In-hospital care

Since the introduction of parenteral nutrition in hospital care the potential microbiological risks associated with the manufacture, preparation, and administration of these products have abated but not disappeared (133,152). Fatal infectious complications still occur. The parenteral nutrition mixture is a good growth medium for microorganisms, more conducive to microbial growth than glucose or amino acid solutions. Storage of mixtures... 

Leape, drawing on the psychology of error and human performance, rejected this formulation on several counts. Many errors are often beyond the individual s conscious control they are precipitated by a wide range of factors, which are often also beyond the individual s control systems that rely on error-free performance are doomed to failure, as are reactive attempts to error prevention that rely on discipline and training. He went on to argue that if physicians, nurses, pharmacists and administrators were to succeed in reducing errors in hospital care, they would need to fundamentally change the way they think about errors (Leape, 1994). 

Fagerhaugh, S. Y, Hazards in Hospital Care Ensuring Patient Safety, Jossey-Bass, San Francisco, 1987. 

Employee Returned to Work Sent Home In Hospital Care ... 

Infectious patients present a difficult challenge when trying to protect health care workers. These patients must be isolated from the health care workers as well as from the other patients in the hospital. Special isolation rooms are used for this purpose. These rooms are generally used for isolation of infectious tuberculosis (TB) patients, but could be used for patients with other airborne-transmitted diseases. In the United States, there were 22 812 new cases of tuberculosis in 1993, equal to 8.7 per 100 000 population. This represents a 2.8% increase since 1985, following a 6-7% annual decline from 1981-1984.Several studies have documented higher than expected tuberculin skin test (TST) conversion rates in hospital personnel.The National Institute for Occupational Safety and Health " reports that multiple-drug-resistant (MDR) strains of TB have been reported in 40 states and have caused outbreaks in at least 21 hospitals, with 18-35% of exposed workers having documented TST conversions. 

The population, in teniis of nmnbers, density, and types of individuals (e.g., facility employees neighborhood residents people in hospitals, schools, nursing homes, prisons, day care centers) Uiat could be witliin a vulnerable zone tlie private and public property (e.g., critical facilities, homes, schools, hospitals, businesses, offices) that may be damaged, including essential support... 

The patient is monitored carefully vital signs are taken frequentiy, and die patient is placed on a cardiac monitor while the drug is being titrated to a therapeutic dose The dosage may be increased more rapidly in hospitalized patients under close supervision. 

In all countries with developed medical care, X-ray contrast media can be expected to be present at appreciable quantities in sewage water. Clara et al [13] detected iopromide at a mean concentration of 3.84 pg in the influent of a WWTP receiving hospital wastewater, while in WWTPs without a hospital within their drainage area this contrast media was not present. lodinated X-ray contrast media are proved to contribute significantly to total absorbable organic iodine in clinical wastewaters up to 130 pg of iodine in the influent of municipal WWTP in Berlin and 10 mg in hospital sewage was detected [23]. 

Bozette et al. (2001) examined expenditures for the care of adult HIV-infected patients since the introduction of highly active antiretroviral therapy. They interviewed a representative random sample of 2,864 patients in early 1996 and followed them for up to 36 months. They estimated the average expenditure per patient per month on the basis of self-reported information. According to their calculations, the mean expenditure was US 1,792 per patient per month at base hne in early 1996, but it decbned to US 1,359 for survivors in 1997, since the increases in pharmaceutical expenditures were smaller than the reductions in hospital costs. After adjustments for the interview date, clinical status, and deaths, the estimated annual expenditure declined from US 20,300 per patient (1996) to US 18,300 (1998). 

Comparisons between Enropean stndies are also difficult. Tolley and Gyldmark (1993) reviewed costs of treatment, care, and support for HIV-positive and AIDS patients in eleven Enropean conntries, which were based on data from the second half of the eighties. The anthors inflated cost fignres to 1990 prices and converted them from local currency to US by using national healthcare-specific price indices and health-specific purchasing power parities. The standardized cost estimates ranged between US 1,700 (social care per HIV-positive) and US 28,200 (hospital care per AIDS person-year), with the exception of a Greek study, which produced an adjusted cost estimate for the hospital treatment and care of AIDS patients of US 70,400 per person-year. 

Uncontrolled mirror-image studies (Table 2.4) largely support these findings. Of seven published studies, five suggested that the use of risperidone reduced hospital bed-stay and some calculated savings in health-care expenditure resulting from this. Conversely, Viale et al (1997) calculated that in-patient savings were offset by increases in community services costs, and Hammond et al (1999) estimated a substantial overall cost increase for community patients switched to risperidone for at least 3 months. 

The most common reason for lack of rt-PA use in otherwise eligible patients remains, however, delay in presentation to the hospital. The California Acute Stroke Pilot Registry (CASPR) investigators examined the effect of various hypothetical interventions on the rate of rt-PA use. Their data suggested that if all patients with a known time of onset presented to medical attention immediately, the expected overall rate of thrombolytic treatment within 3 hours would have increased from 4.3% to 28.6%. By comparison, the expected rate of treatment that would result from instantaneous prehospital response was 5.5%, from perfect hospital care was 11.5%, and from extension of time window to 6 hours was 8.3%. 

Following their hospitalization, all infants were placed with foster parents or in the care of extended-family members. Four infants were discharged to relatives and eight infants were placed in foster care. Later, two of the foster children were also... 

Intravenous or oral doses of a P-blocker should be administered early in the care of a patient with STE ACS, and then oral agents should be continued indefinitely. Early administration of a P-blocker to patients lacking a contraindication within the first 24 hours of hospitalization is a quality care indicator.2,3 In ACS the benefit of P-blockers mainly results from the competitive blockade of P,-adrenergic receptors located on the myocardium. Pi-Blockade produces a reduction in heart rate, myocardial contractility, and blood pressure, decreasing myocardial oxygen demand. As a result of these effects, P-blockers reduce the risk for recurrent ischemia, increase in infarct size and risk of reinfarction, and occurrence of ventricular arrhythmias in the hours and days following MI.39... 

Despite the growing emphasis on pain management, pain often remains undertreated and continues to be a problem in hospitals, long-term care facilities, and the community. In one series of reports, 50% of seriously ill hospitalized patients reported pain however, 15% were dissatisfied with pain control, and some remained in pain after hospitalization.14,15... 

For approximately 20% to 30% of people with schizophrenia, drug treatment is ineffective. A standard definition of treatment resistance includes patients who have persistent positive symptoms despite treatment with at least two different antipsychotics given at adequate doses (at least 600 chlorpro-mazine equivalents) for an adequate duration (4 to 6 weeks). In addition, patients must have a moderately severe illness as defined by rating instruments, and have a persistence of illness for at least 5 years.40 These patients are often highly symptomatic and require extensive periods of hospital care. 

Pressures sores, also known as decubitous ulcers or bedsores, affect 1.5 to 3 million Americans annually.35 The cost of healing pressure sores can be substantial, with current estimates ranging from 2000 to 70,000 per wound.35 Although the prevalence of pressure sores is highest in long-term care facilities, 57% to 60% of new pressure sores actually develop in the hospital, most commonly in intensive-care and orthopedic patients. Elderly patients and those with spinal cord injuries are most at risk36... 

Candida species are the most common opportunistic fungal pathogens encountered in hospitals, ranking as the third to fourth most common cause of nosocomial bloodstream infections in United States Hospitals.18 The incidence of nosocomial candidiasis has increased steadily since the early 1980s, with the widespread use of central venous catheters, broad-spectrum antimicrobials, and other advancements in the supportive care... 

Most health care workers are at risk for exposure to many diseases in the normal course of their work. Additionally, health care workers may transmit vaccine-preventable diseases to their patients. At the time of employment and on a regular basis, health care workers should be screened for immunity to measles, rubella, and varicella if found to be non-immune, the measles, mumps, and rubella, and varicella vaccines should be administered. The hepatitis B series should be given if not already completed. Tetanus should be updated and given every 10 years. Health care personnel in hospitals and ambulatory settings with direct patient contact should receive Tdap if not already received an interval as short as 2 years from the last tetanus-containing vaccine should be used. Priority for receiving Tdap should be given to personnel with direct contact with infants less than 12 months of age. 

Maintaining adequate nutritional status, especially during periods of illness and metabolic stress, is an important part of patient care. Malnutrition in hospitalized patients is associated with significant complications, including increased infection risk, poor wound healing, prolonged hospital stay, and increased mortality, especially in surgical and critically ill patients.1 Specialized nutrition support refers to the administration of nutrients via the oral, enteral, or parenteral route for therapeutic purposes.1 Parenteral nutrition (PN), also... 

There are various severity of illness scoring systems for sepsis and trauma (R11). Severity scoring can be used, in conjunction with other risk factors, to anticipate and evaluate outcomes, such as hospital mortality rate. The most widely used system is the Acute Physiology, Age, Chronic Health Evaluation II (APACHE II) classification system (K12). The APACHE III was developed to more accurately predict hospital mortality for critically ill hospitalized adults (K13). It provides objective probability estimates for critically ill hospitalized patients treated in intensive care units (ICUs). For critically ill posttrauma patients with sepsis or SIRS, another system for physiologic quantitative classification and severity stratification of the host defense response was described recently (R11). However, this Physiologic State Severity Classification (PSSC) has yet not been applied routinely in ICU setting. 

Intravenous (i.v.) solutions are commonly administered to patients in hospitals, long-term care facilities, and ambulances. They are used primarily to replace body fluids and to serve as a vehicle for injecting drugs into the body. The advantages of this pharmaceutical dosage form include the rapid onset of action, the ability to treat patients unable to take medication orally and the ability to administer a medication unavailable in any other dosage form. 

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