preferred single rooms with comfort, control, privacy, flexibility for visitors and en-suite bathrooms among the factors they liked. 

However, only 18% of staff indicated a preference for 100% single rooms, with most saying they would prefer a mix of single rooms and multi-bedded accommodation to allow them more panoptic surveillance of very sick and frail elderly patients in particular.

Nurses felt ill-prepared for working on single-bed wards and had to adapt their working practices significantly, the study found. The move to single rooms also resulted in staff walking distances increasing, according to findings in BMJ Quality and Safety.

A temporary increase in falls and medication errors found in one ward was likely to be associated with the need to adjust work patterns, rather than associated with single rooms per se, the authors said.

“Our findings suggest that a move to all single rooms may have significant implications for the nature of teamwork in the longer term, confirming evidence that suggests 100% single room facility-design made team communication and patient-monitoring difficult,and that it limited social interaction among staff,” the authors wrote.

Night work doesn’t compromise surgeons’ day procedures

Surgeons who provide medical care after midnight then go on to perform daytime elective procedures do not pose any additional risk to patients, a study shows.

The study covered almost 40,000 patients in Ontario, Canada, undergoing 12 different procedures performed by 1448 physicians across 147 academic and community hospitals.

Despite concerns that surgeons’ sleep loss might have an effect on patient outcomes, there was no significant difference in the primary outcomes of death, readmission or complications between patients who underwent a daytime procedure performed by a physician who had provided patient care after midnight compared with patients treated by the same physician but after a night when they had not performed any clinical work.

“The results were consistent across a wide range of procedures and physician characteristics and in academic and non-academic institutions,” the researchers wrote in the New England Journal of Medicine.

The authors suggested that the physicians working nights might self-regulate their practice the next day by cancelling surgeries or arranging for cover by colleagues if they felt too fatigued to perform surgery safely. 

“These data suggest that calls for broad-based policy shifts in duty hours and practices at attending surgeons may not be necessary at this time,” they wrote, although they added that the effect of profound sleep loss may warrant further study.

Longer shifts for nurses linked to dissatisfaction

Nurses who work shifts of 12 hours or longer have higher rates of burnout and job dissatisfaction and are more likely to plan to leave their job than those working shorter shifts, according to a study that shows longer shifts come at the expense of nurses’ psychological wellbeing.

The study involved a sample of 31,627 registered nurses in 488 hospitals across 12 European countries, including some countries such as England, Ireland and Poland, where it has become increasingly common for nurses to be rostered on for shifts of 12 hours or longer.

While the most common shift length was ≤8 hours, 31% of nurses worked shifts of 8.1‒10 hours, 4% worked 10.1 to ≤12 hours and 14% reported working from 12‒13 hours. More than a quarter of the nurses reported working overtime on their last shift.

Findings in BMJ Open showed that all shifts longer than eight hours appeared to be detrimental to nurses’ job satisfaction. Those nurses working shifts of 12 hours or more were more likely than those working shorter shifts (≤8 hours) to experience burnout in terms of emotional exhaustion, depersonalisation and low personal accomplishment. They were also more likely to experience job dissatisfaction, dissatisfaction with work schedule flexibility and to report intention to leave their job due to dissatisfaction.

“Employers should be aware of the multiple consequences of burnout, including higher risks of medical error, decreased quality of care, reduced wellbeing and economic loss through increased absenteeism and higher turnover rates,” they wrote.

Managers and nurses alike should question routine implementation of shifts longer than eight hours, the authors said.

Medication shortfalls common in elderly before hospitalisation

One in four older patients admitted to hospital have not had their medications managed appropriately in the community prior to their hospitalisation, according to an Australian study that calls for routine monitoring of medication-related clinical indicators in the elderly.

The study of 164,813 hospitalisations of veterans over a five year period (encompassing 83,430 patients) assessed patients’ medication-related care before they were hospitalised, as defined by a set of clinical indicators.

It found that 25.2% of hospitalisations were preceded by suboptimal medication–related processes of care, according to findings in the MJA. The conditions most likely to be preceded by inappropriate medication-related care were fracture and congestive heart failure.

Of patients admitted for fractures, 85% were aged over 65 years and had received a medicine which posed a falls-risk before admission, while 20% of men and 17% in women with fractures had a history of prior fracture or osteoporosis but had not received osteoporosis medication.

At least one in 10 hospitalisations for chronic heart failure, ischaemic stroke, asthma, gastrointestinal ulcer or bleeding, fracture, renal failure or nephropathy, hyperglycaemia or hypoglycaemia was preceded by inappropriate medication management, the study found.

The authors suggested that collaborative home medicine reviews involving the patient, pharmacist and GP could potentially identify and resolve some of the medication issues highlighted in the study.

They said the study also showed that administrative health databases were a useful tool for monitoring and improving health system performance, and suggested there should be routine prospective monitoring of evidence-based, medication–related clinical indictors to help improve the management of common conditions.

Delirium a predictor of poor outcomes

Researchers have called for routine monitoring of older emergency department (ED) patients to identify patients at high risk of delirium, after confirming the condition is associated with poorer outcomes in elderly patients. They assessed 260 patients daily for delirium for three days in a US hospital inpatient ward.
			It is remarkable that delirium status over such a short period of time can still be predictive of poor outcomes, the authors wrote

Many cases not recognised

Findings in BMJ Open showed that 15% of the patients (aged 65 amd older) were delirious at least once during the first three days of hospitalisations, and in nearly three-quarters of those patients, the condition persisted in ensuing days when the patients were moved to inpatient wards.

Delirium was not recognised in 52% of the ED patients.

Even one episode of delirium between ED and day three in hospital was associated with an increased risk for unanticipated ICU admission or in-hospital death, they found.

The study also found that persistent delirium during early hospitalisation was associated with a higher risk for decline in discharge status, even after adjusting for confounding factors.

“It is remarkable that delirium status over such a short period of time can still be predictive of poor outcomes,” the authors wrote.

They added: “These findings are important because they identify delirium status during early hospitalisation as a useful prognostic factor for poor short-term outcomes, highlighting the clinical importance of early detection and serial delirium screening in older adults."

Safety concerns over opioid patch use in aged care

Researchers have raised safety concerns about the use of opioid patches for managing residents’ pain in aged care homes, after finding that the patches are initiated inappropriately in a third of cases.

The study, which covered 60 aged care facilities in NSW, looked at the proportion of residents who had were not taking any opioid medication (or were opioid-naïve) in the four weeks prior to being started on an opioid transdermal patch to manage chronic, non-cancer pain.

Australian guidelines recommend a stepwise approach to treating such pain, with gradual increases in the potency and the dose of medications.

The authors said fentanyl patches were not recommended in opioid-naïve patients because of the risk of toxicity, including respiratory depression and overdose-related mortality.

The study found that an opioid patch was initiated in 596 of 5297 residents, with 2.6% of residents receiving fentanyl patches and 8.7% receiving buprenorphine patches.

The proportion of recipients who were opioid-naïve before patch initiation was 34% for fentanyl and 49% for buprenorphine, according to findings in the MJA.

Most patients were started on the lowest available patch strength, and the dose was increased if needed after initiation, as recommended, the study found

The authors said the findings suggested there was a degree of inappropriate initiation of opioid patches in Australian residential aged care.

They wrote: “Given the difficulties with the dose titration of transdermal buprenorphine patches and concerns about the safety of fentanyl in opioid-naïve patients, the use of transdermal preparations in older patients should be limited to opioid-tolerant patients with stable opioid requirements.”

Hip fracture: same outcome, big cost difference

Costs and the use of resources for treating hip fractures varies widely among Australian states, despite there being little difference in patients’ outcomes after one year, a study shows.

The study, covering the six states, found the adjusted total hospital cost of treating hip fracture, ranged from $24,792 in South Australia to $35,494 in Western Australia, with the mean cost across the six states being $31,208.

There were no significant differences in fracture incidence, patient demographics or fracture type among the states, but the adjusted total mean length of hospital stay ranged from 24.7 days (SA) to 35 days (WA). Rates of referral to rehabilitation ranged from 31.7% to 50.4%, with Victoria and NSW having the highest rates.

However, the findings, in Australian Health Review, showed that after one year, there were no differences among the states in key outcome determinants for patient mortality, or for the proportion of patients who retained their independent living status.

“These findings indicate a potential for substantial cost-efficiencies in hospital management of hip fractures without compromise in patient outcomes,” the authors wrote.

The study comes after a report released by the National Health Performance Authority earlier this year also found wide variations in the cost of treating hip fractures across hospitals. It found that in 2011‒12, the average cost of hip replacement without complications in a major public hospital was $19,400, but the average cost per admission ranged from $12,500 at one hospital to $25,600 at another hospital.

Meanwhile, a study of 690,995 French patients found that those who undergo surgery for a hip fracture have higher risks of mortality and of major complications than those who undergo an elective total hip replacement, even after adjusting for confounding factors like age and comorbidities.

The authors, writing in JAMA said more research was needed into the causes of the difference, but they suggested reducing the delay between a hip fracture and surgery may limit the excess risks.

Bariatric surgery effective for long-term diabetes control

Bariatric surgery is more effective than medical treatment for the long-term control of type 2 diabetes in obese patients, according to a study that suggests surgery should be considered among the treatment options for diabetes. 

While several studies had shown that bariatric surgery improved diabetes in the short-term, the Italian study involving 60 obese patients who received either medical treatment or bariatric surgery, was one of the first to follow up patients for a longer period of five years, the researchers said.

They found that both gastric bypass and biliopancreatic diversion surgery were more effective than standard medical treatment for the long-term control of hyperglycaemia and for patients’ overall metabolic profile.

More than half of the patients who had bariatric surgery were diabetes-free after five years, compared with none of the medically-treated patients, the study found.
Patients who underwent surgery also had a better quality of life than those treated medically, and had greater reductions in cardiovascular risk, diabetes-related complications and medication use, according to findings in The Lancet.

The authors said continued monitoring of glycaemic control was warranted in patients who underwent bariatric surgery, as some of those in the study did have a relapse of hyperglycaemia after two years in remission.

But they said the findings supported “consideration of surgery in the treatment algorithm of type 2 diabetes”.

Meanwhile, another study found that people who believed their weight was genetically determined did less exercise, made less healthy food choices and had poorer health than those who believed they could change their weight. The US study, in Health Education & Behaviour, suggested that by fighting the perception that weight is unchangeable, healthcare providers might be able to increase healthy behaviour among their patients.

Borderline pneumonia patients do better in ICU

Admitting older, low-risk or borderline patients with pneumonia to the ICU rather than treating them on general wards reduces their risk of dying, without increasing costs, according to a US study. The researchers said that pneumonia was a leading reason for hospitalisation, so it was important to understand the implications of delivering intensive care to such patients.
			Factors that may have influenced the reduced mortality rate included closer attention from nurses in ICU allowing for more timely recognition if a patient’s condition worsened and earlier, more aggressive care in the event of sepsis

Reduced mortality

They analysed data from a cohort of more than one million patients aged over 64 years with pneumonia who were admitted to almost 3000 hospitals in the US. Of those, 30% were admitted to ICU.

The decision to admit to the ICU was deemed discretionary in 13% of patients, as it depended only on how close they lived to a hospital with a high ICU admission rate.

The findings, published in JAMA, showed that the 30-day mortality rate among borderline patients was 14.8%, compared with 20.5% among patients admitted to general wards ‒ a 5.7% absolute decrease in mortality.

However, there were no significant differences in Medicare spending or hospital costs for those patients.

Factors that may have influenced the reduced mortality rate included closer attention from nurses in ICU allowing for more timely recognition if a patient’s condition worsened and earlier, more aggressive care in the event of sepsis, the authors hypothesised.

Patients in ICU may have been treated by pulmonary and critical care specialists, they suggested, and previous studies had suggested that ICU admission for pneumonia was associated with higher adherence to guideline-based treatment which was linked with improved mortality and reduced cost.

They suggested a randomised trial may be warranted to assess whether more liberal ICU admissions policies could improve mortality for older patients with pneumonia.

Study finds more aggressive blood pressure treatment saves lives

A major US trial of hypertension treatment has been stopped ahead of schedule, after it found more aggressive treatment of high blood pressure reduced rates of cardiovascular events such as heart attack, heart failure and stroke by almost a third and the risk of death by almost a quarter.

The US National Institutes of Health (NIH) announced that its Systolic Blood Pressure Intervention Trial (SPRINT) had been stopped earlier than originally planned in order to quickly disseminate the significant preliminary results.

The study, which began in 2009, included more than 9300 participants aged 50 and older across the US and Puerto Rico. It evaluated the benefits of maintaining a target of systolic pressure of less than 120 mm Hg, compared to the target systolic pressure of 140 mm Hg that was recommended for healthy adults in well-established clinical guidelines.

The study found that maintaining a systolic pressure of 120 mm Hg by using more intensive use of hypertension medication, could help save lives among adults aged 50 and older who had a combination of high blood pressure and at least one additional risk factor for heart disease.

The NIH said the full trial results would be published within the next few months.