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The written discharge summary is the main vector of communication and serves as a critical method of patient information transfer between hospitalist and primary care provider. It is a shown challenge to timely delivery and completeness of a discharge letter, especially when it involves patients in palliative care or with a limited life expectancy. Despite the implementation of standardized letters and guidelines. Personalized interactive information transfer of hospital discharge summary between hospitalist and primary care provider should include a written as well as the strong consideration of an oral transmission. This should ensure continuity of care and limit deficiencies in content and availability of critical medical information. Joint responsibility of continuous care instead of simply a transfer.

The written discharge summary is the main vector of communication and serves as a critical method of patient information transfer between hospitalist and primary care provider. It is a shown challenge to timely delivery and completeness of a discharge letter, especially when it involves patients in palliative care or with a limited life expectancy. Despite the implementation of standardized letters and guidelines. Personalized interactive information transfer of hospital discharge summary between hospitalist and primary care provider should include a written as well as the strong consideration of an oral transmission. This should ensure continuity of care and limit deficiencies in content and availability of critical medical information. Joint responsibility of continuous care instead of simply a transfer.

The written discharge summary is the main vector of communication and serves as a critical method of patient information transfer between hospitalist and primary care provider. It is a shown challenge to timely delivery and completeness of a discharge letter, especially when it involves patients in palliative care or with a limited life expectancy. Despite the implementation of standardized letters and guidelines. Personalized interactive information transfer of hospital discharge summary between hospitalist and primary care provider should include a written as well as the strong consideration of an oral transmission. This should ensure continuity of care and limit deficiencies in content and availability of critical medical information. Joint responsibility of continuous care instead of simply a transfer.

Gurwitz and colleagues showed that a complex intervention, aimed at a reduction of drug-related adverse events and medication errors immediately after hospital discharge, did not result in a significant outcome difference between the intervention and control groups. We feel that the intervention lacked standardization, that a better outcome might have been achieved by intervening prior to hospital discharge, that more details about the nature of observed medication errors and acceptance of the intervenor recommendations should have been reported. Also, the number of unpreventable adverse drug events was higher in the intervention (n = 37) than in the control group (n = 27), suggesting a Hawthorne effect. The small number of adverse drug events detected overall points to a low sensitivity of the detection method used. We recommend that future studies be designed differently, including a stronger focus on physician-pharmacist collaboration, patient participation and improved communication between the hospital and general practice.

A prospective cohort study recently published in JAMA looked at the difference in survival to hospital discharge between intra-arrest transport vs continued on-scene resuscitation among patients with out-of-hospital cardiac arrest (OHCA). The conclusion of this study is that intra-arrest transport is associated with a lower survival compared to continuous on-site treatment. Research by the Amsterdam Resuscitation Study (ARREST) shows that in OHCA patients who are transported intra-arrest, survival decreases significantly if the time on-scene increases. Patients who are transported within 20 minutes have the highest chance of survival. This suggests that the decision for transport should be made early in the resuscitation process. National and regional circumstances (availability of a mobile medical team, distance to hospital etc.), and pre-hospital resuscitation treatments may make that different scenarios can be considered. In some scenarios extracorporeal cardiopulmonary resuscitation (eCPR) can be brought to the patient; in other scenarios the patient can be transported to the eCPR.

Evaluation of an early discharge program for COVID-19-patients who still required additional oxygen support, supervised by their own general practitioner (GP) in a home setting. We evaluated safety and gathered experiences from patients, caregivers and GPs.Cohort study (prospective and retrospective inclusion) METHOD: Adult COVID-19-patients admitted to one of the three Amsterdam hospitals, the Netherlands, were eligible when clinically stable for at least 48 hours, with a minimum oxygen saturation of 94% and a maximum of 3 l/min oxygen support. Patients were included from 23-10-2020 to 26-03-2021.We included 113 patients, of whom 40 retrospectively . Median age was 58 years and median length of hospital stay 8 days. Four patients (3.7%) were readmitted within 14 days after discharge. Median duration of oxygen support at home was 8 days. Almost no home visits were conducted by GPs, but contact by telephone was regular (median 6 times in 2 weeks). All stakeholders reported feeling safe, able and confident while delivering the necessary (self) care. The program was graded by patients and GPs with an 8 (on a scale of 1 to 10).Early discharge for COVID-19-patients with a necessity for oxygen support, under supervision of the GP, is safe and was positively evaluated by all stakeholders involved.

To evaluate the implementation of home telemonitoring and oxygen therapy in COVID-19 patients. Primary outcomes were safety, patient satisfaction, reduction of hospital stay, and cost-effectiveness.Retrospective cohort study.All COVID-19 patients who were discharged with home telemonitoring and oxygen therapy between June 1st and November 1st 2020 were included. Eligible patients had a maximum oxygen requirement of 2 liters per minute during the 24 hours prior to discharge with a minimal peripheral oxygen saturation of 94%. A mobile application for telemonitoring was used, which patients or relatives had to be able to use independently. Patient demographics, clinical parameters, data on telemonitoring and readmissions were extracted from the electronic patient records. A survey for patient satisfaction and a cost-effectiveness analysis were performed.Out of 619 admissions, 49 patients were discharged with home telemonitoring and oxygen therapy. Median duration of home oxygen therapy was 11 days with a potential reduction in hospitalization of 616 days. Six patients were readmitted and were significantly more febrile on discharge (67% versus 14%, p=0.01) and had lower oxygenation (95%, (IQR 93-96) versus 96%, (IQR 95-97), p=0.02) with similar levels of oxygen administration. Patient satisfaction was high with a mean score of 5 to 6 on a scale measuring satisfaction from 1 to 7. Estimated total cost reduction was € 146.736.This study shows that home telemonitoring and oxygen administration can be safely applied in COVID-19 patients resulting in a high patient satisfaction and reduction in hospital stay and costs.

Hospitalization for corona virus disease 2019 (COVID-19) may be followed by complications after discharge. We aimed to evaluate mortality, readmission rate, and readmission characteristics after hospitalization with COVID-19.A retrospective cohort study METHODS: Inclusion of all patients hospitalized for COVID-19 between March 1, 2020, and June 1, 2020 in Zuyderland Medical Centre, The Netherlands. Main outcome measures were mortality and readmission after hospitalization. Univariate and multivariate regression analysis were performed to identify risk factors for death and readmission.A total of 769 patients hospitalized with COVID-19 (mean age 70 ± 14 years; 39% female) were included in the study. In-hospital mortality was 22.4% , as such 596 patients were discharged alive and followed after discharge with a median of 80 days (IQR 66-91). Total mortality after discharge was 6.4% (n=38) and readmission rate was 11.7% (n=70). Main reasons for readmission were respiratory insufficiency (31%), arterial and venous thrombotic events (16%) or related to a chronic comorbidity (14%). Mortality rates were higher in older patients and patients who experienced delirium during hospital stay. Risk factors for readmission were male sex, discharge to a long-term care facility and COPD.1 out of 6 COVID-19 positive patients died or was readmitted after discharge. This shows an ongoing vulnerability of COVID-19 patients. Physicians and policy makers should consider this high rate when making decisions on discharge, hospital-capacity planning, and patient monitoring after discharge.

To describe and study (a) the implementation of direct discharge from a Dutch Emergency Department (ED) for patients with relatively simple stable injuries (SSIs), (b) preliminary logistical and financial effects, and (c) patients' experiences.Prospective cohort study.Following the example of a healthcare reorganisation in the United Kingdom, in May 2019 we changed the treatment protocols of eleven SSIs. Since that time, no standard follow-up appointment has been scheduled for these patients. Patients are given information about treatment and the recovery period, and a form of immobilization is applied which can easily be removed at home. This information is summarised in a discharge leaflet and a smartphone application. A telephone helpline is available for any concerns or questions. During the implementation phase we determined compliance with, and deviation from, the protocol daily for 3 months. To determine the logistical and financial effects we compared the healthcare utilization of all patients with SSIs three months before and after implementation. Patient satisfaction and the shift in treatment towards primary care were determined by means of questionnaires.In the three months before implementation 275 patients with an SSI presented to our ED, compared with 318 in the same period after implementation; 304 of the 318 patients were directly discharged (protocol compliance 95.6%). We found a significant reduction in follow-up appointments (-91%), radiological imaging (-72%), and costs. Patient satisfaction was comparable. There was no shift towards primary care in healthcare utilisation.In the Netherlands, direct discharge from the ED seems to be an effective and safe alternative to traditional treatment with outpatient follow-up. Further studies on patient-reported outcomes should determine if this process is in concordance with the principle of Value Based Health Care.

Here we describe the characteristics of the first 100 laboratory confirmed COVID-19 patients admitted to the Elisabeth-Tweesteden Hospital (Tilburg, The Netherlands). The median age was 72 years, 67% was male, approximately 80% had co-morbidity, approximately 50% of which consisted of hypertension, cardiac and or pulmonary conditions and 25% diabetes. At admission 61% of patients had fever and about 50% presented at day 6 or more after onset of symptoms. At the time of writing 38 patients were discharged, 19 admitted to the intensive care unit (ICU) and 20 patients had died. The median age of ICU patients was 67 years and 63% had co-morbidity. The median time to discharge or to death was 6 and 5.5 days, respectively.

Introduction: Frail COPD patients are frequently not accepted for regular pulmonary rehabilitation programs due to low physical condition and functional limitations. Rehabilitation programs in nursing homes for geriatric patients with COPD have been developed. The effects of such programs are largely unknown. Aims: To assess the course of COPD-related hospital admissions and exercise tolerance in a cohort of frail COPD patients participating in geriatric COPD rehabilitation. Methods: Retrospective observational study with a follow up of 12 months after discharge from rehabilitation. COPD related hospital admission days were measured in the year before and after participating rehabilitation. Exercise tolerance was measured by the six minute walk test (6MWT) at admission and at discharge from rehabilitation. Results: Fifty-eight participants accomplished the rehabilitation program. Twelve patients died in the first year after discharge. The median number of hospital admission days in the year before participating rehabilitation was 21 (IQR 10–33). The first year after discharge this was decreased to a median of 6 (IQR 0–12). The 6MWT increased from 194 (SD 85) meters at admission to 274 (SD 95) meters at discharge (mean difference 80 m, SD 72; p < 0.05). Conclusions: Geriatric COPD rehabilitation in a nursing home setting seems to reduce hospital admissions in frail COPD patients and to increase exercise tolerance.

To gain insight into the differences in emergency care offered to elderly (65+ years) and younger patients (20-64 years). The emergency care pathway includes: out-of-hours general practitioner cooperatives, regional ambulance services, psychiatric emergency medical services, accident and emergency departments and acute cardiac care units.Retrospective cohort study.We used data from all emergency care contacts from the Emergency Care Monitor of April 2015 and April 2016 from an emergency care region in the east of the Netherlands ('Acute Zorgregio Oost'); this involved 84,647 care contacts with 55,061 patients. We defined pathway emergency care contacts as multiple emergency care contacts with different healthcare providers within the emergency care pathway, and differentiated between single or repeated care contacts with a single emergency healthcare provider. We investigated differences in presenting symptoms, diagnoses, lead time, hospital admissions and mortality in the chain care.Emergency care contact was more often pathway contact in elderly than in younger patients (26% vs. 16%; p0.0001). Elderly patients more often received a diagnosis of CVA, pneumonia or exacerbation of COPD, while younger patients more often had simple contusions or abdominal symptoms. Pathway lead time was longer in elderly than in younger patients (median difference: 33 minutes; 95% CI: 25-40. Elderly patients were admitted to hospital more often (71% vs. 39%, p0.0001) and their mortality rate was higher (2.0% vs. 0.5%; p0.0001).Elderly patients in the emergency care pathway have more frequent and longer pathway contact and present themselves with a more complicated and life-threatening clinical picture than younger patients. New solutions should be explored to ensure that the emergency care pathway remains accessible and available and offers sufficient quality for the increasing number of elderly.

Increasingly restrictive red blood cell transfusion strategies have led to growing numbers of patients being discharged from hospital with moderate anaemia, and doubts about the effects of this trend on the outcomes of patients with anaemia are growing. One advantage of doubts is that they lead to variation in practice, which, in theory, allows the study of routinely collected data on the effects of an intervention (transfusion) on patient-relevant outcomes. To do this in a reliable way, we need solid data on outcomes and on all the potentially relevant clinical characteristics that are associated with both the decision to transfuse and the outcomes. Currently, such data are not available. As part of routine practice, clinicians should be encouraged to document the arguments for their treatment decisions and the intended outcomes. This will allow learning from daily practice in the field of transfusion medicine and in other health care disciplines.

To examine issues in care for patients who come to the emergency department after a suicide attempt.Cross-sectional multicentre questionnaire survey.In 2015, 7 emergency departments across the Netherlands participated in a questionnaire survey of the 113 Suicide Prevention (113 Zelfmoordpreventie) service as a part of the 2014-2017 National Suicide Prevention Agenda. Emergency physicians and nurses and managers answered 25 multiple-choice questions about: (a) current treatment of and contact with patients who attempted suicide, (b) available knowledge and skills of emergency physicians and nurses and (c) after-care for patients who attempted suicide.In total, 33 emergency physicians, 40 emergency nurses and 5 managers completed the questionnaire. When a patient comes to the emergency department after a suicide attempt, emergency physicians and nurses often consult with the crisis service, psychiatrist or a colleague and they request extra diagnostics. The most important issue indicated by emergency staff is that they do not have enough time, knowledge and skills to estimate the suicide risk and to conduct a conversation with the patient about her or his suicidal thoughts. One-fifth of the respondents indicated that they do not always treat patients who committed a previous suicide attempt with respect. The respondents also thought that the emergency department environment is too restless or unsafe and thought that they have to wait for the crisis service for a long time. The majority of the emergency physicians and nurses worried about the condition of the patient after her or his discharge, especially when they estimate a high probability of another suicide attempt.Insufficient knowledge and skills of emergency department staff, a sometimes negative attitude towards people who attempted suicide and a heavy workload are hindering care at the emergency department for people who attempted suicide. Targeted training, a quiet area and deployment of specialised care could improve this care.

In the last decennia, the length of hospital stay of admitted patients has significantly decreased in all medical fields. As a result, postoperative recovery mainly takes place at home, inherently leading to new challenges. Here, two patients are being discussed for whom the postoperative period was substandard. To guarantee optimal quality of care in the home situation, the medical specialist and the general practitioner need to make the necessary arrangements. We would first of all recommend providing each discharged patient with specific, structured and individualised advices regarding postoperative recovery but also regarding alarm symptoms and logistics (e.g. who to call in case of emergency). Finally, we believe that, as (serious) complications are rare, it should be agreed on the fact that the responsible medical specialist is the coordinator of the postoperative period and the first contact point for postoperative patients.

Acute upper gastrointestinal bleeding is still an important emergency situation with an incidence of 48-62 per 100,000 adults per year in the Netherlands. An international multicentre prospective study evaluated different risk scoring systems for patients presenting with upper gastrointestinal bleeding. The authors showed that patients with a Glasgow Blatchford score of 0 or 1 could be safely discharged without endoscopy. Thirty-day all-cause mortality in this group was 0.4%. In the current Dutch guideline, there is no clear advice on management of low-risk patients. The new guideline is expected in 2017 and should include this clear advice of discharging low-risk patients (Glasgow Blatchford score ≤ 1). It can therefore be concluded that with optimal selection about 20% of all patients presenting to the emergency room with acute upper gastrointestinal bleeding can be discharged the same day without intervention.

Frail COPD patients are frequently not accepted for regular pulmonary rehabilitation programs due to low physical condition and functional limitations. Rehabilitation programs in nursing homes for geriatric patients with COPD have been developed. The effects of such programs are largely unknown.To assess the course of COPD-related hospital admissions and exercise tolerance in a cohort of frail COPD patients participating in geriatric COPD rehabilitation.Retrospective observational study with a follow up of 12 months after discharge from rehabilitation. COPD related hospital admission days were measured in the year before and after participating rehabilitation. Exercise tolerance was measured by the six minute walk test (6MWT) at admission and at discharge from rehabilitation.Fifty-eight participants accomplished the rehabilitation program. Twelve patients died in the first year after discharge. The median number of hospital admission days in the year before participating rehabilitation was 21 (IQR 10-33). The first year after discharge this was decreased to a median of 6 (IQR 0-12). The 6MWT increased from 194 (SD 85) meters at admission to 274 (SD 95) meters at discharge (mean difference 80 m, SD 72; p 0.05).Geriatric COPD rehabilitation in a nursing home setting seems to reduce hospital admissions in frail COPD patients and to increase exercise tolerance.

When patients are transferred from the hospital to other health care settings, responsibility for the patient is transferred from the treating physician, nurse, paramedic or pharmacist at the hospital to the next health care provider. Good patient handovers from hospital to other healthcare settings are essential to ensure continuity of care. However, handovers are often delayed or incomplete and the patient is barely involved in her or his own transfer. Risks related to an incomplete handover may be considerable. More than half of the preventable adverse events that occur after discharge are attributable to ineffective communication between hospital and other healthcare providers. Through the implementation of some adjustments, the discharge process can become a point of focus during a patient's hospital stay. Examples to improve patient handovers are standardizing the discharge process and the content of patient handovers, planning a target discharge date, starting the collection of transfer data on time and involving the patient in her or his transfer.

Acute generalised exanthematous pustulosis (AGEP) is a rare and self-limiting pustular cutaneous reaction to a drug or infection.A 62-year-old male presented to the Emergency Department with fever, erythema and pustules on both thighs. The initial blood analysis showed increased inflammatory parameters. The patient was admitted to the Dermatology Department with suspected AGEP. All medication was stopped. The diagnosis was confirmed histologically. During hospitalisation, the cutaneous reaction spread over 30% of the skin surface. Seven days after onset, the skin disorder regressed and the patient was discharged after 16 days. Use of amoxicillin/clavulanic acid was very likely the triggering factor for the development of AGEP.AGEP, although self-limiting, can have a fulminant course, requiring admission to a burns centre. It is imperative that rechallenge with the triggering drug is avoided.

Patients admitted to an intensive care unit (ICU) comprise of a heterogeneous population with substantial differences in admission diagnosis, length of stay and co-morbidity. Therefore, very often the prognosis for each patient differs. In the Netherlands, over 20% of the more than 80,000 patients treated in ICU annually will die within a year of admission. Some of those who survive and are discharged from ICU experience persistent physical, mental and cognitive health problems post-discharge; this is called post-intensive care syndrome (PICS). One year following discharge, circa 50% of patients continue to report physical symptoms, including muscle weakness and walking difficulties. Approximately one in five patients discharged from ICU will develop symptoms akin to post-traumatic stress disorder, and one third will experience depressive symptoms for some time. It remains unclear to what extent the actual ICU admission may potentially contribute to the decline in performance status and quality of life.

We investigated whether a classification method for readmissions, first developed in the United Kingdom, can be applied to Dutch (re-)admission data and possibly used as an indicator of quality.Retrospective analysis of Dutch administrative hospital admission data supplied to the Dutch National Medical Registration database.Readmissions are urgent inpatient admissions that occur within 30 days of discharge from a previous inpatient admission in the same hospital, with the latter being the index admission. Based on the original UK research, readmissions have been classified into seven categories: (A) complication following index admission; (B) anticipated but unpredictable hospital care; (C) patient or healthcare professional preference; (D) artefact; (E) related to a different body system; (F) related to the same body system; (G) social-economic, psychosocial or other indication. This classification was applied to admission data for 18 Dutch hospitals covering the period 2009-2013.Of a total of 1,633,466 admissions, 120,343 (7.37%) were followed by a readmission. The most common category contributing to readmissions was 'the same body system' (category F, 44.07%), followed by readmissions related to different body systems (category E, 27.85%). The most prominent avoidability categories 'complications following index admission (category A, 17.66%) and anticipated hospital care (category B, 5.31%) ended up in third and fourth place respectively. Finally, the joint share for categories C, D and G was 5.55%. The classification of readmissions differs only slightly between different types of hospitals (university, top clinical, general). Large differences in the classification distribution are found between clinical specialties.The classification system for readmissions can be applied well to Dutch admission data and offers an insight into the patterns of admissions and readmissions. Closer in-depth research may provide more evidence concerning the suitability of this classification system as an indicator of hospital quality.

The percentage of readmissions within 30 days after discharge is an official quality indicator for Dutch hospitals in 2016. In this commentary the authors argue why readmissions cannot be regarded as a reliable way of assessing quality of healthcare in a hospital. To date, policy makers have been struggling with its precise definition and the indicator has not been properly formulated yet. It does not distinguish between planned and unplanned readmissions and does not take into account the 'preventability'. Therefore the authors believe that the indicator in its current form might falsely interpret the quality of care of a hospital and it is questionable to use readmissions as a quality indicator.

In the Netherlands there is no up-to-date information about the attitude of the public to (discharged) psychiatric patients. Also, very little is known about which population groups hold stigmatising views.To measure the public's attitudes to (discharged) psychiatric patients and to find out whether these attitudes differ according to the background characteristics (e.g. demographics, respondent's psychiatric history).In our study we used attitudes collected via the Netherlands Mental Health Survey and Incidence Study-2, a psychiatric epidemiological study of the adult general population (n = 6646; aged 18-64 years). The psychiatric history of the respondents was assessed by means of the Composite International Diagnostic Interview 3.0.More than 70% of the respondents stated that they had no objection to having a (discharged) psychiatric patient as a neighbour, friend or colleague. However, their ´willingness´ declined markedly, namely to less than 30%, when they were asked if they would be willing to have a (discharged) psychiatric patient as their son-in-law or baby-sitter. A comparison with other earlier Dutch studies indicates that since 1987 the willingness of members of the public to let (ex-)psychiatric patients participate in their private and/or family life has increased only very slightly.Nowadays, just as in past decades, most Dutch citizens are not opposed to living alongside (discharged) psychiatric patients, but they have reservations about letting such persons participate in their private and family life.

To assess the prevalence and predictors of readmission in patients of 65 years or older.Retrospective data analysis.We used a dossier analysis to identify the number of readmissions and patient characteristics of all patients aged 65 years or older admitted to the Radboud University Medical Centre between 29 September 2013 and 4 October 2014. We also used data from the Dutch hospital safety tool (VMS) screening bundle for frail elderly patients. Predictors for readmission were investigated using logistic regression analysis.The readmission rate within 30 days of discharge was 10.9% (95% CI 10.2 - 11.7) of all admissions of elderly patients. The most common symptom associated with readmission was dyspnea (24.9%). Diseases with an increased risk for readmission were: heart failure (OR=2.6; 95% CI 1.9 - 3.7), chronic obstructive pulmonary disease (OR=2.2; 95% CI 1.5 - 3.2), renal insufficiency (OR=1.8; 95% CI 1.3 - 2.6) and cancer (OR=1.5; 95% CI 1.1 - 2.1). Total burden of disease and functional limitations accounted jointly for 49% of the variance in readmissions. Repeated readmissions could be less well predicted (explained variance: 14%); the use of more than 3 drugs (OR=1.07; 95% CI 1.02 - 1.13) and a low body mass index (OR=0.94; 95% CI 0.88 - 0.99) were predictors for multiple readmissions.Elderly patients suffering from dyspnea have the highest risk for readmission. Patients with heart failure, COPD, renal failure, cancer, functional loss or malnutrition require extra attention on transition from hospital to home in order to lower the number of unnecessary readmissions.

Healthcare is becoming more complex and healthcare providers are often only involved in a small part of the process of patient care. Measuring the outcome of the process, in this case healthcare-related infections, with feedback to the professionals involved is indispensable for assessment and improvement of quality of care. Prevalence surveys are used frequently to determine the quality of the process. This method has important limitations that can lead to a biased result. This problem is discussed on the basis of a case and a recent publication on healthcare-related infections occurring after discharge.

An increase in the length of time until the first escorted leave is granted to a patient detained by court order (tbs) results in a longer period of treatment. Physicians involved in the treatment and clinic managers are striving to reduce, in a responsible manner, the length of the period of treatment preceding the patient's first escorted leave.br/Forensic Psychiatric Clinic (fpk) 'De Woenselse Poort' aims to find out to what extent gender, pathology and the type of offence committed by the detainee influence the length of time that elapses before the patient's first leave is granted.We conducted a retrospective study based on patients' records.Although men use physical aggression more often than women, we found that gender, pathology and the type of offence had no influence on the length of the treatment period that preceded the granting of the patient's first escorted leave.Partly on the basis of risk management scales, clinicians judge whether the patient has adopted a more positive or a more negative attitude to risk factors relating to his or her offence. If the risk factors have become more positive, one would expect the application for leave to be made earlier. Surprisingly, this was not the case. In order to speed up the decision-making process regarding the application for leave, a clinical method for evaluating risk related treatment needs to be developed in which offence related risk factors are identified and the patient's positive or negative attitude to these risks are measured and monitored. At each treatment evaluation practitioners should be required to produce arguments that determine whether or not the patient is to be granted permission to go on leave at a particular moment.

To make an inventory of the number of intensive care (ICU) patients per year in the Netherlands who have been discharged home to die, and the conditions under which this does or should take place.Descriptive, survey study.A survey was conducted across all ICU departments in the Netherlands in the spring of 2012. They were approached in writing and requested to answer a few questions about the possibility of immediate discharge home for ICU patients with a short life expectancy and receiving palliative care.A total of 46 surveys (52%) was returned from the 89 ICUs approached. Of these, 21 (46%) had discharged patients home at the request of the patient or their family so that the anticipated death could take place at home. Of the respondents, 39 (85%), supported discharge home for these patients, and 7 (15%) were opposed to it. These opinions were equally divided across all three ICU levels in the Netherlands. Higher-level ICUs had discharged patients home more often in comparison with lower-level ICUs (19%, 43% and 75% for levels 1, 2 and 3, respectively). The preconditions for transfer can be subdivided into patient conditions, care conditions and general conditions.ICU patients do sometimes want to die at home. It does not happen every day, but the wish is often granted in the Netherlands. There are certain general and patient-related conditions that have to be fulfilled. This article suggests a national guideline that could provide support on this subject.

Healthcare is becoming more complex and healthcare providers are often only involved in a small part of the process of patient care. Measuring the outcome of the process, in this case healthcare-related infections, with feedback to the professionals involved is indispensable for assessment and improvement of quality of care. Prevalence surveys are used frequently to determine the quality of the process. This method has important limitations that can lead to a biased result. This problem is discussed on the basis of a case and a recent publication on healthcare-related infections occurring after discharge.

Healthcare is becoming more complex and healthcare providers are often only involved in a small part of the process of patient care. Measuring the outcome of the process, in this case healthcare-related infections, with feedback to the professionals involved is indispensable for assessment and improvement of quality of care. Prevalence surveys are used frequently to determine the quality of the process. This method has important limitations that can lead to a biased result. This problem is discussed on the basis of a case and a recent publication on healthcare-related infections occurring after discharge.

To explore stroke patients needs of care after discharge from hospital or rehabilitation facility.Semi-structured interviews with twenty stroke patients and their partners in the region Midden-Kennemerland in the Netherlands.'That's when it really begins'; at home it becomes clear what the real consequences of the stroke are on daily life. After returning home patients would have liked to (1) have had more information/support and they have a need for support for a long time after their stroke; (2) have had the possibility to get support later on (after having said 'no' in the first place). On the other hand there are (3) patients who are inclined to search for solutions by themselves.Only after returning home stroke patients and their partners can really assess what their need for care is. Therefore the need for care of stroke patients should be assessed after a period of time after the patients return home. The care should be available for a long time after the stroke. Because patients don't realize that they can get help for the neuropsychological consequences, it is important that the initiative to organize the care lies in the hands of the caregivers.

To study the effectiveness of combined integral somatic and psychiatric treatment in a medical-psychiatric unit (MPU).Retrospective case-note study.The case notes of all patients admitted to the MPU at the VU Medical Center, Amsterdam, in 2011 were analysed. Data on reasons for referral and somatic and psychiatric diagnoses were collected. Using a global clinical assessment scale and the Health of the Nations Outcome Scales (HoNOS), data on psychiatric symptomology and limitations, behavioural problems, social problems and limitations associated with physical health problems were collected on both admission and discharge. In this way the effect of the admission period on various problems was determined.In 2011 there were 139 admissions to the MPU with a wide variation of somatic and psychiatric diagnoses. The average admission period was 9 days. Global clinical evaluation of the treatment goals set for somatic and psychiatric conditions showed that more than 90% and 85% of the treatment goals, respectively, were completely achieved. HoNOS scores showed a reduction in severity of both psychiatric and somatic problems. The total HoNOS-core was significantly reduced by nearly 3.5 points - a large effect size.The MPU has succeeded in its goal to deliver integral care to a very diverse group of patients with somatic and psychiatric co-morbidities. It is able to offer care to a vulnerable patient group in which it can be presumed that treatment on a non-integrated unit could not have been delivered or not delivered adequately, due to the complexity of their somatic and behavioural problems.

An article pertaining to a large European qualitative study into the discharge of patients from hospital was published in the Dutch Journal of Medicine (Nederlands Tijdschrift voor Geneeskunde). Earlier qualitative and quantitative research in the Netherlands had resulted in the same findings: patients wish to receive more information upon discharge. Improvements have been realised, but not at every hospital or department. There is considerable variation as to how much information is desired by individual patients. Healthcare providers should take these differences into account and provide personalised information. For some patients, too much information increases their anxiety. We agree with the recommendations of the authors of the article. It is very important that nurses and doctors communicate with patients who are to be discharged. The elderly and patients who live alone need extra attention. GPs and specialists should discuss amongst themselves how to best compose a format for the specialist's report, including what type of information the GPs need to inform their patients adequately. As performance indicators, the telephone accessibility of GPs and the time it takes to receive the specialist's report could be considered as options.

To study the changes in standardised in-hospital mortality in the period 2005 to 2010.Retrospective, descriptive study.Data from the National Medical Registration (LMR) for the period 2005 to 2010 were used to calculate a time-series of the standardised in-hospital mortality rate. Predicted mortality was calculated for 50 principle diagnosis groups using logistic regression models with 8 explanatory variables. This was used, in combination with actual in-hospital mortality, to calculate the Time-Series Standardised Hospital Mortality Ratio (TSHMR).The TSHMR decreased significantly each year in the period 2005 to 2010. The greatest decrease was from 2009 to 2010, which was partly due to a registration effect. Total age- and sex-standardised mortality in the population also decreased in the period 2005 to 2010, mortality out of hospital decreasing less than in-hospital mortality. Standardised hospital mortality decreased significantly in all adult age categories (≥ 25 years of age). The TSHMR fell most sharply in the diagnosis groups 'gastrointestinal haemorrhage' and 'deficiencies and other anaemias'. The diagnosis groups 'heart valve disorders' and 'aspiration pneumonia due to food or vomitus' showed the smallest decrease in TSHMR, and this decrease was not significant.The decrease in standardised in-hospital mortality shows that the risk of dying in hospital has decreased substantially in the past few years. The size of the decrease in TSHMR differed per diagnosis group. There can be many reasons for this decrease in in-hospital mortality, including improved quality of care; however, it may also be due to, for instance, changes in hospital admission and discharge policies.

To evaluate the reliability of data registration in calculating the hospital standardised mortality ratio (HSMR).Retrospective, descriptive.Data were collected from a research database on all patients who had undergone a partial pancreatoduodenectomy for pancreatic cancer in 2009 and 2010 at our hospital. These data were compared with information about these same patients recorded in the Dutch National Medical Registry (LMR), obtained from the medical administration department of our hospital. The differences between these 2 databases were evaluated on the basis of 3 variables: mortality, main diagnosis and secondary diagnoses (differentiated into complications and co-morbidities). Using the Charlson index, the co-morbidity score from both registries was calculated per patient.A total of 118 patients had been registered in the research database. Of these patients, 103 appeared in the LMR data; 15 had not been registered in this database. There were no differences in patient characteristics or mortality (2.5%) between the registries. In the LMR, the main diagnosis of 5 patients had been incorrectly recorded. This database contained information on 136 complications and 51 co-morbidities, of which 35 comorbities had been correctly recorded. The research database contained information on 188 complications and 99 comorbidities on these same patients. In the research database, comorbidity comprised 34% of all secondary diagnoses; in the LMR, 19% (p0.001). The median score on the Charlson index was 0 for all patients in the LMR and 3 in the research database (p0.001).Comorbidities in patients with pancreatic carcinoma who undergo a resection are being inadequately recorded in the LMR. This results in insufficient correction in the case mix and a low score on the Charlson index, which could result in an incorrect HSMR.

To study the impact of casemix variations within primary diagnostic groups on hospital standardised mortality ratios and to improve the current HSMR model.Descriptive, model analysis.We calculated the HSMRs and the standardised mortality ratios at diagnostic group level (SMRs) of 84 Dutch hospitals over a 5-year period using 2 HSMR models. Both models adjusted for severity of diagnosis at admission (primary diagnostic level according to the International Classification of Diseases (ICD-9)) using a severity classification. The severity classification in the current model (model 1) was based on WHO mortality data, whereas our adapted 'Dutch' model (model 2) was based on Dutch hospital mortality data. The HSMRs and SMRs and the corresponding c-statistics of both models were compared in order to test whether the models adequately adjusted for high-risk versus low-risk ICD-9 codes.Model 1 did not adequately adjust for casemix differences on the ICD-9 diagnostic level for 40 out of 48 diagnostic groups analysed; model 2 did not adequately adjust for 25 diagnostic groups. Model 2 showed better c-statistics than model 1. Relative differences between models 1 and 2 in SMR outcomes varied from -63% to 202% when comparing model 2 to model 1. At the HSMR level these differences varied from -6.7% to 4.3%.The HSMR model currently used in the Netherlands does not adequately adjust for casemix differences at the level of ICD-9 primary diagnoses. A model using a severity classification of ICD-9 codes based on actual Dutch hospital mortality allows for a better, albeit not perfect, adjustment. We recommend implementation of the 'Dutch' severity classification in order to improve the HSMR model.

Two patients were seen by medical specialists at hospital, but the general practitioner received their discharge letters too late. The first patient was a man aged 50 referred to the emergency department of the hospital with suspected pulmonary embolism. He was sent home and was found dead two days later. The cause of death was pulmonary embolism. The day after, the GP received the discharge letter from the hospital, in which no attention was paid to the possibility of a pulmonary embolism. The second patient, a 57-year-old man, was send to the hospital by his GP for a suspected urinary tract infection. The urologist diagnosed a prostate carcinoma, but the GP was not informed for 4 months. If the GP had been informed in time, the death of the first patient maybe could have been prevented. The second patient was very anxious and uncertain for a long time, as the GP could not offer appropriate guidance and support, due to a lack of information. In both cases the medical specialist did not follow the guidelines for mutual communication established by the professional associations of GPs and medical specialists.

The association between the pro-inflammatory state of schizophrenia and increased tryptophan degradation into kynurenine has been reported. However, the relationship between metabolites from subdivisions of the kynurenine pathway, kynurenic acid and 3-hydroxykynurenine, remains unknown. The present study tested the relationship between these kynurenine metabolites in the plasma of medication-naive (n = 35) or medication-free (n = 18) patients with schizophrenia at admission and following 6-week antipsychotic treatment compared to healthy controls (n = 48). The plasma concentrations of kynurenic acid (nmol/l) were lower (difference = -8.44 (-13.22 to -3.65); p = 0.001) and of 3-hydroxykynurenine (nmol/l) were higher (difference = 11.24 (8.11-14.37); p

To analyse the variation in the registration of hospital admissions across Dutch hospitals and determine how this variation affects the Hospital Standardised Mortality Rate (HSMR).Retrospective, descriptive.We used data from the National Medical Registration (LMR), covering the records of all hospital admissions in 2005 in Dutch hospitals, to analyse the variation between hospitals in 3 variables: the number of secondary diagnoses, the percentage of unplanned admissions, and the percentage of non-specified diagnoses ('other diagnoses'). The impact of this variation on the HSMR was analysed by calculating the correlation between the HSMR and each of the variables. The correlation between the original HSMR and the HSMR without adjustment for these variables was also calculated.The variation in the percentages of unplanned admissions and admissions with a non-specified diagnosis was low. The variation in these two variables had a small or no effect on the HSMR. There was a considerable variation in the mean number of secondary diagnoses per hospital. This variation had a limited but statistically significant effect on the HSMR. The HSMR calculated without adjustments for secondary diagnoses correlated strongly with the original HSMR.This analysis does not support the view that the HSMR is strongly affected by variation in the registration of hospital admissions and is therefore not reliable. Therefore, there is no need for restraint with regard to publication of the Dutch HSMR.

To investigate the impact of coding variations on 'hospital standardized mortality ratio' (HSMR) and to define variation reduction measures.Retrospective, descriptive.We analysed coding variations in HSMR parameters for main diagnosis, urgency of the admission and comorbidity in the national medical registration (LMR) database of admissions in 6 Dutch top clinical hospitals during 2003-2007. More than a quarter of these admission records had been included in the HSMR calculation. Admissions with ICD-9 main diagnosis codes that were excluded from HSMR calculations were investigated for inter-hospital variability and correct exclusion. Variation in coding admission type was signalled by analyzing admission records with diagnoses that had an emergency nature by their title. Variation in the average number of comorbidity diagnoses per admission was determined as an indicator for coding variation. Interviews with coding teams were used to check whether the conclusions of the analysis were correct.Over 165,000 admissions that were excluded from HSMR calculations showed large variability between hospitals. This figure was 40% of all admissions that were included. Of the admissions with a main diagnosis indicating an emergency, 34% to 93% were recorded as an emergency. The average number of comorbidity diagnoses varied between hospitals from 0.9 to 3.0 per admission.Coding of main diagnoses, urgency of admission and comorbidities showed strong inter-hospital variation with a potentially large impact on the HSMR outcomes of the hospitals. Coding variations originated from differences in interpretation of coding rules, differences in coding capacity, quality of patient records and discharge documentation and timely delivery of these.

To examine the impact of specialised medical procedures (SMPs) on the hospital standardized mortality ratio (HSMR) in Dutch cardiac centres.Retrospective, calculation of the HSMR.Data from 2004 from the National Medical Registration (LMR) were used to calculate the HSMR in 12 cardiac centres and all other hospitals in the Netherlands. The HSMRwas then recalculated for the 12 cardiac centres excluding either percutaneous transluminal coronary angioplasty (PTCA) or open heart surgery or both to determine the impact of these SMPs on the HSMR.Exclusion of SMPs from the HSMR calculation changed the HSMR for individual cardiac centres, ranging from a 4.7% decrease to a 5.3% increase. Change in HSMR was related to the relative frequency of the two procedures at each cardiac centre. Mortality risk was lower than average for PTCA and higher than average for open heart surgery. PTCA accounted for 5.6%-20.2% of total admissions in the 12 cardiac centres. A relatively high proportion of PTCA procedures was associated with a lower HSMR, to a maximum decrease of nearly 7% in one cardiac centre. Open heart surgery accounted for 2.1%-12.6% of total admissions per cardiac centre. A relatively high proportion ofopen heart procedures was associated with an increased HSMR, to a maximum increase of nearly 8% in one cardiac centre.Specialised medical procedures for heart conditions influence the HSMR of cardiac centres. The increase or decrease in HSMR is related to the relative frequency of PTCA and open heart surgery. These results can be used to help interpret the differences in HSMR among cardiac centres and other hospitals.