Tertiary hospitals

Hussein Z, Wentworth JM, Nankervis AJ, Proietto J, Colman PG. Effectiveness and side effects of thiazolidine-diones for type 2 diabetes real-life experience from a tertiary hospital. Med J Aust 2004 181 536-9. 

In a one-year retrospective study at a tertiary hospital in Spain, 17% of 148 episodes of diarrhea associated with C. difficile developed after therapy with clindamycin (26). The possible association of toxin-positive C. difficile-induced colitis and the use of clindamycin phosphate vaginal cream for bacterial vaginosis has been reported in a 25-year-old white woman postpartum (27). 

Barreiro PM, Pintor E, Rosario Buron M, Diaz B, Valverde J, de la Torre F. Diarrea asociada a Clostridium difficile. Estudio retrospectiro a un ano en un hospital ter-ciario. [Diarrhea associated with Clostridium difficile. One-year retrospective study at a tertiary hospital.] Enferm Infecc Microbiol Clin 1998 16(8) 359-63. 

Over 75 percent of the New Zealand health system is publicly funded. Public health services are delivered at the local level by Hospital and Health Services, each based around a single large tertiary hospital. The recently established Health Funding Agency (HFA) is responsible for purch2ising and monitoring health services across the country. 

Time from arrival at tertiary hospital until first balloon inflation during PCI. Source Ref. 34. 

The distribution and use of technology is closely linked with equity concern and the gap between the haves and have-nots. In many countries, sophisticated tertiary hospitals heavily concentrated in the largest cities and dominated by indiscriminate use of low-volume, high-cost technology are often available only for those who can afford them. At the same time, there is a severe shortage of essential services of a higher priority at a district level and for primary health care in cities themselves, which makes those who are most in need— the rural population and urban poor—suffer most. 

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. 

Noel has no memory of the events that followed. When Jan arrived at the hospital, she was immediately taken for the first of many surgeries on her arm. When she awoke, Noel was already gone—he had been airlifted to a major tertiary hospital in the nearest capital city. The Royal Flying Doctor Service was called for Jan, and she too was transported to Sydney, where Simon and his parents-in-law were anxiously waiting for her. She arrived at 11 p.m., and discovered that Noel had got there around an hour earlier. 

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. 

Luo, N. et al. (2004). Drug utilization review of risperidone for outpatients in a tertiary referral hospital in Singapore. Hum. Psychopharmacol, 19, 259-64. 

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. 

A second series of reports in the literature purport to discuss the toxicity of phenol to newborns. These, however, deal with an excessive level of hyperbilirubinemia, or jaundice, in newborns in hospital nurseries where a phenolic disinfectant detergent was used to clean the nursery and its equipment (bassinets and mattresses) (Doan et al. 1979, Wysowski et al. 1978). Review of these reports indicated that the detergent did not contain phenol per se. rather it contained more complex phenolics such as o-benzyl-p-chlorophenol and p-tertiary amylphenol. 

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]. 

There have been five double-blind studies comparing the antidepressant efficacy of different SSRIs versus different TCAs in patients with HDRS scores of 25 or more (122, 123,124, 125 and 126). Three of these studies permitted inclusion of both inpatients and outpatients ( 122, 123 and 124), whereas the other two were solely done in outpatients (125, 126). Three were placebo-controlled (1.23, 125,126). In these three studies, the SSRI (i.e., fluvoxamine, paroxetine, or sertraline) was either superior to both the f CA and placebo or was comparable with the TCA and superior to placebo. In the other two studies, the SSRI was not different from the TCA and there was no placebo control. There have also been four studies and one metaanalysis of European clinical trials which found no difference in antidepressant efficacy between several different SSRIs and several different tertiary amine TCAs in patients hospitalized for major depression ( 127,128, 129,130 and 131). Finally, there have been two relatively small studies showing that fluoxetine and fluvoxamine both had antidepressant efficacy superior to placebo in patients with melancholia ( 132, 133). Another larger study failed to find a difference between paroxetine and amitriptyline in treating such patients ( 134). 

Researchers J, Versieck and L. Vanballenberghe (University Hospital, Ghent. Belgium) have observed, Tin has chemical properties offering potentials for a biological function, The element has a tendency to form truly covalent linkages as well as coordination complexes hence, it was hypothesized that it could well contribute to the tertiary structure of proteins or other biologically important macromolcculcs, such as nucleic acids. 

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. 

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