Janis E. Bozzo

Proactive Psychiatric Consultation Services Reduce Length of Stay for Admissions to an Inpatient Medical Team

BACKGROUND Some studies suggest intensive psychiatric consultation services facilitate medical care and reduce length of stay (LOS) in general hospitals. OBJECTIVE To compare LOS between a consultation-as-usual model and a proactive consultation model involving review of all admissions, rapid consultation, and close follow-up. METHODS LOS was compared in an ABA design between a 33-day intervention period and 10 similar control periods, 5 before and 5 after the intervention, on an internal medical unit. During the intervention period, a staff psychiatrist met with the medical team each weekday, reviewed all admissions, provided immediate consultation as needed, and followed all cases throughout their hospital stay. RESULTS Time required for initial case review was brief, 2.9 ± 2.2 minutes per patient (mean ± S.D.). Over 50% of admissions had mental health needs: 20.3% were estimated to require specialist consultation to avoid potential delay of discharge. The consultation rate for the intervention sample was 22.6%, significantly greater than in the control sample, 10.7%. Mean LOS was significantly shorter in the intervention sample, 2.90 ± 2.12 versus 3.82 ± 3.30 days, and the fraction of cases with LOS > 4 days was significantly lower, 14.5% versus 27.9%. A rough cost benefit analysis was favorable with at least a 4.2 ratio of financial benefit to cost. CONCLUSIONS Psychiatric review of all admissions is feasible, indicates a high incidence of mental health barriers to discharge, identifies more necessary consultations than typically requested, and results in earlier consultation. A proactive consultation model can reduce hospital LOS.

Multidisciplinary Proactive Psychiatric Consultation Service: Impact on Length of Stay for Medical Inpatients

Background: Mental illness correlates with an increased length of stay (LOS) for patients hospitalized for medical conditions. While psychiatric consultations help manage mental illness among those hospitalized for medical conditions, consultations initiated by nonpsychiatric mental disease may lack maximum effectiveness. Methods: In a before-and-after design, in 2 contiguous years LOS for internist-initiated, conventional consultation (CC) as usual treatment was compared to LOS of a proactive, mental health professional-initiated, multidisciplinary intervention delivered by the behavioral intervention team (BIT) on the same units. The patient populations included general medical patients with a variety of illnesses. Patients were treated in 3 different inpatient settings with a total capacity of 92 beds serving 15,858 patient visits over 3 comparison years. BIT comprised a psychiatrist, a nurse, and a social worker, each of whom performed the specific tasks of their professional discipline, while collaborating among themselves and their health-care colleagues. BIT provided timely, appropriate, and effective patient care alongside consultative advice and education to their corresponding professional peers. BIT was compared to CC on the outcome of LOS. Results: There was a statistically significant reduction of LOS favoring BIT over CC for patients with an LOS of <31 days which persisted while controlling for multiple co-morbid factors. Also, a statistically significant spillover effect was suggested by the overall improvement of LOS on units implementing BIT. Conclusion: BIT is a promising means of lowering LOS on general medical units while providing a high level of care and staff support.

Evaluating Inpatient Glycemic Management: The Quality Hyperglycemia Score

BACKGROUND Inpatient hyperglycemia has become a major focus at many hospitals. However, although several professional organizations have pushed for improved inpatient glucose management, glycemic control at many institutions remains suboptimal. There is a general consensus that improved quality of care is needed, but objective assessment of care quality remains a challenge. Lack of clear, effective performance feedback to clinicians is one element that may derail efforts to improve practice. METHODS We developed a simplified grading system, the Quality Hyperglycemia Score (QHS), to allow clinicians and managers to easily review and compare glycemic management on adult medical-surgical and intensive care units over the prior 3 months and to more fully engage patient care teams in quality improvement. RESULTS The QHS represents a single value from 0 to 100, incorporating elements of glycemic management influenced by all team members. The scoring system rewards the maintenance of blood glucose levels in or near the normal range and adherence to the hospital policy on the use of bedside glucose meters, but penalizes frequent hypoglycemic episodes and severe hyperglycemic excursions. Each element is weighted independently and summed to produce the QHS. Scores then correspond to a color code highlighting each units performance level. CONCLUSIONS To date, the QHS reflects the spectrum of blood glucose management at our hospital. While refinement and internal and external validation with clinical outcomes are planned, we propose the QHS as a standardized, objective measure of the quality of inpatient glycemic management.

Using the Glucometrics Website to Benchmark ICU Glucose Control Before and After the NICE-SUGAR Study

Background: Prior to 2009, intensive glycemic control was the standard in main intensive care units (ICUs). Glucose targets have been recalibrated after publication of the NICE-SUGAR study in that year, followed by updated guidelines that endorsed more moderated control. We sought to determine if the prevalence of hyperglycemia in US ICUs had increased after the NICE-SUGAR study’s results were reported. Methods: We used data from hospitals submitted to the Yale Glucometrics™ website to assess mean blood glucose values, percentage of blood glucose within various ranges, and the prevalence of hypo- and hyperglycemic excursions, based on the patient-day method, comparing the pre- to post-NICE-SUGAR time period. Results: Among more than a total of 2 million blood glucose determinations, comprising 408 790 patient-days, median patient-day blood glucose decreased from 144 mg/dL to 141 mg/dL (P < .001) in the pre- versus post-NICE-SUGAR time period. The percentage of patient days with a mean blood glucose of 110-179 mg/dl increased from 58.3 to 63.6%. The percentage of patient-days with either hypoglycemia (<70 mg/dl) or severe hyperglycemia (≥300 mg/dl) decreased during this time. Conclusions: Our results suggest that glycemic control in US ICUs has improved when comparing time periods before versus after publication of the NICE-SUGAR study. We found no evidence that fewer hypoglycemic events were achieved at the expense of more hyperglycemia.

Marijuana Use in Adults Living with Sickle Cell Disease

Abstract Introduction: Legal access to marijuana, most frequently as “medical marijuana,” is becoming more common in the United States, but most states do not specify sickle cell disease as a qualifying condition. We were aware that some of our patients living with sickle cell disease used illicit marijuana, and we sought more information about this. Materials and Methods: We practice at an urban, academic medical center and provide primary, secondary, and tertiary care for ∼130 adults living with sickle cell disease. We surveyed our patients with a brief, anonymous, paper-and-pen instrument. We reviewed institutional records for clinically driven urine drug testing. We tracked patient requests for certification for medical marijuana. Results: Among 58 patients surveyed, 42% reported marijuana use within the past 2 years. Among users, most endorsed five medicinal indications; a minority reported recreational use. Among 57 patients who had at least one urine drug test, 18% tested positive for cannabinoids only, 12% tested positive for cocaine and/or phencyclidine only, and 5% tested positive for both cannabinoids and cocaine/phencyclidine. Subsequent to these studies, sickle cell disease became a qualifying condition for medical marijuana in our state. In the interval ∼1.5 years, 44 patients have requested certification. Conclusion: Our findings and those of others create a rationale for research into the possible therapeutic effects of marijuana or cannabinoids, the presumed active constituents of marijuana, in sickle cell disease. Explicit inclusion of sickle cell disease as a qualifying condition for medical marijuana might reduce illicit marijuana use and related risks and costs to both persons living with sickle cell disease and society.

Association of inpatient and outpatient glucose management with inpatient mortality among patients with and without diabetes at a major academic medical center

BACKGROUND Hospitalized patients with diabetes have experienced a disproportionate reduction in mortality over the past decade. OBJECTIVE To examine whether this differential decrease affected all patients with diabetes, and to identify explanatory factors. DESIGN Serial, cross-sectional observational study. SETTING Academic medical center. PATIENTS All adult, nonobstetric patients with an inpatient discharge between January 1, 2000 and December 31, 2010. MEASUREMENT We assessed in-hospital mortality; inpatient glycemic control (percentage of hospital days with glucose below 70, above 299, and between 70 and 179 mg/dL, and standard deviation of glucose measurements), and outpatient glycemic control (hemoglobin A1c). RESULTS We analyzed 322,938 admissions, including 76,758 (23.8%) with diabetes. Among 54,645 intensive care unit (ICU) admissions, there was a 7.8% relative reduction in the odds of mortality in each successive year for patients with diabetes, adjusted for age, race, payer, length of stay, discharge diagnosis, comorbidities, and service (odds ratio [OR]: 0.923, 95% confidence interval [CI]: 0.906-0.940). This was significantly greater than the 2.6% yearly reduction for those without diabetes (OR: 0.974, 95% CI: 0.963-0.985; P < 0.001 for interaction). In contrast, the greater decrease in mortality among non-ICU patients with diabetes did not reach significance. Results were similar among medical and surgical patients. Among ICU patients with diabetes, the significant decline in mortality persisted after adjustment for inpatient and outpatient glucose control (OR: 0.953, 95% CI: 0.914-0.994). CONCLUSIONS Patients with diabetes in the ICU have experienced a disproportionate reduction in mortality that is not explained by glucose control. Potential explanations include improved cardiovascular risk management or advances in therapies for diseases commonly affecting patients with diabetes.

Front & Back Matter

Abstracts should be no longer than 250 words for regular articles, and no longer than 150 words for clinical notes. They should include the following information: Background: the problem that prompted the study and the purpose of the study; Methods: data sources, subjects, design, measurements, data analysis; Results: most important findings; Conclusions: implications, future directions. Abstracts for Special Articles do not need to be structured. Editorials, Case Management articles and Letters to the Editor should not have an abstract. Footnotes: Avoid footnotes. When essential, they are numbered consecutively and typed at the foot of the appropriate page. Tables and illustrations: Tables and illustrations (both numbered in Arabic numerals) should be prepared on separate sheets. Tables require a heading and figures a legend, also prepared on a separate sheet. For the reproduction of illustrations, only good drawings and original photographs can be accepted; negatives or photocopies cannot be used. Due to technical reasons, figures with a screen background should not be submitted. When possible, group several illustrations on one block for reproduction (max. size 180  223 mm) or provide crop marks. On the back of each illustration, indicate its number, the author’s name, and ‘top’ with a soft pencil. Electronically submitted b/w half-tone and color illustrations must have a final resolution of 300 dpi after scaling, line drawings one of 800–1,200 dpi. Color illustrations Online edition: Color illustrations are reproduced free of charge. In the print version, the illustrations are reproduced in black and white. Please avoid referring to the colors in the text and figure legends. Print edition: Up to 6 color illustrations per page can be integrated within the text at CHF 800.– per page. Data analysis: Adequate description of statistical analysis should be provided, including the types of statistical tests and whether they were oneor two-tailed. Standard deviations, instead of standard errors of the mean, are preferred. All significant results must include the test value, degree(s) of freedom, and probability level. References: In the text identify references by Arabic numerals [in square brackets]. Material submitted for publication but not yet accepted should be noted as [unpublished data] and not be included in the reference list. The list of references should include only those publications which are cited in the text. Do not alphabetize; number references in the order in which they are first mentioned in the text. The surnames of the authors followed by initials should be given. There should be no punctuation other than a comma to separate the authors. Preferably, please cite all authors. Abbreviate journal names according to the Index Medicus system. Also see International Committee of Medical Journal Editors: Uniform requirements for manuscripts submitted to biomedical journals (www.icmje.org). Examples (a) Papers published in periodicals: Sun J, Koto H, Chung KF: Interaction of ozone and allergen challenges on bronchial responsiveness and inflammation in sensitised guinea pigs. Int Arch Allergy Immunol 1997;112:191–195. (b) Papers published only with DOI numbers: Theoharides TC, Boucher W, Spear K: Serum interleukin-6 reflects disease severity and osteoporosis in mastocytosis patients. Int Arch Allergy Immunol DOI: 10.1159/000063858. (c) Monographs: Matthews DE, Farewell VT: Using and Understanding Medical Statistics, ed 3, revised. Basel, Karger, 1996. (d) Edited books: Parren PWHI, Burton DR: Antibodies against HIV-1 from phage display libraries: Mapping of an immune response and progress towards antiviral immunotherapy; in Capra JD (ed): Antibody Engineering. Chem Immunol. Basel, Kar ger, 1997, vol 65, pp 18–56. Reference Management Software: Use of EndNote is recommended for easy management and formatting of citations and reference lists. Digital Object Identifier (DOI) S. Karger Publishers supports DOIs as unique identifiers for articles. A DOI number will be printed on the title page of each article. DOIs can be useful in the future for identifying and citing articles published online without volume or issue information. More information can be found at www.doi.org. Supplementary Material Supplementary material is restricted to additional data that are not necessary for the scientific integrity and conclusions of the paper. Please note that all supplementary files will undergo editorial review and should be submitted together with the original manuscript. The Editors reserve the right to limit the scope and length of the supplementary material. Supplementary material must meet production quality standards for Web publication without the need for any modification or editing. In general, supplementary files should not exceed 10 Mb in size. All figures and tables should have titles and legends and all files should be supplied separately and named clearly. Acceptable files and formats are: Word or PDF files, Excel spreadsheets (only if the data cannot be converted properly to a PDF file), and video files (.mov, .avi, .mpeg). Author’s ChoiceTM Karger’s Author’s ChoiceTM service broadens the reach of your article and gives all users worldwide free and full access for reading, downloading and printing at www. Karger.com. The option is available for a one-time fee of CHF 3,000.–, which is a permissible cost in grant allocation. More information can be found at www.karger.com/ authors_choice. NIH-Funded Research The U.S. National Institutes of Health (NIH) mandates under the NIH Public Access Policy that final, peer-reviewed manuscripts appear in its digital database within 12 months of the official publication date. As a service to authors, Karger submits the final version of your article on your behalf to PubMed Central. For those selecting our premium Author’s ChoiceTM service, we will send your article immediately upon publishing, accelerating the accessibility of your work without the usual embargo. More details on NIH’s Public Access Policy is available at http://publicaccess.nih.gov/policy.htm Self-Archiving Karger permits authors to archive their pre-prints (i.e. prerefereeing) or post-prints (i.e. final draft post-refereeing) on their personal or institution’s servers, provided the following conditions are met: Articles may not be used for commercial purposes, must be linked to the publisher’s version, and must acknowledge the publisher’s copyright. Authors selecting Karger’s Author’s ChoiceTM feature, however, are also permitted to archive the final, published version of their article, which includes copyediting and design improvements as well as citation links. Page Limitations and Charges There are no page charges for papers of 7 or fewer printed pages (including tables, illustrations and references). Each additional complete or partial page is charged to the author at CHF 325.–. The allotted size of a paper is equal to approx. 18 manuscript pages (including tables, illustrations and references). Letters commenting on published articles should not exceed 500 words of text plus references. Research letters should not exceed 1,000 words of text plus a maximum of 10 references. They may have only one table or figure. Proofs Unless indicated otherwise, proofs are sent to the corresponding author and should be returned with the least possible delay. Alterations other than the correction of printer’s errors are charged to the author. Reprints Order forms and a price list are sent with the proofs. Orders submitted after the issue is printed are subject to considerably higher prices.