Nursing care left undone in psychiatric hospitals and its association with nurse staffing: A cross-sectional multi-centre study in Switzerland

INTRODUCTION

Nursing care left undone occurs when nurses omit activities because of resource shortfalls. Higher levels of nursing care left undone are associated with worse nurse staffing and organizational factors. Plentiful evidence from acute, long-term and community care supports such associations; however, mental healthcare settings are under-studied.

AIM

The aim of the study was to describe nursing care left undone's frequency in mental health inpatient settings and explore its association with nurse staffing levels.

METHOD

As part of the multi-centre cross-sectional MatchRN Psychiatry study, data were collected by questionnaire from 114 units in 13 Swiss psychiatric hospitals. Nursing care left undone was analysed describing frequencies descriptively and used linear mixed models to assess its association with staffing.

RESULTS

Data from 994 nurses were analysed. The most commonly omitted activities were evaluating nursing processes (30.5%), formulating nursing diagnoses (27.4%) and defining care objectives (22.7%). Nursing care left undone was higher in units with low staffing levels.

DISCUSSION

As in somatic care settings, in psychiatric hospitals, 'indirect' care activities are most commonly omitted.

IMPLICATIONS FOR PRACTICE

This study highlights factors affecting the frequency of nursing care left undone, including staffing levels and perceived leadership. The findings emphasize the importance of nurse managers taking action to improve work environment factors.

Distinct smell and taste disorder phenotype of post-acute COVID-19 sequelae

PURPOSE

Olfactory dysfunction (OD) commonly accompanies coronavirus disease 2019 (COVID-19). We investigated the kinetics of OD resolution following SARS-CoV-2 infection (wild-type and alpha variant) and its impact on quality of life, physical and mental health.

METHODS

OD prevalence was assessed in an ambulatory COVID-19 survey (n = 906, ≥ 90 days follow-up) and an observational cohort of ambulatory and hospitalized individuals (n = 108, 360 days follow-up). Co-occurrence of OD with other symptoms and effects on quality of life, physical and mental health were analyzed by multi-dimensional scaling, association rule mining and semi-supervised clustering.

RESULTS

Both in the ambulatory COVID-19 survey study (72%) and the observational ambulatory and hospitalized cohort (41%) self-reported OD was frequent during acute COVID-19. Recovery from self-reported OD was slow (survey: median 28 days, observational cohort: 90 days). By clustering of the survey data, we identified a predominantly young, female, comorbidity-free group of convalescents with persistent OD and taste disorders (median recovery: 90 days) but low frequency of post-acute fatigue, respiratory or neurocognitive symptoms. This smell and taste disorder cluster was characterized by a high rating of physical performance, mental health, and quality of life as compared with convalescents affected by prolonged fatigue or neurocognitive complaints.

CONCLUSION

Our results underline the heterogeneity of post-acute COVID-19 sequelae calling for tailored management strategies. The persistent smell and taste disorder phenotype is characterized by good clinical, physical, and mental recovery and may pose a minor challenge for public health.

STUDY REGISTRATION

ClinicalTrials.gov: NCT04661462 (survey study), NCT04416100 (observational cohort).

[Prevention of Post-operative Delirium]

Postoperative delirium (POD) is an adverse but often preventable complication of surgery and surgery-related anaesthesia, and increasingly prevalent. This article provides an overview on non-pharmacological preventive measures, divided into individualized and non-individualized measures. Non-individualized measures, such as the most minimally invasive surgical procedure, avoidance of unnecessary fasting before surgery, and the most tolerable anaesthesia are used to minimize the risk of POD in all patients. Based on the results of preoperative screenings for risk factors such as frailty or cognitive impairment, individualized measures may encompass prehabilitation, treatment of specific risk factors, operation room companionship or cognitive, motor, and sensory stimulation as well as social support. This article additionally lists several examples of best practice approaches already implemented in German-speaking countries and websites for further readings.

Adolescent Mental Health during the COVID-19 Pandemic: The Interplay of Age, Gender, and Mental Health Outcomes in Two Consecutive Cross-Sectional Surveys in Northern Italy

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the mental health and well-being of adolescents. This study aimed to investigate the development of health-related quality of life (HRQoL) and mental health among adolescents in Northern Italy by comparing cross-sectional surveys conducted in 2021 and 2022, with a particular focus on the influence of age and gender. The sample included adolescents aged 11-19 years from public schools in South Tyrol. Validated psychometric instruments were used to assess HRQoL, anxiety and depression symptoms, and psychosomatic complaints. Sociodemographic variables, COVID-19 burden, and pandemic-related factors were measured. Statistical analyses included chi-square tests, correlation coefficients, and logistic regression analyses. The results indicated that while the self-reported burden of adolescents decreased significantly in 2022 (n = 1885) compared to 2021 (n = 1760), there were no significant differences in symptoms of anxiety, depressive symptoms, low HRQoL, and increased psychosomatic complaints between the two surveys for both early and late adolescents. Females consistently had higher percentages for all outcome variables, and symptoms of anxiety increased with age in females, but not in males. Both genders experienced an increase in depressive symptoms and low HRQoL with age. The co-occurrence of mental health outcomes was observed, suggesting overlapping patterns among anxiety, depression, low HRQoL, and psychosomatic complaints. These findings underscore the intricate relationship between age, gender, and mental health outcomes among adolescents during the pandemic. It is important to recognize that late adolescents may exhibit distinct vulnerabilities and may require tailored support approaches to address their specific mental health challenges, differing from those needed for early adolescents.

Administrative burden in Swiss nursing homes and its association with care workers' outcomes-a multicenter cross-sectional study

BACKGROUND

Care workers in nursing homes often perform tasks that are rather related to organizational or management activities than 'direct patient care'. 'Indirect care activities', such as documentation or other administrative tasks are often considered by care workers as a burden, as they increase overall workload and keep them away from caring for residents. So far, there is little investigation into what kind of administrative tasks are being performed in nursing homes, by which type of care workers, and to which extent, nor how administrative burden is associated with care workers' outcomes.

PURPOSE

The objective of this study was to describe care workers' administrative burden in Swiss nursing homes and to explore the association with four care worker outcomes (i.e., job dissatisfaction, emotional exhaustion, intention to leave the current job and the profession).

METHODS

This multicenter cross-sectional study used survey data from the Swiss Nursing Homes Human Resources Project 2018. It included a convenience sample of 118 nursing homes and 2'207 care workers (i.e., registered nurses, licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the administrative tasks and burden, staffing and resource adequacy, leadership ability, implicit rationing of nursing care and care worker characteristics and outcomes. For the analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, 73.9% (n = 1'561) of care workers felt strongly or rather strongly burdened, with one third (36.6%, n = 787) reporting to spend 2 h or more during a "normal" day performing administrative tasks. Ratings for administrative burden ranged from 42.6% (n = 884; ordering supplies and managing stocks) to 75.3% (n = 1'621; filling out the resident's health record). One out of four care workers (25.5%, n = 561) intended to leave the profession, whereby care workers reporting higher administrative task burden (OR = 1.24; 95%CI: 1.02-1.50) were more likely to intend to leave the profession.

CONCLUSION

This study provides first insights on care workers' administrative burden in nursing homes. By limiting care workers' burdensome administrative tasks and/or shifting such tasks from higher to lower educated care workers or administrative personnel when appropriate, nursing home managers could reduce care workers' workload and improve their job satisfaction and retention in the profession.

Evolution of Youth's Mental Health and Quality of Life during the COVID-19 Pandemic in South Tyrol, Italy: Comparison of Two Representative Surveys

BACKGROUND

The coronavirus disease 2019 pandemic has led to an increase in youth mental health problems worldwide. Studies have revealed substantial variation in the incidence of these problems across different regions. Longitudinal studies of children and adolescents in Italy are lacking. This study aimed to investigate the development of health-related quality of life (HRQoL) and mental health in Northern Italy by comparing surveys conducted in June 2021 and in March 2022.

METHODS

A representative, large cross-sectional, online survey investigated HRQoL, psychosomatic complaints, and symptoms of anxiety and depression among 5159 and 6675 children and adolescents in 2021 and 2022, respectively, using the KIDSCREEN-10 index, HBSC symptom checklist, SCARED, CES-DC, and PHQ-2 instruments. Statistical analyses included a multivariate linear regression analysis.

RESULTS

Baseline characteristics showed significant differences in demographic variables between the two surveys. Girls and their parents reported a significantly lower HRQoL in 2021 than in 2022. Psychosomatic complaints differed significantly between sexes, and the results showed no decrease in psychosomatic complaints, anxiety, or depression between 2021 and 2022. Predictors of HRQoL, anxiety, depressive symptoms, and psychosomatic complaints in 2022 differed from those in 2021.

CONCLUSIONS

The characteristics of the 2021 pandemic, including lockdowns and home schooling, may have contributed to the differences between the two surveys. As most pandemic restrictions ended in 2022, the results confirm the need for measures to improve the mental and physical health of children and adolescents after the pandemic.

[Interrater reliability and concurrent validity of 4AT for the detection of postoperative delirium: A prospective cohort study]

Interrater reliability and concurrent validity of 4AT for the detection of postoperative delirium: A prospective cohort study Abstract. Background: Numerous tools for detecting postoperative delirium are available. Guidelines recommend the 4 A's Test (4AT). However, there is little evidence on the validity and reliability of the German version of 4AT. Aim: To assess the interrater reliability of the German version of 4AT test for the detection of postoperative delirium in general surgical and orthopedic-traumatological patients, and the concurrent validity with the Delirium Observation Screening Scale (DOS). Methods: The present work is part of a prospective cohort study with a sample of 202 inpatients (≥ 65 years) who underwent surgery. The interrater reliability of the 4AT (intraclass coefficients) was determined with a subsample of 33 subjects who were rated by two nurses. Concurrent validity between the DOS scale and the 4AT was calculated using Pearson's correlation coefficient. Results: Interrater reliability for the 4AT total score and dichotomized total score were 0.92 (95% CI 0.84-0.96) and 0.98 (95% CI 0.95-0.98), respectively. The correlation between DOS and 4AT (Pearson) was 0.54 (p < 0.001). Conclusions: The 4A test can be used by nurses as a screening instrument for the detection of postoperative delirium in older patients on general surgery and orthopedic traumatology wards. In case of positive 4AT results further assessment by nurse experts or physicians is required.

Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms - A prospective observational study

BACKGROUND

An immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms.

METHODS

All patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient's ECG. The main study outcome was the diagnosis of an acute cardiovascular event.

RESULTS

Of the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse-physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001).

CONCLUSIONS

ECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.

Relationship between depression, anxiety, stress, and SARS-CoV-2 infection: a longitudinal study

Objectives

We aimed to (1) describe the course of the emotional burden (i.e., depression, anxiety, and stress) in a general population sample during the coronavirus pandemic in 2020 and 2021 and (2) explore the association between emotional burden and a serologically proven infection with SARS-CoV-2.

Study design

This longitudinal study involved a sample of community-dwelling persons aged ≥14 years from the general population of South Tyrol (Province of Bolzano-Bozen, Northern Italy). Data were collected at two stages over a 1-year period in 2020 and 2021.

Methods

Persons were invited to participate in a survey on socio-demographic, health-related and psychosocial variables (e.g., age, chronic diseases, Depression Anxiety Stress Scale, DASS-21), as well as in the serological testing for of SARS-CoV-2-specific immunoglobulins.

Results

In 2020, 855 (23.8%) out of 3,600 persons participated; in 2021, 305 (35.7%) out of 855 were tested again. We observed a statistically significant decrease in mean DASS-21 scores for depression, stress, and total scores between 2020 and 2021, yet not for anxiety. Persons with a confirmed SARS-CoV-2-infection between the first and second data collection exhibited increased emotional burden compared to those without SARS-CoV-2-infection. The odds of participants with a self-reported diagnosis of mental disorder for future infection with SARS-CoV-2 was almost four times higher than that of participants without mental disorders (OR:3.75; 95%CI:1.79-7.83).

Conclusion

Our findings support to the hypothesis of a psycho-neuroendocrine-immune interplay in COVID-19. Further research is necessary to explore the mechanisms underlying the interplay between mental health and SARS-CoV-2 infections.

CARE WORKERS’ ADMINISTRATIVE BURDEN IN SWISS NURSING HOMES: A MULTICENTER CROSS-SECTIONAL STUDY

Apart from ‘direct’ resident care, care workers in nursing homes also perform tasks that are related to organizational or management activities. ‘Indirect’ care activities, such as administrative tasks, are often considered as burdensome, as they increase overall workload and keep care workers away from caring for their residents. So far, there is little investigation on care workers’ administrative burden. The multicenter cross-sectional Swiss Nursing Homes Human Resources Project (2018) study included a convenience sample of 118 Swiss nursing homes and 2207 care workers (i.e., registered nurses and licensed practical nurses). Care workers completed questionnaires assessing the administrative burden, staffing and resource adequacy, leadership ability, implicit rationing of nursing care and care worker characteristics and outcomes. For the analysis, we applied 2-level binomial generalized linear mixed models. Overall, 73.91% (n=1561) of care workers felt strongly or rather strongly burdened, with one third (36.6%, n=787) reporting to spend 2h or more during a "normal" day performing administrative tasks. Ratings ranged from 42.6% (n=884; ordering supplies and managing stocks) to 75.3% (n=1621; filling out the patient’s medical record). One out of four care workers (25.5%, n=561) intended to leave the profession, whereby care workers reporting higher administrative burden (OR=1.24; 95%CI: 1.02-1.50) were more likely to leave the profession. This study provides first insights on care workers’ administrative burden in nursing homes, which can inform the development of interventions to reduce the workload related to ‘indirect care activities’ and to improve care workers’ job satisfaction and retention in the profession.

The effect of time-varying capacity utilization on 14-day in-hospital mortality: a retrospective longitudinal study in Swiss general hospitals

BACKGROUND

High bed-occupancy (capacity utilization) rates are commonly thought to increase in-hospital mortality; however, little evidence supports a causal relationship between the two. This observational study aimed to assess three time-varying covariates-capacity utilization, patient turnover and clinical complexity level- and to estimate causal effect of time-varying high capacity utilization on 14 day in-hospital mortality.

METHODS

This retrospective population-based analysis was based on routine administrative data (n = 1,152,506 inpatient cases) of 102 Swiss general hospitals. Considering the longitudinal nature of the problem from available literature and expert knowledge, we represented the underlying data generating mechanism as a directed acyclic graph. To adjust for patient turnover and patient clinical complexity levels as time-varying confounders, we fitted a marginal structure model (MSM) that used inverse probability of treatment weights (IPTWs) for high and low capacity utilization. We also adjusted for patient age and sex, weekdays-vs-weekend, comorbidity weight, and hospital type.

RESULTS

For each participating hospital, our analyses evaluated the ≥85th percentile as a threshold for high capacity utilization for the higher risk of mortality. The mean bed-occupancy threshold was 83.1% (SD 8.6) across hospitals and ranged from 42.1 to 95.9% between hospitals. For each additional day of exposure to high capacity utilization, our MSM incorporating IPTWs showed a 2% increase in the odds of 14-day in-hospital mortality (OR 1.02, 95% CI: 1.01 to 1.03).

CONCLUSIONS

Exposure to high capacity utilization increases the mortality risk of inpatients. Accurate monitoring of capacity utilization and flexible human resource planning are key strategies for hospitals to lower the exposure to high capacity utilization.

Awareness and use of home remedies in Italy’s alps: a population-based cross-sectional telephone survey

Background

Belief in complementary and alternative medicine practices is related to reduced preparedness for vaccination. This study aimed to assess home remedy awareness and use in South Tyrol, where vaccination rates in the coronavirus pandemic were lowest in Italy and differed between German- and Italian-speaking inhabitants.

Methods

A population-based survey was conducted in 2014 and analyzed using descriptive statistics, multiple logistic regression, and latent class analysis.

Results

Of the representative sample of 504 survey respondents, 357 (70.8%) participants (43.0% male; primary language German, 76.5%) reported to use home remedies. Most commonly reported home remedies were teas (48.2%), plants (21.0%), and compresses (19.5%). Participants from rural regions were less likely (odds ratio 0.35, 95% confidence interval 0.19–0.67), while female (2.62, 1.69–4.10) and German-speaking participants (5.52, 2.91–9.88) were more likely to use home remedies. Latent classes of home remedies were “alcoholic home remedies” (21.4%) and “non-alcohol-containing home remedies” (78.6%). Compared to the “non-alcohol-containing home remedies” class, members of the “alcoholic home remedies” class were more likely to live in an urban region, to be male and German speakers.

Conclusion

In addition to residence and sex, language group membership associates with awareness and use of home remedies. Home remedies likely contribute to socio-cultural differences between the language groups in the Italian Alps. If the observed associations explain the lower vaccination rates in South Tyrol among German speakers requires further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03781-0.

Rural-Urban Disparities in Vaccine Hesitancy among Adults in South Tyrol, Italy

BACKGROUND

The demographic determinants of hesitancy in Coronavirus Disease-2019 (COVID-19) vaccination include rurality, particularly in low- and middle-income countries. In the second year of the pandemic, in South Tyrol, Italy, 15.6 percent of a representative adult sample reported hesitancy. Individual factors responsible for greater vaccination hesitancy in rural areas of central Europe are poorly understood.

METHODS

A cross-sectional survey on a probability-based sample of South Tyrol residents in March 2021 was analyzed. The questionnaire collected information on sociodemographic characteristics, comorbidities, COVID-19-related experiences, conspiracy thinking, and the likelihood of accepting the national vaccination plan. A logistic regression analysis was performed.

RESULTS

Among 1426 survey participants, 17.6% of the rural sample (n = 145/824) reported hesitancy with COVID-19 vaccination versus 12.8% (n = 77/602) in urban residents (p = 0.013). Rural residents were less likely to have post-secondary education, lived more frequently in households with children under six years of age, and their economic situation was worse than before the pandemic. Chronic diseases and deaths due to COVID-19 among close relatives were less frequently reported, and trust in pandemic management by national public health institutions was lower, as was trust in local authorities, civil protection, and local health services. Logistic regression models confirmed the most well-known predictors of hesitancy in both urban and rural populations; overall, residency was not an independent predictor.

CONCLUSION

Several predictors of COVID-19 vaccine hesitancy were more prevalent in rural areas than in urban areas, which may explain the lower vaccine uptake in rural areas. Rurality is not a determinant of vaccine hesitancy in the economically well-developed North of Italy.

Repeated assessments and predictors of nurses' shift-specific perceived workload

BACKGROUND

Workload perception is of interest to researchers and policymakers as it captures subjective assessments of nurses' workload which has implications for staffing and patient outcomes.

AIMS

We aimed to describe repeated assessments of nurses' perceived workload among registered nurses (RNs) in day and night shifts and to examine the association of perceived workload with workdays, units, and nurse-staffing.

METHODS

Repeated data on the indictors of interest were collected from 90 RNs across 91 shifts in a Lebanese acute-care hospital. Perceived workload was assessed using the NASA-Task-Load Index (NASA-TLX). Linear mixed-effect models were used for analysis.

RESULTS

Mean perceived workload was high reaching 6.63 (95% confidence interval [CI] = 6.34, 6.92) in day and 5.90 (95% CI = 5.43, 6.36) in night shifts. In mixed-effect models, perceived workload was lower on weekends/holidays as compared to weekdays in day (ß = -.32; 95% CI = -0.53, -0.12) and night (ß = -.46; 95% CI = -0.85, -0.07) shifts. Higher perceived workload (ß = .19; 95% CI = 0.04, 0.33) was associated with higher patient-to-nurse ratio in the day but not night shifts.

CONCLUSION

Repeated workload assessments support the presence of elevated perceived workload among RNs which is related to weekdays and higher patient-to-nurse ratio. Future investigations would benefit from better characterization of workload particularities to address perceived burden and improve organizational and management decisions.

Delirium in elderly postoperative patients: A prospective cohort study

AIM

To describe the incidence, time in days and risk factors for postoperative delirium in elderly patients.

DESIGN

Prospective cohort study.

METHODS

Patients over 65 years were daily screened with the 4A's Test and the Delirium Observation Screening Scale for postoperative delirium. A psychiatrist assessed according to the DSM-V. We performed descriptive and logistic regression analyses.

RESULTS

From 202 patients, 7.5% (N = 15) had a diagnosed postoperative delirium, whereby 73.3% (N = 11) developed the delirium during the first 48 hr after surgery. The median duration was 1 day. Patients over 80 years suffering from heart failure with surgical drains, bladder catheter, central venous catheter had higher odds for developing a postoperative delirium. The incidence of postoperative delirium in our sample was lower compared with other surgical and ortho-geriatric populations. Despite age, several modifiable postoperative factors were associated with the occurrence of postoperative delirium.

Variation in detected adverse events using trigger tools: A systematic review and meta-analysis

Background

Adverse event (AE) detection is a major patient safety priority. However, despite extensive research on AEs, reported incidence rates vary widely.

Objective

This study aimed: (1) to synthesize available evidence on AE incidence in acute care inpatient settings using Trigger Tool methodology; and (2) to explore whether study characteristics and study quality explain variations in reported AE incidence.

Design

Systematic review and meta-analysis.

Methods

To identify relevant studies, we queried PubMed, EMBASE, CINAHL, Cochrane Library and three journals in the patient safety field (last update search 25.05.2022). Eligible publications fulfilled the following criteria: adult inpatient samples; acute care hospital settings; Trigger Tool methodology; focus on specialty of internal medicine, surgery or oncology; published in English, French, German, Italian or Spanish. Systematic reviews and studies addressing adverse drug events or exclusively deceased patients were excluded. Risk of bias was assessed using an adapted version of the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Our main outcome of interest was AEs per 100 admissions. We assessed nine study characteristics plus study quality as potential sources of variation using random regression models. We received no funding and did not register this review.

Results

Screening 6,685 publications yielded 54 eligible studies covering 194,470 admissions. The cumulative AE incidence was 30.0 per 100 admissions (95% CI 23.9–37.5; I² = 99.7%) and between study heterogeneity was high with a prediction interval of 5.4–164.7. Overall studies’ risk of bias and applicability-related concerns were rated as low. Eight out of nine methodological study characteristics did explain some variation of reported AE rates, such as patient age and type of hospital. Also, study quality did explain variation.

Conclusion

Estimates of AE studies using trigger tool methodology vary while explaining variation is seriously hampered by the low standards of reporting such as the timeframe of AE detection. Specific reporting guidelines for studies using retrospective medical record review methodology are necessary to strengthen the current evidence base and to help explain between study variation.

Increasing implicit rationing of care in nursing homes: A time-series cross-sectional analysis

BACKGROUND

Implicit rationing of nursing care is a socio-ecological problem where care workers, due to lack of resources, have to leave necessary nursing care activities undone. Cross-sectional studies on implicit rationing of nursing home care revealed associations with organizational and work environment characteristics. However, little is known on how implicit rationing of nursing care varies over time in nursing homes.

OBJECTIVE

This study's purpose was to describe changes in levels and patterns of implicit rationing of nursing care in Swiss nursing homes over time, while accounting for key explanatory factors related to organizational, work environment, and individual characteristics.

DESIGN

Time-series cross-sectional analysis.

SETTING

Nursing homes in Switzerland.

PARTICIPANTS

A convenience sample of 47 nursing homes and 3269 care workers from all educational levels participating in two multicenter cross-sectional studies (the Swiss Nursing Home Human Resources Project) conducted in 2013 and 2018.

METHODS

To quantify implicit rationing of nursing care, care workers' data were collected via the nursing home version of the Basel Extent of Rationing of Nursing Care instrument. To control for leadership ability, staffing and resource adequacy, we used the Nursing Work Index-Practice Environment Scale. Objective measures including turnover, staffing and skill mix levels were aggregated at the nursing home level. Our analyses included multiple linear mixed models, using time as a fixed effect and nursing home as a random effect.

RESULTS

We found overall increases of rationing of care activities over the five-year period studied, with documentation and social activities most rationed at both measurement points (overall coefficients varied between 0.11 and 0.23, as well as the 95%-confidence intervals between 0.05 and 0.30). Moreover, a considerable increase in rationing of activities of daily living (coefficient of 0.47 in 2013 and 0.63 in 2018) was observed.

CONCLUSIONS

Alongside long-term deterioration of staff resources, increases in rationing of nursing care are a worrying development, particularly given their potential negative impacts both on residents and on care workers. To assess nursing home care quality and to determine adequate staffing levels and skill mixes, policy makers and nursing home managers should consider regular monitoring of rationing of nursing care.

TWEETABLE ABSTRACT

Time-series cross-sectional analysis reveals increasing rationing of nursing care activities in Swiss nursing homes from 2013 to 2018.

Health information-seeking behavior associated with linguistic group membership: latent class analysis of a population-based cross-sectional survey in Italy, August to September 2014

Background

Evidence suggests an increasing demand for culturally and linguistically responsive disease prevention programs and health interventions. It is important to understand how individuals seek health information to address the potential needs of the health care system.

Methods

Latent classes of health information-seeking behaviors in a linguistically mixed region of Italy were explored through a population-based telephone survey of ten health information sources. Data were collected in August and September 2014 from 504 adults in South Tyrol, Italy (primary language German, 68%; Italian, 28%), and analyzed using latent class analysis and latent class multinomial logistic regression models.

Results

Three classes of health information-seeking behaviors emerged: “multidimensional” (23.3%), “interpersonal” (38.6%) and “technical/online” (38.1%). Compared to the “technical/online” class, “interpersonal” class members were older, had lower education than high school, and were less likely to be of Italian ethnicity. “Multidimensional” class members were more likely to be female, older, and of German ethnicity than those in the “technical/online” class.

Conclusions

Linguistic ethnicity explains membership in classes on health information-seeking behavior. Policymakers and healthcare providers should consider the health information-seeking behaviors of population subgroups to promote health and medical care in linguistic minority groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00847-w.

Disaster Response in Italian Nursing Homes: A Qualitative Study during the COVID-19 Pandemic

Nursing homes (NHs) have been among the care settings most affected by both the virus itself and collateral damage through infection protection and control measures (IPC). However, there is a paucity of research regarding disaster response and preparedness of these institutions. The present study aimed to analyze disaster response and management and to develop prospective strategies for disaster management in NHs. A qualitative survey including (i) residents, (ii) nursing staff, (iii) relatives of residents, and (iv) NHs’ medical leads was performed. Data were collected by 45 in-depth interviews. Our results indicate that the shift from resident-centered care towards collective-protective approaches led through the suspending of established care principles to an emergency vacuum: implementable strategies were lacking and the subsequent development of temporary, immediate, and mostly suboptimal solutions by unprepared staff led to manifold organizational, medical, and ethical conflicts against the background of unclear legislation, changing protocols, and fear of legal consequences. IPC measures had long-lasting effects on the health and wellbeing of residents, relatives, and professionals. Without disaster preparedness protocols and support in decision-making during disasters, professionals in NHs are hardly able to cope with emergency situations.

Who Is at Risk of Poor Mental Health Following Coronavirus Disease-19 Outpatient Management?

Background

Coronavirus Disease-19 (COVID-19) convalescents are at risk of developing a de novo mental health disorder or worsening of a pre-existing one. COVID-19 outpatients have been less well characterized than their hospitalized counterparts. The objectives of our study were to identify indicators for poor mental health following COVID-19 outpatient management and to identify high-risk individuals.

Methods

We conducted a binational online survey study with adult non-hospitalized COVID-19 convalescents (Austria/AT: n = 1,157, Italy/IT: n = 893). Primary endpoints were positive screening for depression and anxiety (Patient Health Questionnaire; PHQ-4) and self-perceived overall mental health (OMH) and quality of life (QoL) rated with 4 point Likert scales. Psychosocial stress was surveyed with a modified PHQ stress module. Associations of the mental health and QoL with socio-demographic, COVID-19 course, and recovery variables were assessed by multi-parameter Random Forest and Poisson modeling. Mental health risk subsets were defined by self-organizing maps (SOMs) and hierarchical clustering algorithms. The survey analyses are publicly available (https://im2-ibk.shinyapps.io/mental_health_dashboard/).

Results

Depression and/or anxiety before infection was reported by 4.6% (IT)/6% (AT) of participants. At a median of 79 days (AT)/96 days (IT) post-COVID-19 onset, 12.4% (AT)/19.3% (IT) of subjects were screened positive for anxiety and 17.3% (AT)/23.2% (IT) for depression. Over one-fifth of the respondents rated their OMH (AT: 21.8%, IT: 24.1%) or QoL (AT: 20.3%, IT: 25.9%) as fair or poor. Psychosocial stress, physical performance loss, high numbers of acute and sub-acute COVID-19 complaints, and the presence of acute and sub-acute neurocognitive symptoms (impaired concentration, confusion, and forgetfulness) were the strongest correlates of deteriorating mental health and poor QoL. In clustering analysis, these variables defined subsets with a particularly high propensity of post-COVID-19 mental health impairment and decreased QoL. Pre-existing depression or anxiety (DA) was associated with an increased symptom burden during acute COVID-19 and recovery.

Conclusion

Our study revealed a bidirectional relationship between COVID-19 symptoms and mental health. We put forward specific acute symptoms of the disease as "red flags" of mental health deterioration, which should prompt general practitioners to identify non-hospitalized COVID-19 patients who may benefit from early psychological and psychiatric intervention.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT04661462].

Effect of the Emergency Department Assessment of Chest Pain Score on the Triage Performance in Patients With Chest Pain

The sensitivity of triage systems in identifying acute cardiovascular events in patients presented to the emergency department with chest pain is not optimal. Recently, a clinical score, the Emergency Department Assessment of Chest Pain Score (EDACS), has been proposed for a rapid assessment without additional instruments. To evaluate whether the integration of EDACS into triage evaluation of patients with chest pain can improve the triage's predictive validity for an acute cardiovascular event, a single-center prospective observational study was conducted. This study involved all patients who needed a triage admission for chest pain between January 1, 2020, and December 31, 2020. All enrolled patients first underwent a standard triage assessment and then the EDACS was calculated. The primary outcome of the study was the presence of an acute cardiovascular event. The discriminatory ability of EDACS in triage compared with standard triage assessment was evaluated by comparing the areas under the receiver operating characteristic curve, decision curve analysis, and net reclassification improvement. The study involved 1,596 patients, of that 7.3% presented the study outcome. The discriminatory ability of triage presented an area under the receiver operating characteristic curve of 0.688 that increased to 0.818 after the application of EDACS in the triage assessment. EDACS improved the baseline assessment of priority assigned in triage, with a net reclassification improvement of 33.6% (p <0.001), and the decision curve analyses demonstrated that EDACS in triage resulted in a clear net clinical benefit. In conclusion, the results of the study suggest that EDACS has a good discriminatory capacity for acute cardiovascular events and that its implementation in routine triage may improve triage performance in patients with chest pain.

Variability, shift-specific workloads and rationed care predictors of work satisfaction among Registered nurses providing acute care: A longitudinal study

Aims

The aim of this study was to explore nurses’ shift‐work satisfaction variability across time and its shift‐specific predictors: perceived workload, patient‐to‐nurse ratio and rationing of nursing care.

Design

Longitudinal study of 90 Registered nurses (N = 1,303 responses) in a Lebanese hospital over 91 days of data collection.

Methods

Intraclass correlation coefficients (ICCs) were computed to determine shift‐work satisfaction variability between individual nurses and working‐unit clusters. Generalized linear mixed models were used to explore the workloads and rationed care predictors of nurses’ shift‐work satisfaction separately for day and night shifts.

Results

Variability in shift‐work satisfaction was noted between individual nurses in day (ICC = 0.43) and night shifts (ICC = 0.37), but not between medical/surgical units. Nurses satisfied with their shift‐specific work were less probably to ration necessary nursing care (OR = 0.68; 95% CI = 0.60–0.77) in day shifts and to perceive high workload demands in both, day (OR = 0.29; 95% CI = 0.23–0.37) and night (OR = 0.29; 95% CI = 0.18–0.47) shifts. Monitoring and lowering workload demands while observing rationing of care is necessary to improve nurses’ shift‐work satisfaction.

Phenotyping of acute and persistent COVID-19 features in the outpatient setting: exploratory analysis of an international cross-sectional online survey

BACKGROUND

Long COVID, defined as presence of COVID-19 symptoms 28 days or more after clinical onset, is an emerging challenge to healthcare systems. The objective of this study was to explore recovery phenotypes in non-hospitalized COVID-19 individuals.

METHODS

A dual cohort, online survey study was conducted between September 2020 and July 2021 in the neighboring European regions Tyrol (TY, Austria, n = 1157) and South Tyrol (STY, Italy, n = 893). Data on demographics, comorbidities, COVID-19 symptoms and recovery adult outpatients were collected. Phenotypes of acute COVID-19, post-acute sequelae and risk of protracted recovery were explored by semi-supervised clustering and multi-parameter LASSO modeling.

RESULTS

Working age subjects (TY: 43 yrs (IQR: 31 – 53), STY: 45 yrs (IQR: 35 – 55)) and females (TY: 65.1%, STY: 68.3%) predominated the study cohorts. Nearly half of the participants (TY: 47.6%, STY: 49.3%) reported symptom persistence beyond 28 days. Two acute COVID-19 phenotypes were discerned: the non-specific infection phenotype and the multi-organ phenotype (MOP). Acute MOP symptoms encompassing multiple neurological, cardiopulmonary, gastrointestinal and dermatological complaints were linked to elevated risk of protracted recovery. The major subset of long COVID individuals (TY: 49.3%, STY: 55.6%) displayed no persistent hyposmia or hypogeusia but high counts of post-acute MOP symptoms and poor self-reported physical recovery.

CONCLUSION

The results of our two-cohort analysis delineated phenotypic diversity of acute and post-acute COVID-19 manifestations in home-isolated patients which needs to be considered for predicting protracted convalescence and allocation of medical resources.

The Manchester Triage System's performance in clinical risk prioritisation of patients presenting with headache in emergency department: A retrospective observational study

OBJECTIVE

Non-traumatic headache is a frequent reason for visits to the emergency department (ED). We evaluated the performance of the Manchester Triage System (MTS) in prioritising patients presenting to the ED with non-traumatic headache.

METHODS

In this single-centre observational retrospective study, we compared the association of MTS priority classification codes with a final diagnosis of a severe neurological condition requiring timely management (ischaemic or haemorrhagic stroke, subarachnoid haemorrhage, cerebral sinus venous thrombosis, central nervous system infection or brain tumour). The study was conducted and reported according to the STROBE statement. The overall prioritisation accuracy of MTS was estimated by the area under the receiver operating characteristic (ROC) curve. The correctness of triage prediction was estimated based on the "very urgent" MTS grouping. An undertriage was defined as a patient with an urgent and severe neurological who received a low priority/urgency MTS code (green/yellow).

RESULTS

Over 30 months, 3002 triage evaluations of non-traumatic headache occurred (1.7% of ED visits). Of these, 2.3% (68/3002) were eventually diagnosed with an urgent and severe neurological condition. The MTS had an acceptable prioritisation accuracy, with an area under the ROC curve of 0.734 (95% CI 0.668-0.799). The sensitivity of the MTS for urgent codes (yellow, orange and red) was 79.4% (95% CI 74.5-84.3), with a specificity of 54.1% (95% CI 52.9-55.3). The triage prediction was incorrect in only 6.3% (190/3002) of patients with headache.

CONCLUSION

The MTS is a safe and accurate tool for prioritising patients with non-traumatic headache in the ED. However, MTS may need further specific tools for evaluating the more complicated symptoms and for correctly identifying patients with urgent and severe underlying pathologies.

RELEVANCE TO CLINICAL PRACTICE

The triage nurse using MTS may need additional tools to improve the assessment of patients with headache, although MTS provides a good safety profile.

Triage assessment of transitory loss of consciousness in the emergency department-A retrospective observational study

AIM

To establish how the Manchester Triage System can correctly prioritize patients admitted to the emergency department for transitory loss of consciousness in relation to their risk of presenting severe acute disease.

DESIGN

A observational retrospective study.

METHODS

A total of 2291 patients who required a triage evaluation for a transitory loss of consciousness at the emergency department of Merano Hospital between 1 January 2017 and 30 June 2019 were considered. Transitory loss of consciousness was classified according to European Society of Cardiology guidelines. The baseline characteristics of the patients were collected and divided according to the priority level assigned at triage into two different study groups: high priority (red/orange) and low priority (blue/green/yellow). The composite outcome of the study was defined as the diagnosis of a severe acute disease.

RESULTS

Of the patients enrolled, 17% (390/2291) had a high-priority code and 83% (1901/2291) received a low-priority code. Overall, a severe acute disease was present in 16.9% of patients (387/2291). The Manchester Triage System had a sensitivity of 42.4%, a specificity of 88.1% and an accuracy of 80.4% for predicting severe acute disease. The discriminatory ability had an area under the receiver operating characteristic curve of 0.651 (CI 95%: 0.618-0.685).

CONCLUSIONS

Despite the good specificity, the low sensitivity does not currently allow the Manchester Triage System to completely exclude patients with a severe acute disease who presented in the emergency department for a transitory loss of consciousness. Therefore, it is important to develop precise nursing tools or assessments that can improve triage performance.

IMPACT

The assessment of a complex symptom can create difficulties in the stratification of patients in triage, assigning low-priority codes to patients with a severe disease. Additional tools are needed to allow the correct triage assessment of patients presenting with transitory loss of consciousness.

Nurse triage accuracy in the evaluation of syncope according to European Society of Cardiology guidelines

AIMS

The role of triage for patients admitted to the emergency department (ED) for a syncopal transitory loss of consciousness (TLOC) has not been debated, and no comparisons with the recent European Society of Cardiology (ESC) guidelines are currently available. To verify the ability of triage to correctly prioritize patients with syncopal TLOC.

METHODS AND RESULTS

All patients who received a triage assessment at the ED of the Merano Hospital (Italy) between 1 January 2017 and 30 June 2019 for a syncope were considered. All syncope were reclassified according to the aetiology reported in the ESC guidelines. The baseline characteristics of the patients were recorded and divided according to the severity code provided during triage into two study groups: high priority (red/orange) and low priority (yellow/green/blue). The outcome of the study was the presence of a diagnosed cardiac cause within 30 days after the admission. A total of 2066 patients were enrolled (14.3% high priority vs. 85.7% low priority). Cardiac syncope was present in 7.5% of patients. Nurse triage showed a sensitivity for cardiac syncope of 44.8%, a specificity of 88.1%, and an accuracy of 84.9%. The observed discriminatory ability presented an area under the receiver operating characteristic curve of 0.685 (95% confidence interval 0.638-0.732). The possible identification of the aetiology of the syncopal TLOC by the nurse showed good agreement with the medical diagnosis (Cohen's kappa 0.857, P < 0.001).

CONCLUSIONS

In cases of syncopal TLOC, nurse triage had a fair specificity but suboptimal sensitivity for cardiac causes. Specific nursing assessments following triage (e.g. precise scores or electrocardiogram) could improve the triage performance.

Variation of Daily Care Demand in Swiss General Hospitals: Longitudinal Study on Capacity Utilization, Patient Turnover and Clinical Complexity Levels

Background

Variations in hospitals’ care demand relies not only on the patient volume but also on the disease severity. Understanding both daily severity and patient volume in hospitals could help to identify hospital pressure zones to improve hospital-capacity planning and policy-making.

Objective

This longitudinal study explored daily care demand dynamics in Swiss general hospitals for 3 measures: (1) capacity utilization, (2) patient turnover, and (3) patient clinical complexity level.

Methods

A retrospective population-based analysis was conducted with 1 year of routine data of 1.2 million inpatients from 102 Swiss general hospitals. Capacity utilization was measured as a percentage of the daily maximum number of inpatients. Patient turnover was measured as a percentage of the daily sum of admissions and discharges per hospital. Patient clinical complexity level was measured as the average daily patient disease severity per hospital from the clinical complexity algorithm.

Results

There was a pronounced variability of care demand in Swiss general hospitals. Among hospitals, the average daily capacity utilization ranged from 57.8% (95% CI 57.3-58.4) to 87.7% (95% CI 87.3-88.0), patient turnover ranged from 22.5% (95% CI 22.1-22.8) to 34.5% (95% CI 34.3-34.7), and the mean patient clinical complexity level ranged from 1.26 (95% CI 1.25-1.27) to 2.06 (95% CI 2.05-2.07). Moreover, both within and between hospitals, all 3 measures varied distinctly between days of the year, between days of the week, between weekdays and weekends, and between seasons.

Conclusions

While admissions and discharges drive capacity utilization and patient turnover variation, disease severity of each patient drives patient clinical complexity level. Monitoring—and, if possible, anticipating—daily care demand fluctuations is key to managing hospital pressure zones. This study provides a pathway for identifying patients’ daily exposure to strained hospital systems for a time-varying causal model.

The ROX index can be a useful tool for the triage evaluation of COVID-19 patients with dyspnoea

Aim

To assess whether the application of a non‐invasive tool, such as ratio of oxygen saturation (ROX) index, during triage can identify patients with COVID‐19 at high risk of developing acute respiratory distress syndrome (ARDS).

Design

A multi‐centre, observational, retrospective study.

Methods

Only COVID‐19 positive patients who required an emergency department evaluation for dyspnoea were considered. The primary objective of the study was to compare the ROX value obtained during triage with the medical diagnosis of ARDS and intubation in 72 h of the triage evaluation. The ROX index value was also compared with objective outcomes, such as the pressure of arterial O₂ (PaO₂)/fraction of inspired oxygen (FiO₂) ratio and the lung parenchyma volume involved in COVID‐19‐related inflammatory processes, based on 3D reconstructions of chest computed tomography (CT).

Results

During the study period, from 20 March 2020 until 31 May 2020, a total of 273 patients with confirmed SARS‐CoV‐2 infection were enrolled. The predictive ability of ROX for the risk of developing ARDS in 72 h after triage evaluation was associated with an area under the receiver operating characteristic (AUROC) of 0.845 (0.797–0.892, p < 0.001), whereas the AUROC value was 0.727 (0.634–0.821, p < 0.001) for the risk of intubation. ROX values were strongly correlated with PaO₂/FiO₂ values (r = 0.650, p < 0.001), decreased ROX values were associated with increased percentages of lung involvement based on 3D CT reconstruction (r = −0.371, p < 0.001).

Conclusion

The ROX index showed a good ability to identify triage patients at high evolutionary risk. Correlations with objective but more invasive indicators (PaO₂/FiO₂ and CT) confirmed the important role of ROX in identifying COVID‐19 patients with extensive pathological processes.

Impact

During the difficult triage evaluation of COVID‐19 patients, the ROX index can help the nurse to identify the real severity of the patient. The triage systems could integrate the ROX in the rapid patient assessment to stratify patients more accurately.

Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation: Multicenter Cross-sectional Survey Study

BACKGROUND

Nursing homes (NHs) are increasingly implementing electronic health records (EHRs); however, little information is available on EHR use in NH settings. It remains unclear how care workers perceive its safety, quality, and efficiency, and whether EHR use might ease the burden of documentation, thereby reducing its implicit rationing.

OBJECTIVE

This study aims to describe nurses' perceptions regarding the usefulness of the EHR system and whether sufficient numbers of computers are available in Swiss NHs, and to explore the system's association with implicit rationing of nursing care documentation.

METHODS

This was a multicenter cross-sectional study using survey data from the Swiss Nursing Homes Human Resources Project 2018. It includes a convenience sample of 107 NHs, 302 care units, and 1975 care workers (ie, registered nurses and licensed practical nurses) from Switzerland's German- and French-speaking regions. Care workers completed questionnaires assessing the level of implicit rationing of nursing care documentation, their perceptions of the EHR system's usefulness and of how sufficient the number of available computers was, staffing and resource adequacy, leadership ability, and teamwork and safety climate. For analysis, we applied generalized linear mixed models, including individual-level nurse survey data and data on unit and facility characteristics.

RESULTS

Overall, the care workers perceived the EHR systems as useful; ratings ranged from 69.42% (1362/1962; guarantees safe care and treatment) to 78.32% (1535/1960; allows quick access to relevant information on the residents). However, less than half (914/1961, 46.61%) of the care workers reported sufficient computers on their unit to allow timely documentation. Half of the care workers responded that they sometimes or often had to ration the documentation of care. After adjusting for work environment factors and safety and teamwork climate, both higher care worker ratings of the EHR system's usefulness (β=-.12; 95% CI -0.17 to -0.06) and sufficient numbers of computers (β=-.09; 95% CI -0.12 to -0.06) were consistently associated with lower implicit rationing of nursing care documentation.

CONCLUSIONS

Both the usefulness of the EHR system and the number of computers available were important explanatory factors for care workers leaving care activities (eg, developing or updating nursing care plans) unfinished. NH managers should carefully select and implement their information technology infrastructure with greater involvement and attention to the needs of their care workers and residents. Further research is needed to develop and implement user-friendly information technology infrastructure in NHs and to evaluate their impact on care processes as well as resident and care worker outcomes.

Acute abdominal pain in triage: A retrospective observational study of the Manchester triage system's validity

OBJECTIVE

Roughly 5% to 10% of patients admitted to the emergency department suffer from acute abdominal pain. Triage plays a key role in patient stratification, identifying patients who need prompt treatment versus those who can safely wait. In this regard, the aim of this study was to estimate the performance of the Manchester Triage System in classifying patients with acute abdominal pain.

METHODS

A total of 9,851 patients admitted at the Emergency Department of the Merano Hospital with acute abdominal pain were retrospectively enrolled between 1 January 2017 and 30 June 2019. The study was conducted and reported according to the STROBE statement. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by the patients and their survival at seven days or the need for acute surgery within 72 h after emergency department access.

RESULTS

Among the patients with acute abdominal pain (median age 50 years), 0.4% died within seven days and 8.9% required surgery within 72 hours. The sensitivity was 44.7% (29.9-61.5), specificity was 95.4% (94.9-95.8), and negative predictive value was 99.7% (99.2-100) in relation to death at seven days.

CONCLUSIONS

The Manchester Triage System shows good specificity and negative predictive value. However, its sensitivity was low due to the amount of incorrect triage prediction in patients with high-priority codes (red/orange), suggesting overtriage in relation to seven-day mortality. This may be a protective measure for the patient. In contrast, the need for acute surgery within 72 h was affected by under-triage.

RELEVANCE TO CLINICAL PRACTICE

The triage nurse using Manchester Triage System can correctly prioritise the majority of patients with acute abdominal pain, especially in low acuity patients. The Manchester Triage System is safe and does not underestimate the severity of the patients.

Comparing Charlson and Elixhauser comorbidity indices with different weightings to predict in-hospital mortality: an analysis of national inpatient data

Background

Understanding how comorbidity measures contribute to patient mortality is essential both to describe patient health status and to adjust for risks and potential confounding. The Charlson and Elixhauser comorbidity indices are well-established for risk adjustment and mortality prediction. Still, a different set of comorbidity weights might improve the prediction of in-hospital mortality. The present study, therefore, aimed to derive a set of new Swiss Elixhauser comorbidity weightings, to validate and compare them against those of the Charlson and Elixhauser-based van Walraven weights in an adult in-patient population-based cohort of general hospitals.

Methods

Retrospective analysis was conducted with routine data of 102 Swiss general hospitals (2012–2017) for 6.09 million inpatient cases. To derive the Swiss weightings for the Elixhauser comorbidity index, we randomly halved the inpatient data and validated the results of part 1 alongside the established weighting systems in part 2, to predict in-hospital mortality. Charlson and van Walraven weights were applied to Charlson and Elixhauser comorbidity indices. Derivation and validation of weightings were conducted with generalized additive models adjusted for age, gender and hospital types.

Results

Overall, the Elixhauser indices, c-statistic with Swiss weights (0.867, 95% CI, 0.865–0.868) and van Walraven’s weights (0.863, 95% CI, 0.862–0.864) had substantial advantage over Charlson’s weights (0.850, 95% CI, 0.849–0.851) and in the derivation and validation groups. The net reclassification improvement of new Swiss weights improved the predictive performance by 1.6% on the Elixhauser-van Walraven and 4.9% on the Charlson weights.

Conclusions

All weightings confirmed previous results with the national dataset. The new Swiss weightings model improved slightly the prediction of in-hospital mortality in Swiss hospitals. The newly derive weights support patient population-based analysis of in-hospital mortality and seek country or specific cohort-based weightings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05999-5.

Strengthening tRansparent reporting of reseArch on uNfinished nursing CARE: The RANCARE guideline

Unfinished, rationed, missed, or otherwise undone nursing care is a phenomenon observed across health-care settings worldwide. Irrespective of differing terminology, it has repeatedly been linked to adverse outcomes for both patients and nursing staff. With growing numbers of publications on the topic, scholars have acknowledged persistent barriers to meaningful comparison across studies, settings, and health-care systems. The aim of this study was thus to develop a guideline to strengthen transparent reporting in research on unfinished nursing care. An international four-person steering group led a consensus process including a two-round online Delphi survey and a workshop with 38 international experts. The study was embedded in the RANCARE COST Action: Rationing Missed Nursing Care: An international and multidimensional Problem. Participation was voluntary. The resulting 40-item RANCARE guideline provides recommendations for transparent and comprehensive reporting on unfinished nursing care regarding conceptualization, measurement, contextual information, and data analyses. By increasing the transparency and comprehensiveness in reporting of studies on unfinished nursing care, the RANCARE guideline supports efficient use of the research results, for example, allowing researchers and nurses to take purposeful actions, with the goal of improving the safety and quality of health-care services.

Interventions to prevent or reduce rationing or missed nursing care: A scoping review

AIMS

To collate and synthesize published research on interventions developed and tested to prevent or reduce the rates of rationed or missed nursing care in healthcare institutions.

BACKGROUND

Rationed and missed nursing care has been widely studied, including its predictors and associations with patient and nurse outcomes.

DESIGN

Scoping review.

DATA SOURCES

We searched for eligible studies, published between 1980-2019, in six electronic databases.

REVIEW METHODS

Researchers independently screened the abstracts of the retrieved studies using the inclusion and exclusion criteria. The decision of whether or not to include any given study was consensus-based.

RESULTS

The search yielded 1,815 records, of which 13 were included. Three studies reported structural interventions, namely increased nurse staffing and improved nursing teamwork, both resulted in significant reductions in the rates of rationed or missed nursing care. The remaining 10 studies reported on process interventions: four concerned reminders (via technology or designated persons) and seven described interventions to change or optimize the relevant care processes. All 10 process interventions contributed to significant reductions in the rates of missed nursing care.

CONCLUSIONS

The results of the scoping review indicate that specific interventions can positively influence the performance of a selected nursing care activity, for example fall prevention. There is no evidence of a global reduction of rationed and missed nursing care through these interventions.

IMPACT

Clinicians, managers and researchers can use the results for adapting and implementing interventions to reduce rationed and missed nursing care.

Errors in nurse-led triage: An observational study

BACKGROUND

Nurses play a crucial role in correctly prioritizing patients entering emergency departments. However, little is known of the accuracy of nurse-led triage systems.

OBJECTIVES

(1) To determine the frequency of nurse-led triage errors within the Manchester Triage System; (2) to explore patient, work environment and individual nurse factors associated with triage errors; and (3) to explore associations between triage errors and patient outcomes (i.e., length of emergency department stay, hospitalization, and 7- and 30-day mortality).

SETTING

This study was conducted in one emergency department in Northern Italy.

PARTICIPANTS

A random sample of 5% (n = 1,929) of all eligible patients accessing the emergency department over an 18-month period.

METHODS

For this retrospective observational study, electronic health record data on triage errors (i.e., incorrect presentational flowchart, specific discriminator and/or priority level) and triage nurses were combined with routine data on patient characteristics, outcomes and the work environment. To explore relationships between these variables, we performed univariate and multivariate logistic regression analyses.

RESULTS

We observed triage errors in 16.3% of patients (n = 314). These were significantly associated with patients' emergency department and hospital stays. Analyses revealed that when > one patient was triaged every 15 min (OR: 2.112;95%CI: 1.331-3.354), older patients (OR: 1.009; 95%CI: 1.003-1.015) with > than two chronic conditions (OR: 1.506; 95%CI: 1.091-2.081) and orange or red priority codes (OR: 1.314; 95%CI: 1.046-1.651,) whose triage nurse had previous experience with another triage system (OR: 3.189; 95%CI: 2.455-4.14) had higher odds of triage errors.

CONCLUSION

We provided primary evidence on triage errors. Confirming our findings on the prevalence, nature and consequences of such errors will require further prospective multicenter studies. Considering patient factors (e.g., age, polychronicity) as additional discriminators could make the nurse-led triage process using the Manchester Triage System more accurate. Investigating the roles of triage nurses' training and background and the emergency department work environment on their mental models regarding the triage process will require qualitative research.

Work environment-related factors and nurses' health outcomes: a cross-sectional study in Lebanese hospitals

Background

Worldwide, studies show a relationship between nurses’ health and some work environment factors; however, data on nurses’ health and self-perceived workload and nursing task allocation are lacking, particularly for Lebanese nurses. We assessed the relationship of several work environment factors: overall workload and specific temporal, physical, mental, effort, frustration, and performance demands (NASA Task Load Index), staffing resources and adequacy and leadership (Practice Environment Scale of Nursing Work Index), teamwork climate (Safety Attitudes Questionnaire), and nursing task allocation (Basel Extent of Rationing of Nursing Care)) with self-reported musculoskeletal, cardiovascular, skin, and mental health diseases (Work Ability Index) and emotional exhaustion (Maslach Burnout Inventory) among Lebanese nurses.

Methods

A cross-sectional self-report survey was distributed to all 289 registered nurses (RNs) in the medical, surgical, and pediatric units in two Lebanese university-affiliated hospitals; 170 RNs had complete data. Adjusted multivariable logistic regression models were used to estimate the association between work environment factors and health outcomes.

Results

The most prevalent outcomes were musculoskeletal disease (69%), emotional exhaustion (59%), and mental health problems (56%); 70% of RNs had ≥2 and 35.29% had ≥4 co-occurring health problems. Musculoskeletal disease was associated with higher overall (OR = 1.36 (95%CI = 1.03, 1.80)), temporal (OR = 1.30 (95%CI = 1.09, 1.55)), and physical demands (OR = 1.20 (95%CI = 1.03, 1.49)), higher task allocation to RNs (OR = 1.11 (95%CI = 1.01, 1.23)) and lower teamwork climate (OR = 0.60 (95%CI = 0.36, 0.98). Higher odds of mental/emotional problems were associated with higher overall, temporal, frustration, and effort demands, and lower teamwork climate, performance satisfaction, and resources adequacy (increased odds ranging from 18 to 88%). Work environment indicators were associated with higher co-occurrence of health problems.

Conclusions

Results show elevated health burden and co-morbidity among Lebanese RNs and highlight the value of comprehensive approaches that can simultaneously improve several work environment factors (namely self-perceived workload, teamwork,, resources, and nursing task allocation) to reduce this burden.

Interprofessional team-based learning in basic sciences: students' attitude and perception of communication and teamwork

OBJECTIVES

To explore whether a team-based learning strategy applied to an interprofessional course on basic science changes students' perception of communication and teamwork skills and attitudes as related to interprofessional learning.

METHODS

A mixed-methods approach was utilized. The participants were selected through an opportunity sample of 33 first-semester anatomy students from occupational therapy and orthoptics programs. Students completed an interprofessional questionnaire before and after the course. The data were analyzed descriptively. Fourteen students were selected randomly for group interviews. Qualitative data was interpreted using thematic analyses.

RESULTS

The pre-test scores for 'communication and teamwork skills' and 'interprofessional learning' were high with mean values of 26.58 and 34.24, respectively. The post-test scores were 27.30 and 34.27, respectively, indicating no relevant changes in students' perception and attitudes. Qualitative data suggested that team-based learning represents a valid strategy to encourage communication and teamwork skills but revealed a lack of interprofessional exchange during the course. Students reported that classroom activities must require the professional knowledge of all participating groups in order to prevent a negative attitudinal shift towards interprofessional education in the later years of their studies.

CONCLUSIONS

Implementing team-based learning in basic sciences can encourage communication and teamwork among students. Mixed classes can help socialize students of different professional groups, although they carry a risk of a negative attitudinal shift towards interprofessional education. Whether, and in what ways, effective interprofessional exchange during the teaching of basic sciences can be achieved needs further investigation.

Correlation between arterial blood gas and CT volumetry in patients with SARS-CoV-2 in the emergency department

•

The severity of SARS-CoV-2 patients is difficult to quickly assess in the ED.

•

The ABG test is a quick and easy tool that can help identify more severe patients.

•

CT cannot be used on all suspected SARS-CoV-2 infected patients admitted in ED.

•

The CT volumetry correlates well with the values of severity reported by the ABG test.

[Types and frequencies of complications associated with midline catheters and PICCs in a South Tyrolean district hospital: a retrospective cohort study]

Types and frequencies of complications associated with midline catheters and PICCs in a South Tyrolean district hospital: a retrospective cohort study Abstract.

BACKGROUND

Specialized registered nurses play a key role in the insertion and management of peripherally inserted central catheters (PICCs) and midline catheters in Anglo-Saxon countries. From the German-speaking area no data on the use of PICCs and midline catheters are available.

AIM

The aim of this study was to describe the types and frequencies of complications of PICCs and midline catheters which were inserted by specialized registered nurses in a South Tyrolean district hospital.

METHODS

We performed a retrospective cohort study of PICCs and midline catheters inserted between 2013 and 2015 in one surgical unit in the district hospital Bruneck (South Tyrol / Italy).

RESULTS

Data from 900 catheters (421 midline catheters and 479 PICCs) inserted in 686 adult patients (404 women, 282 men) were analysed. The cumulative incidence was 29.2 % complications for midline catheters (incidence rate: 13 complications / 1000 catheter days) and 16.0 % for PICCs (incidence rate: 3 complications / 1000 catheter days). The most frequent complication was the removal of the catheter by the patients (PICCs: 6.7 %, midline catheters: 15.7 %). Other less frequent complications were mechanical complications, occlusions, infections and thromboses.

CONCLUSIONS

This study in one district hospital revealed similar types and frequencies of complications as previous international studies. Specialized and clinically competent nurses in German-speaking countries could develop advanced roles in the insertion and management of PICCs and midline catheters.

Patient readiness for hospital discharge and its relationship to discharge preparation and structural factors: A cross-sectional study

BACKGROUND

Nursing discharge preparation is vital to successful hospital-to-home transitions. However, despite a wealth of evidence on its effectiveness, little is known of the structure- and process-related factors that facilitate or impede its use in clinical practice. Specifically, the associations between unit size and type, leadership support, skill mix, staffing, nurse and patient characteristics, discharge teaching and patient readiness for discharge have rarely been studied.

OBJECTIVES

This study aimed to explore the associations between structure-individual characteristics (i.e., unit, nurse and patient characteristics) and process-related (i.e., teaching of self-care and symptom management) factors and patient readiness for hospital discharge.

DESIGN

A secondary data analysis of the multicentre observational "Matching Registered Nurse services with changing care demands (Match^RN)" study.

SETTING AND PERIOD

Data were collected between September 2015 and January 2016 on 123 surgical, medical and mixed units in 23 Swiss acute care hospitals.

PARTICIPANTS

A total of 1833 registered nurses and 1755 patients were included in the analyses.

METHODS

Structure-, process- and patient readiness-related hospital discharge variables were assessed using validated items either from existing instruments or self-developed. Multilevel mixed-effects logistic regression was used to test associations.

RESULTS

Fewer than half of the patients hospitalized (47.8%) reported readiness for hospital discharge. Fifty-eight percent reported receiving discharge preparation interventions for self-care and 30% for symptom management. Patients' readiness for hospital discharge was significantly lower in larger units (β = -0.001; 95% confidence interval (CI) = -0.002 to -0.001) and on medical units (β = -0.44; 95% CI = -0.70 to -0.19). Higher nurses' experience (β = .004; 95% CI = 0.001 to 0.01), better patient self-reported health (β = -0.11; 95% CI = -0.17 to -0.05), higher patient ratings of self-care teaching (β = 1.33; 95% CI = 1.07-1.59) and symptom management teaching (β = 0.79; 95% CI = 0.52-1.06) were significantly associated with greater patient readiness for hospital discharge.

CONCLUSIONS

Patient readiness for hospital discharge is associated with process- and structure-related factors. Our findings suggest that, for successful uptake in clinical practice, the development and implementation of effective discharge preparation programs should consider the structural context, i.e., patient population, unit size, and experience of nurses within the team. Further research, using a more accurate measure of patient readiness for hospital discharge, is needed to test associations with the nurse work environment and staffing.

Discursive practice - lean thinking, nurses' responsibilities and the cost to care

PURPOSE

The purpose of this paper is to explore the literature regarding work intensification that is being experienced by nurses, to examine the effects this is having on their capacity to complete care. The authors contend that nurses' inability to provide all the care patients require, has negative implications on their professional responsibility.

DESIGN/METHODOLOGY/APPROACH

The authors used institutional ethnography to review the discourse in the literature. This approach supports inquiry through the review of text in order to uncover activities that remain institutionally accepted but unquestioned and hidden.

FINDINGS

What the authors found was that the quality and risk management forms an important part of lean thinking, with the organisational culture influencing outcomes; however, the professional cost to nurses has not been fully explored.

RESEARCH LIMITATIONS/IMPLICATIONS

The text uncovered inconsistency between what organisations accepted as successful cost savings, and what nurses were experiencing in their attempts to achieve the care in the face of reduced time and human resources. Nurses' attempts at completing care were done at the risk of their own professional accountability.

PRACTICAL IMPLICATIONS

Nurses are working in lean and stressful environments and are struggling to complete care within reduced resource allocations. This leads to care rationing, which negatively impacts on nurses' professional practice, and quality of care provision.

ORIGINALITY/VALUE

This approach is a departure from the standard qualitative review because the focus is on the textual relationships between what is being advocated by organisations directing cost reduction and what is actioned by the nurses working at the coalface. The discordant standpoints between these two juxtapositions are identified.

The occurrence, types, consequences and preventability of in-hospital adverse events - a scoping review

Background

Adverse events (AEs) seriously affect patient safety and quality of care, and remain a pressing global issue.

This study had three objectives: (1) to describe the proportions of patients affected by in-hospital AEs; (2) to explore the types and consequences of observed AEs; and (3) to estimate the preventability of in-hospital AEs.

Methods

We applied a scoping review method and concluded a comprehensive literature search in PubMed and CINAHL in May 2017 and in February 2018. Our target was retrospective medical record review studies applying the Harvard method–or similar methods using screening criteria–conducted in acute care hospital settings on adult patients (≥18 years).

Results

We included a total of 25 studies conducted in 27 countries across six continents. Overall, a median of 10% patients were affected by at least one AE (range: 2.9–21.9%), with a median of 7.3% (range: 0.6–30%) of AEs being fatal. Between 34.3 and 83% of AEs were considered preventable (median: 51.2%). The three most common types of AEs reported in the included studies were operative/surgical related, medication or drug/fluid related, and healthcare-associated infections.

Conclusions

Evidence regarding the occurrence of AEs confirms earlier estimates that a tenth of inpatient stays include adverse events, half of which are preventable. However, the incidence of in-hospital AEs varied considerably across studies, indicating methodological and contextual variations regarding this type of retrospective chart review across health care systems. For the future, automated methods for identifying AE using electronic health records have the potential to overcome various methodological issues and biases related to retrospective medical record review studies and to provide accurate data on their occurrence.

[Extent and type of implicit rationing of nursing care in seven South Tyrolean hospitals: a descriptive study]

. Extent and type of implicit rationing of nursing care in seven South Tyrolean hospitals: a descriptive study.

INTRODUCTION

Implicit rationing of nursing care is an international phenomenon, defined as withholding of or failure to carry out necessary nursing interventions due to a lack of nursing resources.

AIMS

To describe the extent and type of nursing care implicitly rationed in South Tyrolean hospitals, and to explore differences across clinical areas and between registered nurses (RNs) and support staff.

METHODS

The Basel Extent of Rationing of Nursing Care (BERNCA) questionnaire was completed between September and November 2015, by 934 RNs and support staff of the seven hospitals, involved in direct adult patient care (24 medical, 13 surgical, 5 rehabilitation, 4 intensive care units). Descriptive and explorative analyses were performed.

RESULTS

The most rationed activities concerned "nursing care planning" (37.3%), "surveillance of confused patient" (30.7%), "providing emotional support" (30.1%) and "talking with patients and family" (28.4%). Of the ten most rationed activities, seven were common to RN and support staff, and across clinical areas, although with different frequencies. Significant differences between clinical areas were observed for: "nursing care planning", "rehabilitation care", and "comfort/talking with patients and family".

DISCUSSION

Implicit rationing of nursing care occurs in South Tyrolean hospitals, mainly related to care planning and documentation. Higher priority is given to activities related to direct patient care. Further investigations on priority setting to increase the awareness among frontline nurses of what is rationed, and to guarantee the safety and quality of care is warranted.