Tertiary care hospitals

TeleStroke consultation can therefore be performed quickly. Its efficiency compares quite favorably to the management of patients in rural Ontario" who receive rt-PA after transfer from a rural hospital to a tertiary-care center (the so-called ship and drip model). The patients located in mral Ontario had a mean total time of 138 minutes between presentation at the rural facility and dmg delivery at the tertiary-care center. The door-to-bolus time at the community hospitals linked to our TeleStroke service was 106 minutes, only 36 minutes longer than that measured by the urban acute stroke service in Houston, which permitted a mean door-to-bolus time of 70 minutes. Whereas the door-to-consult time within a telemedicine system may decrease with training and practice, interfacility transfer times, such as those observed in Ontario, are not easily shortened. 

The main process (Fig. 1.1) for the care of a patient is normally the Primary care process (the patient handles their own drugs)—or the community care process (the patient gets help from community nurses at home or at a nursing home). All other processes such as hospital care (secondary/tertiary care) and the pharmacy process must support the main patient process. For improvement we must focus on patient safety and reduce drug-related problems. This means correct prescription and correct use (follow-up, documentation and communication) from the supportive process to the main process. 

Medication errors are costly to both the patient (direct costs such as additional treatment and increased hospital stay) and to society (indirect costs such as decreased employment, costs of litigation) [1,5]. The cost of medication errors in a 700-bed teaching hospital based on a study in eleven medical and surgical units in two hospitals over a six-month period, was estimated to be 2.8 million dollars annually [2]. The increased length of stay associated with a medication error was estimated to be 4.6 days [2]. In a four-year study of the eosts of adverse drug events (ADEs) in a tertiary care center, 1% of these events were elassified as medication errors. The excess hospital costs for ADEs over the study period were almost 4,500,000 with almost 4,000 days of increased hospital stay [12]. 

In a prospective, observational cohort study in a tertiary-care hospital, there were abnormal serum TSH concentrations in 26 of 42 patients) who took sunitinib for renal cell carcinoma or GIST. Persistent primary hypothyroidism, isolated TSH suppression, and transient mild rises in TSH were found in 36%, 10%, and 17% of patients respectively. There appears to be a correlation between the duration of use of sunitinib and suppressed TSH concentrations as well as a risk of hypothyroidism. Whether sunitinib induces destructive thyroiditis through follicular cell apoptosis has not been fully elucidated (1078,1079,1080). 

The director of pharmacy uses an expense report prepared on a monthly or weekly basis. In this report, all pharmacy department expenses are categorized into at least five major sections. Each expense is also given a unique code so that not only the pharmacy department but also the hospitals central accounting office can access and monitor expenses. The expense report indicates the amount budgeted for each expense, the actual expense incurred, the variance between budgeted and incurred expenses, and the variance percentage. Table 15-10 shows an abbreviated, simplified expense report for the pharmacy department of a large tertiary-care hospital. 

Laboratory investigations play an essential role in medicine. Laboratory results are taken into consideration in about two thirds of all medical decisions in medical systems of industrialized countries today. The vast majority of clinical chemistry analyses are based on few analytical principles including photometry, ligand binding assays and potentiometry. For these standard methods complete automation has been achieved and multi-channel, random access analyzers realize several hundred analyses per instrument and hour on a very high level of user-friendliness. Consequently, clinical chemistry is very cost efficient today typically clinical chemistry analyses contribute less than 5 % of all costs of tertiary care hospitals. 

A third variety, so-called delayed-onset heparin-induced thrombocytopenia has also been described in several reports. In 12 patients, recruited from secondary and tertiary care hospitals, thrombocytopenia and associated thrombosis occurred at a mean of 9.2 (range 5-19) days after the withdrawal of heparin nine received additional heparin, with further falls in platelet counts (32). In a retrospective case series, 14 patients, seen over a 3-year period, developed thromboembolic complications a median of 14 days after treatment with heparin (33). The emboli were venous (n — 10), or arterial (n — 2), or both (n — 2) of the 12 patients with venous embolism, 7 had pulmonary embolism. Platelet counts were mildly reduced in all but two patients at the time of the second presentation. On readmission, 11 patients received therapeutic heparin, which worsened their clinical condition and further reduced the platelet count. 

OPTIME-CHF (5) was a randomized, placebo-controlled study in which 951 patients (mean age 65 years 92% with baseUne NYHA class III or IV mean left ventricular ejection fraction 23%) with acute exacerbations of chronic heart failure in 78 community and tertiary care hospitals in the USA were randomly assigned to a 48-hour infusion of either milrinone (0.5 micrograms/kg/minute initially for 24 hours) or saline (6). The median number of days in hospital for cardiovascular causes within 60 days after randomization did not differ significantly between patients given milrinone (6 days) or placebo (7 days). Sustained hypotension requiring intervention (11 versus 3.2%) and new atrial dysrhythmias (4.6 versus 1.5%) were more common in the patients who received milrinone. There was no difference in hospital mortality (3.8 versus 2.3%), 60-day mortality (10 versus 8.9%), or the composite incidence of death or readmission (35 versus 35%). The authors concluded that these results do not support the routine use of intravenous milrinone as an adjunct to standard therapy in patients with an exacerbation of chronic heart failure. 

Gelone, S.P. Lorber, B. St. John, K. Badelino, M. Axelrod, P. Criner, G. Prospective evaluation of antibiotic rotation on three intensive care units at a tertiary care university hospital. Pharmacotherapy 2000, 20, abstract 107. 

Boyko, W.L. Yurkowski, P.J. Ivey, M.F., et al. Pharmacist influence on economic and morbidity outcomes in a tertiary care teaching hospital. Am. J. Health-Syst. Pharm. 1997, 54, 1591-1595. 

Fraser VJ, Jones M, Dunkel J, etal. Candidemia in a tertiary care hospital Epidemiology, risk factors, and predictors of mortahty. Chn Infect Dis 1992 15 414-421. 

Herout and Erstad, 2004 (USA) 1 month Tertiary care teaching hospital - SICU 206 infusions involving 71 patients Observations recorded on a daily basis 105.9 per 1000 patient-days... 

Due to concern of the recent changes to the status of the infant, additional labs including a metabolic panel and plasma ammonia are recommended immediately. These labs show the baby is extremely acidotic as well as hyperammonemic. The infant is airlifted to a children s hospital for tertiary care by the metabolic team. However, due to the extent of the acidosis and hyperammonemia as well as the prematurity, care is terminated. 

Camilla, a newborn female, was delivered in a forceps-assisted vaginal delivery after a normal pregnancy. The infant did well for the first 3 days of life, but began showing seizure-like activity. A CT scan showed a small trauma from the forceps-assisted birth including a small bleed and skull fracture. Laboratory studies obtained showed mild metabolic acidosis and mild hyperammonemia. The infant was transferred to the children s hospital for further tertiary care. Repeat plasma ammonia showed increasing hyperammonemia. 

Oei TT, Dulai GS, Gralnek IM, et al. (2002) Hospital care for low-risk patients with acute, nonvariceal upper GI hemorrhage a comparison of neighboring community and tertiary care centers. Am J Gastroenterol 97 2271-2278... 

Observational studies Neonatal exposure to benzyl alcohol and propylene glycol, pharmaceutical excipients present in parenteral medications, has been studied retrospectively in a neonatal and pediatric intensive unit in a tertiary care university hospital [8 ]. In 170 randomly selected episodes of exposure to parenteral medications containing benzyl alcohol ( = 88) or propylene glycol ( = 82), there were a wide range of cumulative doses of the excipients. The median cumulative dose was 4.5 mg/kg/day for benzyl alcohol and 205 mg/kg/day for... 

VNHE)—a study from tertiary care referral university hospital, north India. J Pak Med Assoc 2008 58(11) 627-31. 

Bruce D, Nokes TJ. Prothrombin complex concentrate (Beriplex P/N) in severe bleeding experience in a large tertiary hospital. Crit Care 2008 12(4) R105. 

Jose J, Rao PG, Kamath MS, Jimmy B. Drug safety reports on complementary and alternative medicines (ayurvedic and homeopathic medicines) by a spontaneous reporting program in a tertiary care hospital J Altern Complement Med 2009 15 (7) 793-7. 

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