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Nates JL, Oropello JM, Badjatia N, Beilman G, Coopersmith CM, Halpern NA, Herr DL, Jacobi J, Kahn R, Leung S, Puri N, Sen A, Pastores SM. Flow-Sizing Critical Care Resources. Crit Care Med 2023; 51:1552-1565. [PMID: 37486677 DOI: 10.1097/ccm.0000000000005967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
OBJECTIVES To describe the factors affecting critical care capacity and how critical care organizations (CCOs) within academic centers in the U.S. flow-size critical care resources under normal operations, strain, and surge conditions. DATA SOURCES PubMed, federal agency and American Hospital Association reports, and previous CCO survey results were reviewed. STUDY SELECTION Studies and reports of critical care bed capacity and utilization within CCOs and in the United States were selected. DATA EXTRACTION The Academic Leaders in the Critical Care Medicine Task Force established regular conference calls to reach a consensus on the approach of CCOs to "flow-sizing" critical care services. DATA SYNTHESIS The approach of CCOs to "flow-sizing" critical care is outlined. The vertical (relation to institutional resources, e.g., space allocation, equipment, personnel redistribution) and horizontal (interdepartmental, e.g., emergency department, operating room, inpatient floors) integration of critical care delivery (ICUs, rapid response) for healthcare organizations and the methods by which CCOs flow-size critical care during normal operations, strain, and surge conditions are described. The advantages, barriers, and recommendations for the rapid and efficient scaling of critical care operations via a CCO structure are explained. Comprehensive guidance and resources for the development of "flow-sizing" capability by a CCO within a healthcare organization are provided. CONCLUSIONS We identified and summarized the fundamental principles affecting critical care capacity. The taskforce highlighted the advantages of the CCO governance model to achieve rapid and cost-effective "flow-sizing" of critical care services and provide recommendations and resources to facilitate this capability. The relevance of a comprehensive approach to "flow-sizing" has become particularly relevant in the wake of the latest COVID-19 pandemic. In light of the growing risks of another extreme epidemic, planning for adequate capacity to confront the next critical care crisis is urgent.
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Affiliation(s)
- Joseph L Nates
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | | - Nitin Puri
- Cooper University Health Care, Camden, NJ
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Barchielli C, Vainieri M, Seghieri C, Salutini E, Zoppi P. The Function of Bed Management in Pandemic Times-A Case Study of Reaction Time and Bed Reconversion. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6179. [PMID: 37372765 DOI: 10.3390/ijerph20126179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023]
Abstract
The last decade was characterized by the reduction in hospital beds throughout Europe. When facing the COVID pandemic, this has been an issue of major importance as hospitals were seriously overloaded with an unexpected growth in demand. The dichotomy formed by the scarcity of beds and the need for acute care was handled by the Bed Management (BM) function. This case study explores how BM was able to help the solidness of the healthcare system, managing hospital beds at best and recruiting others in different settings as intermediate care in a large Local Health Authority (LHA) in central Italy. Administrative data show how the provision of appropriate care was achieved by recruiting approximately 500 beds belonging to private healthcare facilities affiliated with the regional healthcare system and exercising the best BM function. The ability of the system to absorb the extra demand caused by COVID was made possible by using intermediate care beds, which were allowed to stretch the logistic boundaries of the hospitals, and by the promptness of Bed Management in converting beds into COVID beds and reconverting them, and by the timely management of internal patient logistics, thus creating space according to the healthcare demands.
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Affiliation(s)
- Chiara Barchielli
- Management and Healthcare Laboratory, Institute of Management, Sant'Anna School of Advanced Studies, 56127 Pisa, Italy
- Department of Nursing and Obstetrics, Azienda USL Toscana Centro, 50123 Firenze, Italy
| | - Milena Vainieri
- Management and Healthcare Laboratory, Institute of Management, Sant'Anna School of Advanced Studies, 56127 Pisa, Italy
| | - Chiara Seghieri
- Management and Healthcare Laboratory, Institute of Management, Sant'Anna School of Advanced Studies, 56127 Pisa, Italy
| | - Eleonora Salutini
- Department of Nursing and Obstetrics, Azienda USL Toscana Centro, 50123 Firenze, Italy
| | - Paolo Zoppi
- Department of Nursing and Obstetrics, Azienda USL Toscana Centro, 50123 Firenze, Italy
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Neugaard B, Politi R, McCay C. Level of Care Appropriateness in VA Inpatient Surgery Cases. Prof Case Manag 2023; 28:98-109. [PMID: 36999758 DOI: 10.1097/ncm.0000000000000609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
PURPOSE OF STUDY Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care. PRIMARY PRACTICE SETTINGS There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service. METHODOLOGY AND SAMPLE All admissions to surgery service during fiscal year 2019 (October 1, 2018 to September 30, 2019) that had a UM review entered in the national database were extracted, including current level of care, recommended level of care, and reasons for not meeting criteria. The following demographic and diagnostic fields were supplemented from a national data warehouse: age, gender, marital status, race, ethnicity, and service connection status. Data were analyzed with descriptive statistics. Characteristics of patient demographics were compared using the χ2 test for categorical variables and the Student's t test. RESULTS A total of 363,963 reviews met conditions to be included in the study: 87,755 surgical admission reviews and 276,208 continued stay reviews. There were 71,274 admission reviews (81.22%) and 198,521 (71.87%) continued stay reviews that met the InterQual criteria. The primary reason for not meeting admission criteria was clinical variance (27.70%), followed by inappropriate level of care (26.85%). The leading reason for not meeting continued stay criteria was inappropriate level of care (27.81%), followed by clinical instability (25.67%). Of the admission reviews not meeting admission criteria, 64.89% were in the wrong level of care and 64.05% of continued stay reviews were also in the wrong level of care. Half of the admission reviews not meeting criteria had a recommended level of care as home/outpatient (43.51%), whereas nearly one-third (28.81%) continued stay reviews showed a recommended level of care of custodial care or skilled nursing. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE This study identified system inefficiencies through admission and continued stay reviews of surgical inpatients. Patients admitted for ambulatory surgery or for preoperative testing prior to day of surgery resulted in avoidable bed days of care that may have contributed to patient flow issues and limited the available hospital beds for other patients. Through early collaboration with case management and care coordination professionals, alternatives can be explored that safely address the patient needs, such as temporary lodging options. There may be conditions or complications that can be anticipated on the basis of patient history. Proactive efforts to address these conditions may help avoid unnecessary bed days and extended lengths of stay.
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Affiliation(s)
- Britta Neugaard
- Britta Neugaard, PhD, MPH, is director of UM Data & Statistics in the VA Utilization Management Program Office. She has conducted extensive research on quality management and health outcomes. She received her master's degree in public health from the University of South Florida and doctorate in health service research from the University of Florida
- Ruth Politi, PhD, MSN, RN, CNE , currently works for the Veterans Health Administration in the National Center for Patient Safety. She also teaches graduate nursing students where she shares her 35 years of nursing experience, which includes 15 years in the areas of case management and utilization review
- Christy McCay, BSBME, is a health systems specialist with the Department of Veterans Affairs. She received a bachelor's degree in biomedical engineering with a minor in mathematics from Tulane University. She has extensive experience with relational database extraction techniques for the purposes of data synthesis with primary interest in health care data
| | - Ruth Politi
- Britta Neugaard, PhD, MPH, is director of UM Data & Statistics in the VA Utilization Management Program Office. She has conducted extensive research on quality management and health outcomes. She received her master's degree in public health from the University of South Florida and doctorate in health service research from the University of Florida
- Ruth Politi, PhD, MSN, RN, CNE , currently works for the Veterans Health Administration in the National Center for Patient Safety. She also teaches graduate nursing students where she shares her 35 years of nursing experience, which includes 15 years in the areas of case management and utilization review
- Christy McCay, BSBME, is a health systems specialist with the Department of Veterans Affairs. She received a bachelor's degree in biomedical engineering with a minor in mathematics from Tulane University. She has extensive experience with relational database extraction techniques for the purposes of data synthesis with primary interest in health care data
| | - Christy McCay
- Britta Neugaard, PhD, MPH, is director of UM Data & Statistics in the VA Utilization Management Program Office. She has conducted extensive research on quality management and health outcomes. She received her master's degree in public health from the University of South Florida and doctorate in health service research from the University of Florida
- Ruth Politi, PhD, MSN, RN, CNE , currently works for the Veterans Health Administration in the National Center for Patient Safety. She also teaches graduate nursing students where she shares her 35 years of nursing experience, which includes 15 years in the areas of case management and utilization review
- Christy McCay, BSBME, is a health systems specialist with the Department of Veterans Affairs. She received a bachelor's degree in biomedical engineering with a minor in mathematics from Tulane University. She has extensive experience with relational database extraction techniques for the purposes of data synthesis with primary interest in health care data
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Russo E, Latta M, Santonastaso DP, Bellantonio D, Cittadini A, Pietrantozzi D, Circelli A, Gamberini E, Martino C, Spiga M, Agnoletti V. Regional anesthesia in the intensive care unit: a single center's experience and a narrative literature review. DISCOVER HEALTH SYSTEMS 2023; 2:4. [PMID: 37520512 PMCID: PMC9870192 DOI: 10.1007/s44250-023-00018-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 01/04/2023] [Indexed: 08/01/2023]
Affiliation(s)
- Emanuele Russo
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Marina Latta
- Anesthesia and Intensive Care Department, Alma Mater Studiorum – Università Di Bologna, Bologna, Italy
| | | | - Daniele Bellantonio
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Alessio Cittadini
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Dario Pietrantozzi
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Alessandro Circelli
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Emiliano Gamberini
- Department of Surgery, Anesthesia and Intensive Care Unit, Infermi Hospital, Rimini, Italy
| | - Costanza Martino
- Department of Anesthesiology and Acute Care, Umberto I Hospital of Lugo, Ausl Della Romagna, Lugo, Italy
| | - Martina Spiga
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
| | - Vanni Agnoletti
- Department of Surgery and Trauma, Anesthesia and Intensive Care Unit, Maurizio Bufalini Hospital, Cesena, Italy
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Impact of ICU strain on outcomes. Curr Opin Crit Care 2022; 28:667-673. [PMID: 36226707 DOI: 10.1097/mcc.0000000000000993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Acute surge events result in health capacity strain, which can result in deviations from normal care, activation of contingencies and decisions related to resource allocation. This review discusses the impact of health capacity strain on patient centered outcomes. RECENT FINDINGS This manuscript discusses the lack of validated metrics for ICU strain capacity and a need for understanding the complex interrelationships of strain with patient outcomes. Recent work through the coronavirus disease 2019 pandemic has shown that acute surge events are associated with significant increase in hospital mortality. Though causal data on the differential impact of surge actions and resource availability on patient outcomes remains limited the overall signal consistently highlights the link between ICU strain and critical care outcomes in both normal and surge conditions. SUMMARY An understanding of ICU strain is fundamental to the appropriate clinical care for critically ill patients. Accounting for stain on outcomes in critically ill patients allows for minimization of variation in care and an ability of a given healthcare system to provide equitable, and quality care even in surge scenarios.
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Agnoletti V, Gamberini E, Circelli A, Martino C, Santonastaso DP, Bolondi G, Bastoni G, Spiga M, Ceccarelli P, Montaguti L, Catena F, Poletti V, Lusenti C, Lazzari C, Altini M, Russo E. Description of an Integrated and Dynamic System to Efficiently Deal With a Raging COVID-19 Pandemic Peak. Front Med (Lausanne) 2022; 9:819134. [PMID: 35372442 PMCID: PMC8971195 DOI: 10.3389/fmed.2022.819134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/14/2022] [Indexed: 11/16/2022] Open
Abstract
Background This study aimed to describe an innovative and functional method to deal with the increased COVID-19 pandemic-related intensive care unit bed requirements. Methods We described the emergency creation of an integrated system of internistic ward, step-down unit, and intensive care unit, physically located in reciprocal vicinity on the same floor. The run was carried out under the control of single intensive care staff, through sharing clinical protocols and informatics systems, and following single director supervision. The intention was to create a dynamic and flexible system, allowing for rapid and fluid patient admission/discharge, depending on the requirements due to the third Italian peak of the COVID-19 pandemic in March 2021. Results This study involved 142 COVID-19 patients and 66 non-COVID-19 patients who were admitted; no critical patient was left unadmitted and no COVID-19 severe patients referring to our center had to be redirected to other hospitals due to bed saturation. This system allowed shorter hospital length-of-stay in general wards (5.9 ± 4 days) than in other internistic COVID-19 wards and overall mortality in line with those reported in literature despite the peak raging. Conclusion This case report showed the feasibility and the efficiency of this dynamic model of hospital rearrangement to deal with COVID-19 pandemic peaks.
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Affiliation(s)
- Vanni Agnoletti
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Cesena, Italy
- *Correspondence: Vanni Agnoletti
| | - Emiliano Gamberini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Cesena, Italy
| | - Alessandro Circelli
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Cesena, Italy
| | - Costanza Martino
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Cesena, Italy
| | - Domenico Pietro Santonastaso
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Cesena, Italy
| | - Giuliano Bolondi
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Cesena, Italy
| | | | - Martina Spiga
- Nursing Department, M Bufalini Hospital, Cesena, Italy
| | | | - Luca Montaguti
- Department of Internal Medicine, M Bufalini Hospital, Cesena, Italy
| | - Fausto Catena
- Department of Emergency Surgery and Trauma, M Bufalini Hospital, Cesena, Italy
| | - Venerino Poletti
- Department of Respiratory Diseases, AUSL Romagna-Morgagni Hospital, Forlì, Italy
| | - Carlo Lusenti
- Hospital Direction M Bufalini Hospital, Cesena, Italy
| | | | - Mattia Altini
- Hospital Direction Azienda Unità Sanitaria Locale della Romagna, Ravenna, Italy
| | - Emanuele Russo
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Cesena, Italy
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Tortola D, Magnani E, Giorgini E, Zani MC, Pazzaglini C, Sambo P, Montaguti L. Managing Complexity: The Experience of an Italian Internal Medicine Unit During the SARS-CoV-2 Pandemic, Looking to the Future. SN COMPREHENSIVE CLINICAL MEDICINE 2022; 4:233. [PMID: 36320815 PMCID: PMC9610320 DOI: 10.1007/s42399-022-01320-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 12/28/2022]
Abstract
The impact of COVID-19 pandemic put the Italian health system into a test. In the period between September 2020 and June 2021, a weekly average of 114 SARS-CoV-2 infections were recorded in Forlì-Cesena province (north of Italy), with a maximum of 330 cases per week in March 2021; in the same months, the Internal Medicine Unit of Cesena M. Bufalini Hospital managed 954 COVID-19 patients. To allow the management of these patients, the ward was divided into areas at different intensity of care, with a maximum of 39-47 beds and 19-24 in ordinary and sub-intensive area, respectively. Patients had an average age of 66 years, and 62% of the total was female; prevalent comorbidities were arterial hypertension (53%), smoking habit (28.7%), obesity (27.9%), uncomplicated (10%), and complicated diabetes (9%). On the total, 339 patients were hospitalized in sub-intensive area, subjected to non-invasive ventilatory support. Hospitalization lasted about 7 days in the ordinary ward and 13 days in the sub-intensive area. One hundred six patients died. In the considered period, the mean percentage of deaths compared to hospitalizations in Italy was equal to 22.21%; in our experience, the overall mortality rate was 11%. Our organizational model, which included different intensity areas in the same ward and various specialist skills, as the ability to manage non-invasive ventilation and bedside ultrasound, allowed flexible management of the "complex" COVID patient. Even the mortality rate may be the result of this model. These features mark what modern Internal Medicine should be like.
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Affiliation(s)
- Daniela Tortola
- Internal Medicine Unit, Cesena M. Bufalini Hospital, AUSL Della Romagna: Azienda Unità Sanitaria Della Romagna, Cesena, Italy
| | - Elena Magnani
- Internal Medicine Unit, Cesena M. Bufalini Hospital, AUSL Della Romagna: Azienda Unità Sanitaria Della Romagna, Cesena, Italy
| | - Enrico Giorgini
- Internal Medicine Unit, Cesena M. Bufalini Hospital, AUSL Della Romagna: Azienda Unità Sanitaria Della Romagna, Cesena, Italy
| | - Maria Cristina Zani
- Internal Medicine Unit, Cesena M. Bufalini Hospital, AUSL Della Romagna: Azienda Unità Sanitaria Della Romagna, Cesena, Italy
| | - Chiara Pazzaglini
- Internal Medicine Unit, Cesena M. Bufalini Hospital, AUSL Della Romagna: Azienda Unità Sanitaria Della Romagna, Cesena, Italy
| | - Paola Sambo
- Internal Medicine Unit, Cesena M. Bufalini Hospital, AUSL Della Romagna: Azienda Unità Sanitaria Della Romagna, Cesena, Italy
| | - Luca Montaguti
- Internal Medicine Unit, Cesena M. Bufalini Hospital, AUSL Della Romagna: Azienda Unità Sanitaria Della Romagna, Cesena, Italy
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De Cassai A, Longhini F, Romagnoli S, Cavaliere F, Caroleo A, Foti L, Furlani E, Gianoli S, Monteleone F, Saraco G, Villa G, Conti G, Navalesi P. Research on SARS-COV-2 pandemic: a narrative review focused on the Italian contribution. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2021. [PMCID: PMC8596088 DOI: 10.1186/s44158-021-00017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Since late 2019, a severe acute respiratory syndrome, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has spread with overwhelming speed causing over 214 million confirmed infections and more than 4.5 million deaths worldwide. In this framework, Italy had the second highest number of SARS-CoV-2 infections worldwide, and the largest number of deaths. A global effort of both the scientific community and governments has been undertaken to stem the pandemic. The aim of this paper is to perform a narrative review of the Italian contribution to the scientific literature regarding intensive care management of patients suffering from COVID-19, being one of the first western countries to face an outbreak of SARS-CoV-2 infection.
Main body
We performed a narrative review of the literature, dedicating particular attention and a dedicated paragraph to ventilatory support management, chest imaging findings, biomarkers, possible pharmacological interventions, bacterial superinfections, prognosis and non-clinical key aspects such as communication and interaction with relatives.
Conclusions
Many colleagues, nurses and patients died leaving their families alone. To all of them, we send our thoughts and dedicate these pages.
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