RESUMEN
INTRODUCTION: Prolonged emergency department boarding times (EDBT) are associated with adverse clinical outcomes and longer hospital stays. A rapid admission protocol was designed at our institution to reduce both EDBT and time to admission orders (EDTAO) for patients admitted to the internal medicine service. METHODS: The existing admission process was examined by a team of clinical and administrative leaders who focused on developing a change management architecture, narrowing clinical roles, mandating direct communication, establishing clear boundaries for patient responsibility and instituting carefully constructed holding orders. The number of steps in the admission process was reduced from 50 to 10. We collected EDBT and EDTAO for all patients admitted to the internal medicine service before and after intervention using a simple interrupted time-series design. RESULTS: The study involved a total of 9604 admissions to one of three inpatient destinations (general medicine ward, telemetry or intensive care unit). The overall EDBT decreased from 360 min in the preintervention period to 270 min in phase 4 (p<0.001). The overall time to admission orders decreased from 210 min in the preintervention period to 75 min in phase 4 (p<0.001) overall. However, no improvements were noted in EDBT for telemetry or ICU patients. CONCLUSIONS: Institution of a rapid admission protocol successfully reduced overall EDBT at our institution, although few gains were noted for patients with a telemetry or ICU destination. In total, the intervention saved 27 884 h, or 1161 emergency department patient-days, over the course of a single year.
Asunto(s)
Protocolos Clínicos , Servicio de Urgencia en Hospital/organización & administración , Innovación Organizacional , Admisión del Paciente/normas , Citas y Horarios , Eficiencia Organizacional , Hospitales Públicos , Humanos , Medicina Interna , Grupo de Atención al Paciente , Evaluación de Procesos, Atención de Salud/métodos , Texas , Factores de TiempoAsunto(s)
Acetonitrilos/envenenamiento , Cosméticos/envenenamiento , Cianuros/envenenamiento , Acetonitrilos/análisis , Adulto , Animales , Preescolar , Cosméticos/análisis , Femenino , Humanos , Masculino , Ratones , Uñas , SolventesRESUMEN
Breath measurement of carbon monoxide (CO) can be rapidly performed in the emergency department setting by a reliable method that closely approximates carboxyhemoglobin. This method is helpful in the immediate determination of CO exposure for individual patients, but could serve as a valuable triage aid when large groups of patients are suspected of CO exposure. Serial CO determinations can be obtained during oxygen treatment to monitor for improvements without painful needle punctures and needless consumption of professional time and expense.
Asunto(s)
Pruebas Respiratorias , Intoxicación por Monóxido de Carbono/diagnóstico , Carboxihemoglobina/análisis , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , TexasAsunto(s)
Política de Salud/legislación & jurisprudencia , Hospitales Públicos/economía , Transferencia de Pacientes/legislación & jurisprudencia , Servicio de Urgencia en Hospital/normas , Hospitales con más de 500 Camas , Indigencia Médica , Evaluación de Procesos y Resultados en Atención de Salud , Formulación de Políticas , TexasAsunto(s)
Hipertensión/tratamiento farmacológico , Agonistas alfa-Adrenérgicos/uso terapéutico , Antagonistas Adrenérgicos alfa/uso terapéutico , Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina , Captopril/uso terapéutico , Sistema Nervioso Central/efectos de los fármacos , Clonidina/uso terapéutico , Diuréticos/uso terapéutico , Ganglios/efectos de los fármacos , Guanetidina/uso terapéutico , Humanos , Hipertensión/fisiopatología , Labetalol/uso terapéutico , Minoxidil/uso terapéutico , Cooperación del Paciente , Prazosina/uso terapéutico , Simpaticolíticos/uso terapéutico , Vasodilatadores/uso terapéuticoRESUMEN
The changes that occur in the cerebral circulation with chronic hypertension are important when considering the therapeutic possibilities in treating patients with severe hypertension. Care must be taken not to lower the blood pressure below the lower limit of autoregulation, no matter what drug is used. In patients with severe, chronic hypertension, blood pressure should be lowered carefully. Rapid blood pressure reduction to a level that is below the lower limit of autoregulation may result in central nervous system dysfunction due to cerebral hypoperfusion. This is especially true in patients with increased intracranial pressure and cerebral edema such as those with hypertensive encephalopathy.
Asunto(s)
Presión Sanguínea , Circulación Cerebrovascular , Animales , Antihipertensivos/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Circulación Cerebrovascular/efectos de los fármacos , Homeostasis , Humanos , Hipertensión/tratamiento farmacológico , Hipertensión/fisiopatologíaRESUMEN
The response to oral clonidine hydrochloride loading in 36 severely hypertensive patients is presented. Each patient initially received 0.2 mg of clonidine hydrochloride, followed by 0.1 mg each hour until a dose of 0.7 mg had been given, or the diastolic blood pressure (BP) reached a predetermined goal (110 mm Hg or total fall of at least 20 mm Hg). Only two patients (6%) failed to reach this goal. Supine BP in the group fell from 212 +/- 22 (SD)/139 +/- 11 (SD) mm Hg to 151 +/- 21 (SD) mm Hg at six hours. The average dose of clonidine required was 0.45 mg and control was maximized at five hours. The response to oral clonidine loading in the individual patient was not predictive of the eventual dose of clonidine necessary to achieve acceptable BP control at two weeks. Oral clonidine loading is safe and effective in the management of "hypertensive urgencies" and offers several advantages over parenteral antihypertensive agents in this clinical situation.
Asunto(s)
Presión Sanguínea/efectos de los fármacos , Clonidina/administración & dosificación , Urgencias Médicas , Hipertensión/tratamiento farmacológico , Administración Oral , Adulto , Clonidina/farmacología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Postura , Factores de TiempoRESUMEN
A case of herpes gastritis is presented. This complication is being described more frequently in the gastrointestinal tract and can be best diagnosed by endoscopic appearance and examination of brush specimens by cytology.
Asunto(s)
Gastritis/etiología , Herpes Simple/complicaciones , Femenino , Gastritis/diagnóstico , Gastritis/patología , Herpes Simple/diagnóstico , Herpes Simple/patología , Humanos , Persona de Mediana EdadRESUMEN
A three-stage approach to carcinoma of the bladder consists of preliminary urinary diversion, radiation therapy, and simple total cystectomy. We have used this method for more than ten years. The survival rates are the same as generally published, and the morbidity and mortality contrast favorably with other reports. To date no patient has died within two months of completion of the course of therapy.