The acute care burden of asthma in children was profoundly reduced during the COVID-19 pandemic: A multi-centre Canadian retrospective study

Objectives

Asthma is a chronic lung condition that can be exacerbated when triggered by viruses. Pandemic public health restrictions aimed to reduce COVID-19 transmission indirectly effected other circulating viruses. This study assessed the impact of the pandemic and associated public health measures on acute paediatric asthma across four tertiary sites in three Canadian provinces. We queried whether pandemic-related changes would impair preventive care and delay presentation to care, increasing asthma exacerbation severity.

Methods

This retrospective study compared the frequency of acute care access and severity of presentation to emergency departments (ED) for acute asthma to four tertiary care children's hospitals during the COVID-19 pandemic (from March 17, 2020 to June 30, 2021) to a pre-lockdown control period (July 1, 2018 to March 16, 2020). Data was subjected to interrupted time series and Chi-square analysis.

Results

Our study included 26,316 acute asthma visits to ED. Sites experienced a 63% to 89% reduction in acute asthma visits during the pandemic, compared with pre-lockdown controls, and a 17% to 85% reduction in asthma, that is out of proportion as a fraction of all-cause ED visits. For asthma, there was no difference in severity measured by rate of ward admission or rate of Paediatric Intensive Care Unit (PICU) admission.

Conclusions

Public health measures appear to have resulted in a specific protective association on acute asthma with reduced acute care utilization over and above the reduction in all-cause presentations, without an increase in severity upon presentation. Our study indicates an importance to antiviral public health and engineering strategies to reduce viral transmission and thereby asthma morbidity.

Missing nurses cause missed care: is that it? Non-trivial configurations of reasons associated with missed care in Austrian hospitals - a qualitative comparative analysis

BACKGROUND

Errors of omissions affect the quality of nursing care in hospitals. The Missed Nursing Care Model explains that the reasons for missed care are linked with 1) demand for patient care, 2) labor resource allocation, 3) material resource allocation, and 4) relationship and communication factors. Scientific evidence points to a lack of adequate nursing staffing as the most important factor triggering missed care. However, it remains unclear how the different theoretical reasons for missed care are interlinked with reports on missed care from the perspective of nurses in acute care settings. The aim of this study was to explore non-trivial configurations of reasons for missed care that are associated with missed care interventions from the perspective of nurses working in general units in Austrian hospitals.

METHODS

A cross-sectional study was conducted. Data collection was performed using the revised MISSCARE-Austria questionnaire. Our sample consisted of 401 nurses who provided complete data. Data were analyzed using qualitative comparative analysis. Configurational models of contextual factors, reasons for missed care, and missed nursing interventions were analyzed.

RESULTS

In our study contextual factors were not consistent precursors of the reasons for missed care. Missed care was consistently present when the demand for patient care was high. A lack of labor resources, in combination with the other known reasons for missed care, was consistently observed when missed care occurred. Different configurations of reasons were found to be non-trivially associated with different types and frequencies of missed care.

CONCLUSIONS

To understand the complexity of the causal mechanisms of missed care, complexity theory may be necessary. Accordingly, a theoretical framework that acknowledges that complex systems, such as missed care, are composed of multiple interacting causal components must be further developed to guide new methodical approaches to enlighten its causal mechanisms.

The association between patient engagement and quality of care interactions among acute care patients with dementia

Effective staff-patient communication is critical in acute care settings, particularly for patients with dementia. Limited work has examined the impact of quality of staff-patient care interactions on patient engagement. The purpose of this study was to determine whether the quality of staff-patient care interactions were associated with active patient engagement during the interaction after controlling for relevant covariates. The study was a secondary data analysis using baseline data from the Function Focused Care for Acute Care intervention study, with a total sample of 286 patients. Descriptive statistics and a generalized linear mixed model were used. The findings indicated that there was a significant relationship between the quality of care interactions and patient engagement such that receiving positive care interactions resulted in higher odds of active patient engagement. These findings can inform future interventions and training for acute care staff to improve quality of care interactions and patient engagement.

Evaluation of obesity and age as a predictive factor of lower extremity compartment syndrome: A national trauma data bank analysis

BACKGROUND

Risk factors of acute compartment syndrome (ACS) of the leg include tibial fractures followed by soft tissue injuries.

METHODS

Data collected from the National Trauma Data Bank (NTDB) between 2017 and 2019 were analyzed for adult patients with lower extremity fractures, including proximal tibia, tibial shaft, and distal tibia. The primary outcome was a diagnosis of ACS.

RESULTS

There were 1052/220,868 patients with lower extremity fractures with a concomitant diagnosis of compartment syndrome. Our study has shown that patients with a BMI of ≥30 had a lower incidence of compartment syndrome when compared with patients with a BMI of 25-29 and controlled for fracture type. Increased age ≥55 in males, and females between 65 and 84, also demonstrated a decreased risk. Proximal tibial fractures (n ​= ​54,696) were significantly associated with ACS compared to midshaft (n ​= ​42,153) and distal (n ​= ​100,432), p ​< ​0.0001.

CONCLUSION

We found that being overweight decreases risk for development of compartment syndrome in patients with lower extremity fractures. This big data study aids in establishing risk factors for development of ACS in adult trauma patients.

Defining Mild Traumatic Brain Injury: From Research Definition to Clinical Practice

INTRODUCTION

Approximately 75% of traumatic brain injuries (TBIs) qualify as mild. However, there exists no universally agreed upon definition for mild TBI (mTBI). Consequently, treatment guidelines for this group are lacking. The Center for Disease Control (CDC), American College of Rehabilitation Medicine (ACRM), Veterans Affairs and Department of Defense (VA/DoD), Eastern Association for the Surgery of Trauma (EAST), and the University of Arizona's Brain Injury Guidelines (BIG) have each published differing definitions for mTBI. The aim of this study was to compare the ability of these definitions to correctly classify mTBI patients in the acute care setting.

METHODS

A single-center, retrospective cohort study comparing the performance of the varying definitions of mTBI was performed at a Level I trauma center from August 2015 to December 2018. Definitions were compared by sensitivity, specificity, positive predictive value, negative predictive value, as well as overtriage and undertriage rates. Finally, a cost-savings analysis was performed.

RESULTS

We identified 596 patients suffering blunt TBI with Glasgow Coma Scale 13-15. The CDC/ACRM definitions demonstrated 100% sensitivity but 0% specificity along with the highest rate of undertriage and TBI-related mortality. BIG 1 included nearly twice as many patients than EAST and VA/DoD while achieving a superior positive predictive value and undertriage rate.

CONCLUSIONS

The BIG definition identified a larger number of patients compared to the VA/DoD and EAST definitions while having an acceptable and more accurate overtriage and undertriage rate compared to the CDC and ACRM. By eliminating undertriage and minimizing overtriage rates, the BIG maintains patient safety while enhancing the efficiency of healthcare systems. Using the BIG definition, a cost savings of $395,288.95-$401,263.95 per year could be obtained at our level 1 trauma facility without additional mortality.

Design and psychometric properties of the acute care quality in trauma emergency units scale

BACKGROUND

Systematic trauma care scale could be designed and used by nurses to completely and adequately fulfill a complex care to improve trauma care quality. The purpose of this study was to design and evaluate the psychometric property of the Nursing Care Quality in Trauma Emergency Units and trauma care promotion.

METHODS

This methodological study was conducted in 2022. The process of designing and psychometric assessment of the scale was performed in two steps such as Generating an Item Pool and Validity and Reliability evaluation (Item reduction). The construct validity was determined using the experimental intervention; for determining the reliability of the scale and internal consistency, we measured the inter-rater reliability (IRR). Data were analyzed using the SPSS software, version 22.

RESULTS

Based on our findings, the CVI and CVR of the scale were 1 and 0.83-1, respectively. A significant difference between the pre- and post-intervention scores in group 1 supports the inference that the construct has been appropriately represented, and the instrument has construct validity (p < 0.001). We found that there was a significant difference in the scores of Patient assessment, Planning and Implementations, and Evaluation of the care plan. The inter-rater reliability method allows the optimal reliability assessment of observational instruments, which was used in this study, and the results confirmed excellent reliability of the instrument.

CONCLUSIONS

The validity and reliability of the Nursing Care Quality in Trauma Emergency Units Scale were confirmed. The instrument could successfully assess the process of nursing care in the trauma emergency ward. The use of this checklist is recommended as a valid observational tool for other researchers.

STUDY TYPE

Therapeutic/care management.

[Closing care gaps after hospitalization: Study results [intersec-CM] on discharge and transfer management according to sect. 39 SGB V for people with cognitive impairments associated with dementia]

In Germany, there are 1.8 million people currently living with dementia, and the trend is rising. In particular, the health system at the transition from hospital to outpatient care is facing major challenges given the high increase in a difficult patient clientele. Legal efforts have been undertaken (sect. 39a of the Fifth Social Code Book [SGB V]) to close the care gaps in the discharge and transfer process. This article aims to provide an overview of the documentation process of the discharge and transfer management for people with cognitive impairments in everyday clinical practice according to SGB V sect. 39 para. 1a after the Discharge Management Act came into force. Furthermore, the manuscript answers the research question "How is the statutory discharge management of people with cognitive impairments (MmkB) aged 65 and over documented" and highlights further characteristics of the discharge documentation for MmkB starting with the transition from the inpatient setting to other care settings. In order to answer the research question(s), a qualitative content analysis of all discharge documents available at the time of discharge was carried out as part of the intervention study on cross-sector care management to support cognitively impaired people during and after a hospital stay [intersec-CM], which was funded by the Federal Ministry of Education and Research. The results of the analysis show that, despite legal efforts, there are currently no standardized, unified processes of discharge management for people with cognitive impairments that can be traced in writing. However, departments with a large proportion of vulnerable patient groups were able to offer valuable insights: for example, their discharge documents included a short social history. Further evidence-based research and development in the domain of discharge management for people with cognitive impairments remains essential.

Optimizing the consent process for emergent laparoscopic cholecystectomy using an interactive digital education platform: a randomized control trial

BACKGROUND

Informed consent is essential for any surgery. The use of digital education platforms (DEPs) can enhance patient understanding of the consent discussion and is a method to standardize the consent process in elective, ambulatory settings. The use of DEP as an adjunct to standard verbal consent (SVC) has not been studied in an acute care setting.

METHODS

We conducted a prospective randomized control trial with patients presenting to the emergency department of a tertiary care hospital with acute biliary pathology requiring a laparoscopic cholecystectomy (LC) between August 2021 and April 2023. Participants were randomized 1:1 to receive either a DEP module with SVC or SVC alone. Baseline procedure-specific knowledge and self-reported understanding of risks and benefits of LC were collected using a questionnaire. Primary outcome was immediate post-intervention knowledge assessed using a 21-question multiple choice questionnaire. Secondary outcomes were delayed procedure-specific knowledge and participants' satisfaction with the consent discussion.

RESULTS

We recruited 79 participants and randomized them 1:1 into the intervention group (DEP + SVC, n = 40) and the control group (SVC, n = 39). Baseline demographics and baseline procedure-specific knowledge were similar between groups. The immediate post-intervention knowledge was significantly higher for participants in the intervention versus the control group with a Cohen's d effect size of 0.68 (85.2(10.6)% vs. 78.2(9.9)%; p = 0.004). Similarly, self-reported understanding of risks and benefits of LC was significantly greater for participants in the intervention versus the control group with a Cohen's effect size of 0.76 (68.5(16.4)% vs. 55.1(18.8)%; p = 0.001). For participants who completed the delayed post-intervention assessment (n = 29), there continued to be significantly higher retention of acquired knowledge in the intervention group with a Cohen's effect size of 0.61 (86.5(8.5)% vs. 79.8 (13.1)%; p = 0.024). There was no difference in participants' self-reported satisfaction with the consent discussion between groups (69.5(6.7)% vs. 67.2(7.7)%; p = 0.149).

CONCLUSION

The addition of digital education platform to standard verbal consent significantly improves patient's early and delayed understanding of risks and benefits of LC in an acute care setting.

Learning from the implementation of a surgical opioid reduction initiative in an integrated health system: a qualitative study among providers and patients

BACKGROUND

Surgical opioid overprescribing can result in long-term use or misuse. Between July 2018 and March 2019, the multicomponent intervention, Minimizing Opioid Prescribing in Surgery (MOPiS) was implemented in the general surgery clinics of five hospitals and successfully reduced opioid prescribing. To date, various studies have shown a positive outcome of similar reduction initiatives. However, in addition to evaluating the impact on clinical outcomes, it is important to understand the implementation process of an intervention to extend sustainability of interventions and allow for dissemination of the intervention into other contexts. This study aims to evaluate the contextual factors impacting intervention implementation.

METHODS

We conducted a qualitative study with semi-structured interviews held with providers and patients of the general surgery clinics of five hospitals of a single health system between March and November of 2019. Interview questions focused on how contextual factors affected implementation of the intervention. We coded interview transcripts deductively, using the Consolidated Framework for Implementation Research (CFIR) to identify the relevant contextual factors. Content analyses were conducted using a constant comparative approach to identify overarching themes.

RESULTS

We interviewed 15 clinicians (e.g., surgeons, nurses), 1 quality representative, 1 scheduler, and 28 adult patients and identified 3 key themes. First, we found high variability in the responses of clinicians and patients to the intervention. There was a strong need for intervention components to be locally adaptable, particularly for the format and content of the patient and clinician education materials. Second, surgical pain management should be recognized as a team effort. We identified specific gaps in the engagement of team members, including nurses. We also found that the hierarchical relationships between surgical residents and attendings impacted implementation. Finally, we found that established patient and clinician views on opioid prescribing were an important facilitator to effective implementation.

CONCLUSION

Successful implementation of a complex set of opioid reduction interventions in surgery requires locally adaptable elements of the intervention, a team-centric approach, and an understanding of patient and clinician views regarding changes being proposed.

Implementation of STAR-VA for behavioral symptoms of dementia in acute care: Lessons learned

As the population grows, the incidence of dementia will increase. A common occurrence in people with dementia is behavioral and psychological symptoms of dementia (BPSD). BPSD can include apathy, aggression, resistance to care, and agitation. BPSD can start or worsen during an acute hospitalization, but these units are not well-equipped to handle BPSD, often relying on pharmacological interventions to address distress behaviors. One known behavioral intervention for BPSD is STAR-VA, an interdisciplinary approach to managing these behaviors. However, this intervention has not been utilized in acute care. Our team implemented STAR-VA in acute care at a Veterans Affairs hospital in the northeastern United States. Using the VA's Quality Enhancement Research Initiative (QUERI) implementation roadmap to guide our work, we first outlined the problem, completed a needs assessment with staff, and began implementation. Results from this quality improvement project demonstrated the feasibility and efficacy of STAR-VA in an acute care setting.

Maximization delays decision-making in acute care nursing

The maximization personality trait refers to the tendency to face decision-making situations along a continuum from exhaustively analysing all the options (maximize) to choosing the one that exceeds a subjective threshold of acceptability (satisfy). Research has revealed the influence of maximizing on decision making, although little is known about its possible role in high risk and high uncertainty situations. A sample of 153 active Spanish nurses, with an average experience of 11 years, completed a maximization questionnaire and responded to written vignettes depicting time-demanding decision making in which three options were offered, representing delayed action, non-action, and immediate action. Two vignettes presented critical situations related to acute care during the COVID-19 pandemic, whilst two vignettes presented non-nursing scenarios. People high in maximization took longer to choose and were more likely to choose non-action. No relationship was found between maximization score and the subjective experience of the person making the choice. Maximization had no significant correlation with years of experience nor perceived expertise. Greater perceived expertise was associated with lower indecision and greater confidence. When participants answered nursing vignettes, they took longer to respond, but chose less delayed action and more immediate action. Our results suggest that maximization plays only a relative role in acute care decision-making in nursing, as compared to contextual variables and expertise. They also support a domain general approach to this personality trait. Findings are consistent with Nibbelink and Reed's Practice-Primed Decision Model for nursing.

We need a radical change to take place now´-The potential of integrated healthcare for rural long-term care facilities

OBJECTIVES

This study explores healthcare professionals' perceptions in rural German long-term care facilities, focusing on integrated health systems. The aim is to understand experiences, challenges, and preferences.

METHODS

Twenty nurses and paramedics participated in in-depth interviews. Thematic analysis was applied to transcripts, revealing key themes: acute healthcare provision, interdisciplinary collaboration, telemedicine use, and preferences for the future healthcare landscape.

RESULTS

Themes highlighted factors influencing acute care situations and the crucial role of interdisciplinary collaboration. Integrated care was infrequently encountered despite high demand in rural long-term care facilities.

CONCLUSIONS

Though uncommon, integrated healthcare remains crucial in addressing long-term care facility residents' complex needs. Healthcare professionals express a strong demand for integrated care in rural areas, citing potential benefits for resident wellbeing, healthcare effectiveness, and job satisfaction. The findings guide healthcare organizations in developing institutional-level strategies for integrated care integration, emphasizing its importance in rural settings.

Job satisfaction among expatriate nurses during the COVID-19 pandemic: A cross-sectional study

AIM

To investigate the association between job resources, job satisfaction, and moderating effect of COVID-19 anxiety and practice setting among expatriate acute care nurses in Qatar.

BACKGROUND

Expatriate nurses are more vulnerable to reduced job satisfaction. Increased COVID-19 anxiety and reduced perceived job resources among acute care nurses impact their job satisfaction more than that of general ward nurses.

METHOD

An online survey was used to recruit 293 expatriate acute care nurses from four public hospitals in Qatar. Data were collected between June and October of 2021. Structural equation modeling was used for data analysis. We ensured to follow STROBE guidelines when doing this research.

RESULTS

Job resources were a significant predictor of job satisfaction among expatriate acute care nurses (β = 0.80, 95% CI: 0.73-0.85, p < 0.001). There was no significant moderating effect of COVID-19 anxiety (β = 0.055, 95% CI: -0.61 to 0.151, p = 0.329) or workplace setting on this relationship (χ2  = 0.077, df = 1, p = 0.781).

DISCUSSION

Our study found that the relationship between job resources and acute care nurses' job satisfaction is consistent across different workplace settings regardless of the level of COVID-19 anxiety. This is in line with previous studies that have highlighted the importance of job resources in determining nurses' job satisfaction.

CONCLUSION

The study emphasizes the need for sufficient job resources for improved job satisfaction among expatriate acute care nurses in Qatar, especially during the COVID-19 pandemic.

IMPLICATIONS FOR NURSING POLICY

Nursing leaders must prioritize adequate resources such as staffing, proper training, and policies that increase nurse autonomy to improve job satisfaction and reduce the negative effects of dissatisfaction.

Addressing Driving in Acute Care: Perceived Relevance and Competence

Background. Recent legislation has expanded the responsibilities of occupational therapists regarding fitness to drive in the Canadian province of Ontario. To date, little is known about the practice of acute care occupational therapy with addressing driving, or how such responsibilities have affected clinical practice. Purpose. The objective of this study was to understand the relevance of driving-related knowledge areas to acute care occupational therapists and examine their self-reported competency for these areas. Method. Anonymous online surveys were administered to 41 occupational therapists working in acute care hospitals in Ontario. Findings. Therapists reported many driving-related knowledge areas are relevant to acute care practice yet consistently reported lower levels of competence for addressing such areas. Implications. Findings support the need for further competency development regarding driving-related practice in acute care. Occupational therapy curriculum and continuing education initiatives are avenues for capacity-building. Future research to identify effective competency development strategies is warranted.

Is state trauma funding associated with mortality among injured hospitalized patients?

BACKGROUND

We sought to quantify the association between state trauma funding and (1) in-hospital mortality and (2) transfers of injured patients.

METHODS

We conducted an observational cross-sectional study of states with publicly available trauma funding data. We analyzed in-hospital mortality using linked data from the Nationwide Inpatient Sample (NIS), American Hospital Association (AHA) Annual Survey, and these State Department of Public Health trauma funding data.

RESULTS

A total of 594,797 injured adult patients were admitted to acute care hospitals in 17 states. Patients in states with >$1.00 per capita state trauma funding had 0.82 (95 ​% CI: 0.78-0.85, p ​< ​0.001) decreased adjusted odds of in-hospital mortality compared to patients in states with less than $1.00 per capita state trauma funding.

CONCLUSIONS

Increased state trauma funding is associated with decreased adjusted in-hospital mortality.

Substance Use Disorders, Mental Illness, and Health Care Utilization Among Adults With Recent Criminal Legal Involvement

OBJECTIVE

Individuals involved with the criminal legal system have higher rates of mental illness, addiction, and health care utilization. The authors examined whether substance use disorders and mental illness alone or in combination drive health care utilization among those with recent criminal legal involvement.

METHODS

This cross-sectional analysis used nationally representative data from U.S. adults with past-year criminal legal involvement (N=9,039) recorded in the National Survey on Drug Use and Health (2015-2019). Using adjusted negative binomial regression models, the authors estimated relative risks for health care utilization. Primary independent variable categories included neither substance use disorder nor mental illness, substance use disorder only, mental illness only, and both conditions. Health care utilization included emergency department (ED) visits and nights spent in inpatient care.

RESULTS

Relative to neither mental illness nor substance use disorder, mental illness alone was associated with significantly increased acute health care services use: for ED visits, incidence risk ratio (IRR)=1.43 (95% CI=1.18-1.75) and for inpatient stays, IRR=2.14 (95% CI=1.47-3.11). Having both conditions was associated with increased ED visits (IRR=1.62, 95% CI=1.38-1.91) and inpatient stays (IRR=4.16, 95% CI=2.98-5.82). Substance use disorder alone was associated only with higher risk for ED visits compared with neither condition (IRR=1.23, 95% CI=1.01-1.50).

CONCLUSIONS

Mental illness with or without co-occurring substance use disorder is a strong driver of acute health care utilization after interaction with the criminal legal system. Interventions tailored to the unique needs of individuals with mental illness or substance use disorder are needed for those with recent criminal legal involvement.

Occupational Therapy Practitioners' Perceptions on Addressing Cognition in Acute Care: A National Survey

This study aimed to identify commonly used standardized cognitive screens and functional performance assessments among occupational therapy practitioners at level 1 trauma centers in the USA. A survey completed by 269 occupational therapy practitioners revealed the most common cognitive screens and the association between cognitive tool training and standardized cognitive tool implementation. Implications for practice are discussed with suggestions for improving occupational therapy practice.

Care quality and satisfaction at the cancer hospital - a questionnaire study of older patients with cancer and their family members

BACKGROUND

The unique life situations of older patients with cancer and their family members requires that health care professionals take a holistic approach to achieve quality care. The aim of this study was to assess the perceptions of older patients with cancer and family members about the quality of care received and evaluate differences between their perceptions. A further aim was to examine which factors explain patients' and family members' levels of satisfaction with the care received.

METHODS

The study was descriptive and cross-sectional in design. Data were collected from patients (n = 81) and their family members (n = 65) on four wards in a cancer hospital, using the Revised Humane Caring Scale (RHCS). Data were analysed using descriptive statistics, crosstabulation, Wilcoxon signed rank test, and multivariable Analysis of Covariance (ANCOVA).

RESULTS

Family members had more negative perceptions of the quality of care than patients did. Dissatisfaction was related to professional practice (p < 0.001), interaction between patient and health care professionals (p < 0.001), cognition of physical needs (p = 0.024), and human resources (p < 0.001). Satisfaction with overall care was significantly lower among those patients and family members who perceived that they had not been involved in setting clear goals for the patient's care with staff (p = 0.002).

CONCLUSIONS

It is important that older patients with cancer and family members receive friendly, respectful, individual care based on their needs and hopes, and that they can rely on professionals. Health care professionals need more resources and education about caring for older cancer patients to provide quality care.

Translation and validation of the Persian version of the perception to care in acute situations (PCAS-P) scale in novice nurses

BACKGROUND

Novice nurses providing care in acute conditions should have satisfactory performance. Accurate and appropriate evaluation of the performance of novice nurses in providing care in acute situations is essential for planning interventions to improve the quality of patient care. This study was conducted to translate and evaluate the psychometric properties of the Persian version of the Perception to Care in Acute Situations (PCAS-P) scale in novice nurses.

METHODS

In this methodological study, 236 novice nurses were selected by the convenience sampling method. 17-item scale PCAS-P was translated into Persian by the forward-backward process. Then, this version was used for psychometric evaluation. For this purpose, face validity, content validity, and construct validity were assessed using confirmatory factor analysis. Internal consistency and stability reliability were calculated. The data were analyzed using SPSS and AMOS software.

RESULTS

The PCAS-P scale maintained the meaning of the original English version and was clear, explicit, and understandable for novice nurses. Confirmatory factor analysis showed that this Persian version is consistent with the proposed model and confirmed the fit of the three-factor model. The values of Cronbach's alpha coefficient, McDonald's omega, Coefficient H, and average inter-item correlation were excellent for the overall scale and its dimensions, and the three latent factors had good convergent and discriminant validity. Additionally, the average measurement size was 0.944 ICC (95% CI 0.909 to 0.969).

CONCLUSION

The PCAS-P scale is valid and reliable for measuring novice nurses' perception of acute situations.

An integrated understanding of the impact of hospital at home: a mixed-methods study to articulate and test a programme theory

BACKGROUND

Hospital at Home (HaH) provides intensive, hospital-level care in patients' homes for acute conditions that would normally require hospitalisation, using multidisciplinary teams. As a programme of complex medical-social interventions, a HaH programme theory has not been fully articulated although implicit in the structures, functions, and activities of the existing HaH services. We aimed to unearth the tacit theory from international evidence and test the soundness of it by studying UK HaH services.

METHODS

We conducted a literature review (29 articles) adopting a 'realist review' approach (theory articulation) and examined 11 UK-based services by interviewing up to 3 staff members from each service (theory testing). The review and interview data were analysed using Framework Analysis and Purposive Text Analysis.

RESULTS

The programme theory has three components- the organisational, utilisation and impact theories. The impact theory consists of key assumptions about the change processes brought about by HaH's activities and functions, as detailed in the organisational and utilisation theories. HaH teams should encompass multiple disciplines to deliver comprehensive assessments and have skill sets for physically delivering hospital-level processes of care in the home. They should aim to treat a broad range of conditions in patients who are clinically complex and felt to be vulnerable to hospital acquired harms. Services should cover 7 days a week, have plans for 24/7 response and deliver relational continuity of care through consistent staffing. As a result, patients' and carers' knowledge, skills, and confidence in disease management and self-care should be strengthened with a sense of safety during HaH treatment, and carers better supported to fulfil their role with minimal added care burden.

CONCLUSIONS

There are organisational factors for HaH services and healthcare processes that contribute to better experience of care and outcomes for patients. HaH services should deliver care using hospital level processes through teams that have a focus on holistic and individually tailored care with continuity of therapeutic relationships between professionals and patients and carers resulting in less complexity and fragmentation of care. This analysis informs how HaH services can organise resources and design processes of care to optimise patient satisfaction and outcomes.

Evaluating a digital hybrid training-of-trainers (TOT) approach for lay first responder trauma education in urban Nigeria during the COVID-19 pandemic

INTRODUCTION

Road traffic injuries (RTIs) are the largest contributor to the global burden of injury, and in 2016 were among the five leading causes of global disability-adjusted life years (DALYs). In regions with limited emergency medical services (EMS), training lay first responders (LFRs) has been shown to increase availability of prehospital care for RTIs, but sustainable mechanisms to scale these programs remain unstudied.

METHODS

Using a training of trainers (TOT) model, a 5.5-h LFR training program was launched in Lagos, Nigeria. The course was taught in a hybrid fashion with primary didactics using videoconferencing software and practical breakout sessions in-person concurrently. Thirty TOTs proceeded to train 350 transportation providers as LFRs over one month. A 23-question, pre- and post-assessment was administered digitally to assess knowledge acquisition. Participants responded to a five-point Likert survey assessing instruction quality and post-course confidence.

RESULTS

TOTs scored a median of 56.5 % (IQR:43.5 %,71.7 %) and 91.3 % (IQR:88.0 %,95.7 %) on the pre- and post-assessments, respectively, with bleeding control scores increasing most (+69.4 %). LFR course trainees scored a median of 34.8 % (IQR: 26.0 %, 43.5 %) and 73.9 % (IQR: 65.2 %, 82.6 %) on the pre- and post-assessments respectively, with airway and breathing increasing the most (+48.6 %). All score increases were statistically significant with p < 0.001. All 30 TOT trainers instructed at least one training session after their initial session. LFR participants' rated confidence in first aid skills went from 3/5 (IQR 3, 4) pre-course to 5/5 (IQR:5,5) post-course, and in emergency transportation it went from 4/5 (IQR:3, 4) to 5/5 (IQR:5, 5), (p < 0.001). LFR course participants rated the quality of education content and TOT instructors to be 5/5 (IQR:5,5). 144 responders provided emergency care in the six-months following training for a total of 351 interventions. Active responders provided a median of 2 (IQR:1,3) interventions.

CONCLUSIONS

This is the first time that a digital hybrid instruction for first responder trainers in low- and middle-income countries has been investigated. Our findings demonstrate negligible attrition, high educational quality ratings, equally effective knowledge acquisition to that of prior in-person courses, and high post-training skill usage. Future work will examine the cost-effectiveness of the training of LFRs and the effect of LFRs on trauma outcomes.

Development of a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers: A multi-method study

BACKGROUND

Delirium is a common yet challenging condition in older hospitalized patients, associated with various adverse outcomes. Environmental factors, such as room changes, may contribute to the development or severity of delirium. Most previous research has focused on preventing and reducing this condition by addressing risk factors and facilitating reorientation during hospital stay.

OBJECTIVE

We aimed to systematically develop a complex intervention to prevent delirium in older hospitalized patients by optimizing discharge and transfer processes and involving caregivers during and after these procedures. The intervention combines stakeholder and expert opinions, evidence, and theory. This article provides guidance and inspiration to research groups in developing complex interventions according to the recommendations in the Medical Research Council framework for complex interventions.

DESIGN AND METHODS

A stepwise multi-method study was conducted. The preparation phase included analysis of the context and current practice via focus groups. Based on these results, an expert workshop was organized, followed by a Delphi survey. Finally, the intervention was modeled and a program theory was developed, including a logic model.

RESULTS

A complex intervention was developed in an iterative process, involving healthcare professionals, delirium experts, researchers, as well as caregiver and patient representatives. The key intervention component is an 8-point-program, which provides caregivers with recommendations for preventing delirium during the transition phase and in the post-discharge period. Information materials (flyers, handbook, videos, posters, defined "Dos and Don'ts", discharge checklist), training for healthcare professionals, and status analyses are used as implementation strategies. In addition, roles were established for gatekeepers to act as leaders, and champions to serve as knowledge multipliers and trainers for the multi-professional team in the hospitals.

CONCLUSIONS

This study serves as an example of how to develop a complex intervention. In an additional step, the intervention and implementation strategies will be investigated for feasibility and acceptability in a pilot study with an accompanying process evaluation.

TWEETABLE ABSTRACT

Delirium prevention can benefit from optimizing discharge and transfer processes and involving caregivers of older patients in these procedures.

STUDY REGISTRATION

DRKS00017828, German Register of Clinical Studies, date of registration 17.09.2019.

Acute care pathway assessed through performance indicators during the COVID-19 pandemic in OECD countries (2020-2021): a scoping review

BACKGROUND

The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends.

METHODS

Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable).

RESULTS

A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%).

CONCLUSION

This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Behavioral sciences applied to acute care teams: a research agenda for the years ahead by a European research network

BACKGROUND

Multi-disciplinary behavioral research on acute care teams has focused on understanding how teams work and on identifying behaviors characteristic of efficient and effective team performance. We aimed to define important knowledge gaps and establish a research agenda for the years ahead of prioritized research questions in this field of applied health research.

METHODS

In the first step, high-priority research questions were generated by a small highly specialized group of 29 experts in the field, recruited from the multinational and multidisciplinary "Behavioral Sciences applied to Acute care teams and Surgery (BSAS)" research network - a cross-European, interdisciplinary network of researchers from social sciences as well as from the medical field committed to understanding the role of behavioral sciences in the context of acute care teams. A consolidated list of 59 research questions was established. In the second step, 19 experts attending the 2020 BSAS annual conference quantitatively rated the importance of each research question based on four criteria - usefulness, answerability, effectiveness, and translation into practice. In the third step, during half a day of the BSAS conference, the same group of 19 experts discussed the prioritization of the research questions in three online focus group meetings and established recommendations.

RESULTS

Research priorities identified were categorized into six topics: (1) interventions to improve team process; (2) dealing with and implementing new technologies; (3) understanding and measuring team processes; (4) organizational aspects impacting teamwork; (5) training and health professions education; and (6) organizational and patient safety culture in the healthcare domain. Experts rated the first three topics as particularly relevant in terms of research priorities; the focus groups identified specific research needs within each topic.

CONCLUSIONS

Based on research priorities within the BSAS community and the broader field of applied health sciences identified through this work, we advocate for the prioritization for funding in these areas.

Perspectives of healthcare workers on the integration of overdose detection technologies in acute care settings

BACKGROUND

People who use drugs (PWUD) face disproportionately high rates of hospitalizations and patient-initiated discharge (leaving against medical advice), explained by a combination of stigma, withdrawal, judgment, blame, and improper pain management. In addition, evidence has shown that despite abstinence-based policies within healthcare settings, PWUD continue to use their substances in healthcare environments often hidden away from hospital staff, resulting in fatalities. Various novel overdose detection technologies (ODTs) have been developed with early adoption in a few settings to reduce the morbidity and mortality from risky substance use patterns within healthcare environments. Our study aimed to gain the perspectives of healthcare workers across Canada on implementing ODTs within these settings.

METHOD

We used purposive and snowball sampling to recruit 16 healthcare professionals to participate in semi-structured interviews completed by two evaluators. Interview transcripts were analyzed using thematic analysis to identify key themes and subthemes.

RESULTS

Participants recognized ODTs as a potentially feasible solution for increasing the safety of PWUD in healthcare settings. Our results suggest the mixed ability of these services to decrease stigma and build rapport with PWUD. Participants further highlighted barriers to implementing these services, including pre-established policies, legal recourse, and coordination of emergency responses to suspected overdoses. Lastly, participants highlight that ODTs should only be one part of a multifaceted approach to reducing harm in healthcare settings and could currently be integrated into discharge planning.

CONCLUSION

Healthcare professionals from across Canada found ODTs to be an acceptable intervention, but only as part of a larger suite of harm reduction interventions to reduce the harms associated with illicit drug use in healthcare settings. In contrast, participants noted institutional policies, stigma on behalf of healthcare workers and leadership would present significant challenges to their uptake and dissemination.

Facilitators and barriers to implementing a specialized care unit for persons with cognitive impairment in an acute geriatric hospital: a process evaluation

BACKGROUND

Implementing dementia care interventions in an acute hospital poses multiple challenges. To understand factors influencing the implementation, in-depth knowledge about specific facilitators and barriers is necessary. The aim of this study was to identify facilitators and barriers to implementing an interprofessional, multicomponent intervention of a specialized unit for persons with cognitive impairment in an acute geriatric hospital.

METHODS

We conducted a process evaluation as part of a participatory action research study. For data collection, semi-structured individual interviews with fifteen professionals involved in the implementation of the specialized unit. We further conducted two focus groups with twelve professionals working on other units of the geriatric hospital. We performed a qualitative content analysis following Kuckartz's content-structuring analysis scheme.

RESULTS

We identified the following barriers to implementing the specialized unit: uncontrollable contextual changes (e.g., COVID-19 pandemic), staff turnover in key functions, high fluctuation in the nursing team, traditional work culture, entrenched structures, inflexible and efficiency-oriented processes, monoprofessional attitude, neglect of project-related communication, and fragmentation of interprofessional cooperation. An established culture of interprofessionalism, an interprofessionally composed project group, cooperation with a research partner, as well as the project groups' motivation and competence of managing change facilitated the implementation.

CONCLUSIONS

The implementation faced numerous barriers that can be described using the key constructs of the i-PARIHS framework: context, recipients, innovation, and facilitation. Overcoming these barriers requires an organizational development approach, extended project duration and increased process orientation. Furthermore, strategically planned, precise and ongoing communication towards all persons involved seems crucial. Differences between the work cultures of the professions involved deserve particular attention with regard to project-related roles and processes.

The multiple makings of a supervised consumption service in a hospital setting

BACKGROUND

Whereas supervised consumption services (SCSs) are common in many community settings, they are seldomly found in acute care hospitals. As hospitals present unique circumstances that can shape the impacts of an SCS, careful consideration of local implementation contexts and practices is required. We explored the pre-implementation stage of an SCS, to examine how an SCS is made and made differently in relation to the material-discursive context of the hospital.

METHODS

We conducted 11 focus groups with 83 staff and clinicians at an inner-city hospital in Toronto, Canada. Data analysis followed principles of grounded theory and was informed by an 'evidence making interventions' framework.

RESULTS

While most participants indicated they would support the establishment of an SCS at the hospital, multiple enactments of an SCS emerged. An SCS was enacted: as a means to reduce drug-related risks for all people who use drugs, as an opportunity to intervene on patients' drug use, as a means to centralize drug use, and as a transformative intervention for the hospital. In our findings, harm reduction, abstinence, security, and risk mitigation goals existed closely together, yielding overlaying realities.

CONCLUSION

Our findings revealed various enactments of an SCS, some of which are likely to negatively affect people who use drugs and service access. As more hospitals consider the implementation of an SCS, understanding how an SCS is made in practice will be key to building a service that focuses on the needs of people who use drugs.

Identification and information management of cognitive impairment of patients in acute care hospitals: An integrative review

Objectives

Recognition of the cognitive status of patients is important so that care can be tailored accordingly. The objective of this integrative review was to report on the current practices that acute care hospitals use to identify people with cognitive impairment and how information about cognition is managed within the healthcare record as well as the approaches required and recommended by policies.

Methods

Following Whittemore & Knafl's five-step method, we systematically searched Medline, CINAHL, and Scopus databases and various grey literature sources. Articles relevant to the programs that have been implemented in acute care hospitals regarding the identification of cognitive impairment and management of cognition information were included. The Mixed Methods Appraisal Tool and AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) Checklist were used to evaluate the quality of the studies. Thematic analysis was used to present and synthesise results. This review was pre-registered on PROSPERO ( CRD42022343577).

Results

Twenty-two primary studies and ten government/industry publications were included in the analysis. Findings included gaps between practice and policy. Although identification of cognitive impairment, transparency of cognition information, and interaction with patients, families, and carers (if appropriate) about this condition were highly valued at a policy level, sometimes in practice, cognitive assessments were informal, patient cognition information was not recorded, and interactions with patients, families, and carers were lacking.

Discussion

By incorporating cognitive assessment, developing an integrated information management system using information technology, establishing relevant laws and regulations, providing education and training, and adopting a national approach, significant improvements can be made in the care provided to individuals with cognitive impairment.

Improving communicative access and patient experience in acute stroke care: An implementation journey

INTRODUCTION

Patient experience for people with aphasia/families in acute care is frequently reported as negative, with communication barriers contributing to adverse events and significant long-term physical and psychosocial sequelae. Although the effectiveness of providing supported communication training and resources for health care providers in the stroke system is well documented, there is less evidence of implementation strategies for sustainable system change. This paper describes an implementation process targeting two specific areas: 1) improving Stroke Team communication with patients with aphasia, and 2) helping the Stroke Team provide support to families. The project aimed for practical sustainable solutions with potential contribution toward the development of an implementation practice model adaptable for other acute stroke contexts.

METHODS

The project was designed to create a communicatively accessible acute care hospital unit for people with aphasia. The process involved a collaboration between a Stroke Team covering two units/wards led by nurse managers (19 participants), and a community-based Aphasia Team with expertise in Supported Conversation for Adults with Aphasia (SCA™) - an evidence-based method to reduce language barriers and increase communicative access for people with aphasia. Development was loosely guided by the integrated knowledge translation (iKT) model, and information regarding the implementation process was gathered in developmental fashion over several years.

OUTCOMES

Examples of outcomes related to the two target areas include provision of accessible information about aphasia to patients as well as development of two new products - a short virtual SCA™ eLearning module relevant to acute care, and a pamphlet for families on how to keep conversation alive. Potential strategies for sustaining a focus on aphasia and communicative access emerged as part of the implementation process.

CONCLUSIONS

This implementation journey allowed for a deeper understanding of the competing demands of the acute care context and highlighted the need for further work on sustainability of communicative access interventions for stroke patients with aphasia and their families.

Patient and family perceptions of a discharge bedside board

Objective

To explore patient and family perspectives of a discharge bedside board for supporting engagement in patient care and discharge planning to inform tool revision.

Methods

This qualitative descriptive study included 45 semi-structured interviews with a purposeful sample of English-speaking patients (n = 44; mean age 58.5 years) and their family members (n = 5) across seven adult inpatient units at a tertiary acute care hospital in mid-western Canada. Thematic (interviews), content (board, organization procedure document), and framework-guided integrated (all data) analyses were performed.

Results

Four themes were generated from interview data: understanding the board, included essential information to guide care, balancing information on the board, and maintaining a sense of connection. Despite application inconsistencies, documented standard procedures aligned with recommended board (re)orientation, timely patient-friendly content, attention to privacy, and patient-provider engagement strategies.

Conclusion

Findings indicate the tool supported consultation and some involvement level engagement in patient care and discharge. Board information was usually valued, however, perceived procedural gaps in tool education, privacy, and the quality of tool-related communication offer opportunities to strengthen patients' and families' tool experience.

Innovation

Novel application of a continuum engagement framework in the exploration of multiple data sources generated significant insights to guide tool revision.

Identifying factors associated with high use of acute care in Canada: a population-based retrospective study

OBJECTIVES

To determine demographic, socioeconomic, and clinical factors associated with being high-cost users (HCUs) in adult patients (≥ 18 years) who received acute care in Canada.

RESEARCH DESIGN

We conducted a retrospective study among adults who had at least one encounter with acute care facilities each year from 2011 to 2014 using national linked data sets. We defined HCUs as patients on the top 10% of the highest acute care cost users in the province, where the care was provided. Risk factors associated with being HCUs were identified using multilevel logistic regression. Provincial variations of identified risk factors were examined using logistic regression. Sensitivity analyses were also performed to investigate the influences of using different metrics and different thresholds to define high system users, missing data, and the inclusion of interaction terms on the study results.

RESULTS

Between 2011 and 2014, a total of 3,891,410 patients with 6,017,430 hospitalizations were included. Patients who were male [odds ratio (OR), 1.60; 95% confidence interval (CI) 1.59-1.61], with low incomes [OR 1.42; 95% CI 1.41-1.43), with higher comorbidity score (OR 1.41; 95% CI 1.40-1.41] and older [OR 1.18; 95% CI 1.17-1.18] were more likely to be acute care HCUs. Significant interactions existed between comorbidity score and age/sex/income status. Across provinces, the associations between socioeconomic factors and being HCUs has the largest variation. When using various high system users (HSUs) definitions, the impacts of living in rural area and being visible minority on the odds of being HSUs differ.

CONCLUSIONS

A few demographic, socioeconomic, and clinical factors was associated with high acute care expenditures. The associations between included risk factors and being acute care HCUs vary across provinces and different definitions of high system users (HSUs).

Appropriateness of acute-care antibiotic prescriptions for community-acquired infections and surgical antibiotic prophylaxis in England: analysis of 2016 national point prevalence survey data

BACKGROUND

Estimates of inappropriate prescribing can highlight key target areas for antimicrobial stewardship (AMS) and inform national targets.

OBJECTIVES

To (1) define and (2) produce estimates of inappropriate antibiotic prescribing levels within acute hospital trusts in England.

METHODS

The 2016 national Healthcare-Associated Infections (HAI), Antimicrobial Use (AMU) and AMS point prevalence survey (PPS) was used to derive estimates of inappropriate prescribing, focusing on the four most reported community-acquired antibiotic indications (CAIs) in the PPS and surgical prophylaxis. Definitions of appropriate antibiotic therapy for each indication were developed through the compilation of national treatment guidelines. A Likert-scale system of appropriateness coding was validated and refined through a two-stage expert review process.

RESULTS

Antimicrobial usage prevalence data were collected for 25,741 individual antibiotic prescriptions, representing 17,884 patients and 213 hospitals in England. 30.4% of prescriptions for the four CAIs of interest were estimated to be inappropriate (2054 prescriptions). The highest percentage of inappropriate prescribing occurred in uncomplicated cystitis prescriptions (62.5%), followed by bronchitis (48%). For surgical prophylaxis, 30.8% of prescriptions were inappropriate in terms of dose number, and 21.3% in terms of excess prophylaxis duration.

CONCLUSIONS

The 2016 prevalence of inappropriate antibiotic prescribing in hospitals in England was approximated to be 30.4%; this establishes a baseline prevalence and provided indication of where AMS interventions should be prioritized. Our definitions appraised antibiotic choice, treatment duration and dose number (surgical prophylaxis only); however, they did not consider other aspects of appropriateness, such as combination therapy - this is an important area for future work.

The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey

Background

Frailty is associated with a range of adverse clinical outcomes in the acute hospital setting. We sought to determine whether frailty and related factors affected clinical processes such as time to assessment during emergency hospital admission within the National Health Service (NHS) in the UK.

Methods

The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual cross-sectional day of care survey. SAMBA 2022 was conducted on Thursday 23rd June 2022. We assessed whether the Clinical Frailty Scale (CFS) and presence of a geriatric syndrome affected performance against nationally recognised clinical quality indicators based on time to initial assessment and time to consultant review. CFS was graded into robust (CFS1-3), mild (CFS 4-5), moderate (CFS 6), severe (CFS7-8) and terminal illness (CFS 9). Plausible values were created for missing variables using multi-level multiple imputation. The association was described using mixed effect generalised linear models adjusting for initial National Early Warning Score 2 (NEWS2) and time of arrival.

Findings

A total of 152 hospitals provided patient level data relating to 7248 emergency medical admissions. Patients with mild, moderate and severe frailty were less likely to be assessed within 4 h of arrival (adjusted OR, mild 0.79, 95% CI 0.68-0.96, moderate 0.67 95% CI 0.53-0.84, severe, 0.75 95% CI 0.58-0.96, terminally ill 0.59 95% CI 0.23-1.43) and less likely to be achieve the clinical quality indicator for consultant review (adjusted OR, mild 0.69 95% CI 0.58-0.83, moderate 0.55 95% CI 0.44-0.70, severe 0.54 95% CI 0.41-0.69, terminally ill 0.76 95% CI 0.42-1.5). Patients with geriatric syndromes were also less likely to be assessed within 4 h of arrival (adjusted OR 0.66 95% CI 0.56-0.76) or by a consultant within the recommended time frame (adjusted OR 0.45 95% CI 0.39-0.51). The difference was partially explained by differential use of SDEC pathways. Sub-group analysis of 5148 patients assessed outside of SDEC areas demonstrated patients with geriatric syndromes (adjusted OR 0.71, 95% CI 0.60-0.83), but not frailty defined by CFS were less likely to be assessed within 4 h of arrival. Moderate and severe frailty and the presence of a geriatric syndrome were associated with a decreased likelihood of achieving the consultant review standard (moderate, adjusted OR 0.75, 95% CI 0.59-0.94, severe adjusted OR 0.75 95% CI 0.58-0.96, geriatric syndrome adjusted OR 0.59, 95% CI 0.50-0.69).

Interpretation

Frailty is associated with delayed clinical assessment. This association may suggest a systemic issue with clinical prioritisation, with important implications for acute care policy.

Funding

The database for SAMBA is funded by the Society for Acute Medicine.

Clinical pharmacy specializations at a school of pharmacy: Development and implementation

BACKGROUND AND PURPOSE

Specializations within doctor of pharmacy (PharmD) programs allow student pharmacists to advance their knowledge and expertise in a specific area of pharmacy. The purpose of this manuscript is to expand the knowledge of pharmacy specializations within a PharmD program by describing two patient care specializations at a school of pharmacy and their assessment strategies.

EDUCATIONAL ACTIVITY AND SETTING

A pediatric pharmacotherapy and acute care pharmacotherapy specialization are described. The development of the specializations and assessment strategies are discussed. Student feedback in addition to postgraduate training and employment in specialization area are used to continually assess the specializations.

FINDINGS

Sixty students completed the patient care specializations by completing the specialization coursework, which included extra assignments and a research project. A total of 34 students (57%) who completed the specializations also completed postgraduate year one training.

SUMMARY

Patient care specializations allow students to develop skills used in specialty areas, and these added skills may help them be successful in finding postgraduate training related to the specialization. Creating detailed specialization requirements and assessment strategies may ensure that the specialization is of appropriate rigor to enhance specialty-specific skills and knowledge. This report can help other schools of pharmacy with their plans for developing a specialization at their institution.

Barriers and enablers to managing challenging behaviours after traumatic brain injury in the acute hospital setting: a qualitative study

BACKGROUND

Challenging behaviours after traumatic brain injury (TBI) in the acute setting are associated with risk of harm to the patient and staff, delays in commencing rehabilitation and increased length of hospital stay. Few guidelines exist to inform practice in acute settings, and specialist services providing multi-disciplinary expertise for TBI behaviour management are predominantly based in subacute inpatient services. This study aims to investigate acute and subacute staff perspectives of barriers and enablers to effectively managing challenging behaviours after TBI in acute hospital settings.

METHODS

Qualitative focus groups were conducted with 28 staff (17 from acute setting, 11 from subacute setting) across two sites who had experience working with patients with TBI. Data were analysed using inductive-deductive reflexive thematic analysis. Data were applied to the constructs of the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to generate themes representing barriers and enablers to managing challenging behaviours after TBI in the acute hospital setting.

RESULTS

Four barriers and three enablers were identified. Barriers include (1) Difficulties with clinical decision making; (2) Concerns for risks to staff and patients; (3) Hospital environment; (4) Intensive resources are required. Enablers were (1) Experienced staff with practical skills; (2) Incorporating person-centred care; and (3) Supportive teams.

CONCLUSION

These findings can inform pre-implementation planning for future improvements to TBI behaviour management in acute hospital settings. Difficulties with clinical decision making, concerns for risks of injury, the hospital environment and lack of resources are major challenges. Implementation strategies developed to address barriers will need to be trialled, with multi-disciplinary team approaches, and tailored to the acute setting.

Care pathways of sepsis survivors: sequelae, mortality and use of healthcare services in France, 2015-2018

BACKGROUND

Individuals who survive sepsis are at high risk of chronic sequelae, resulting in significant health-economic costs. Several studies have focused on aspects of healthcare pathways of sepsis survivors but comprehensive, longitudinal overview of their pathways of care are scarce. The aim of this retrospective, longitudinal cohort study is to identify sepsis survivor profiles based on their healthcare pathways and describe their healthcare consumption and costs over the 3 years following their index hospitalization.

METHODS

The data were extracted from the French National Hospital Discharge Database. The study population included all patients above 15 years old, with bacterial sepsis, who survived an incident hospitalization in an acute care facility in 2015. To identify survivor profiles, state sequence and clustering analyses were conducted over the year following the index hospitalization. For each profile, patient characteristics and their index hospital stay and sequelae were described, as well as use of care and its associated monetary costs, both pre- and post-sepsis.

RESULTS

New medical (79.2%), psychological (26.9%) and cognitive (18.5%) impairments were identified post-sepsis, and 65.3% of survivors were rehospitalized in acute care. Cumulative mortality reached 36.6% by 3 years post-sepsis. The total medical cost increased by 856 million € in the year post-sepsis. Five patient clusters were identified: home (65.6% of patients), early death (12.9%), late death (6.8%), short-term rehabilitation (11.3%) and long-term rehabilitation (3.3%). Survivors with early and late death clusters had high rates of cancer and primary bacteremia and experienced more hospital-at-home care post-sepsis. Survivors in short- or long-term rehabilitation clusters were older, with higher percentage of septic shock than those coming back home, and had high rates of multiple site infections and higher rates of new psychological and cognitive impairment.

CONCLUSIONS

Over three years post-sepsis, different profiles of sepsis survivors were identified with different mortality rates, sequels and healthcare services usage and cost. This study confirmed the importance of sepsis burden and suggests that strategies of post-discharge care, in accordance with patient profile, should be further tested in order to reduce sepsis burden.

Disparities in cannabis-related emergency department visits across depressed and non-depressed individuals and the impact of recreational cannabis policy in Ontario, Canada

BACKGROUND

Recreational cannabis policies are being considered in many jurisdictions internationally. Given that cannabis use is more prevalent among people with depression, legalisation may lead to more adverse events in this population. Cannabis legalisation in Canada included the legalisation of flower and herbs (phase 1) in October 2018, and the deregulation of cannabis edibles one year later (phase 2). This study investigated disparities in cannabis-related emergency department (ED) visits in depressed and non-depressed individuals in each phase.

METHODS

Using administrative data, we identified all adults diagnosed with depression 60 months prior to legalisation (n = 929 844). A non-depressed comparison group was identified using propensity score matching. We compared the pre-post policy differences in cannabis-related ED-visits in depressed individuals v. matched (and unmatched) non-depressed individuals.

RESULTS

In the matched sample (i.e. comparison with non-depressed people similar to the depressed group), people with depression had approximately four times higher risk of cannabis-related ED-visits relative to the non-depressed over the entire period. Phases 1 and 2 were not associated with any changes in the matched depressed and non-depressed groups. In the unmatched sample (i.e. comparison with the non-depressed general population), the disparity between individuals with and without depression is greater. While phase 1 was associated with an immediate increase in ED-visits among the general population, phase 2 was not associated with any changes in the unmatched depressed and non-depressed groups.

CONCLUSIONS

Depression is a risk factor for cannabis-related ED-visits. Cannabis legalisation did not further elevate the risk among individuals diagnosed with depression.

Intervention to improve acute care nurses confidence and knowledge in hospital dementia care

PROBLEM

Acute care nurses are the front line of hospital care for persons with dementia (PwD), yet many have inadequate dementia education and lack the confidence to appropriately manage PwD in the hospital setting.

IMPLEMENTATION

Two acute care units with high rates of PwD in a large tertiary-care hospital were provided an education intervention involving interactive case-based discussion of the challenges of inpatient dementia care.

RESULTS

Out of 190 nurses, 171 completed a one-hour virtual educational session, 142 completed pre/post-session confidence surveys, and 123 completed pre/post-session knowledge tests. There was a statistically significant improvement in knowledge scores from 75.8% pre-session to 88.4% post-session (p < 0.001), and pre/post-session dementia care confidence increased from 3.49 to 4.44 ( + 27.22%; p < 0.001) CONCLUSION: An interactive virtual education intervention improves acute care nurses' confidence and knowledge in managing PwD in the acute care setting and may improve hospital outcomes for this population.

Contextualizing the results of an integrative review on the characteristics of dementia-friendly hospitals: a workshop with professional dementia experts

BACKGROUND

To become a dementia-friendly hospital (DFH) is increasingly being discussed in health care practice, research, politics and society. In our previous integrative review, we identified six characteristics of DFHs. To thoroughly discuss and contextualize these characteristics in relation to hospitals in Germany, we involved professional dementia experts in our review process.

METHODS

At the end of our review process, we involved professional dementia experts at the 'contributing' level of the ACTIVE framework to discuss and reflect on the six DFH characteristics we identified. We conducted a group process in the form of a one-day workshop. The workshop consisted of four steps: 1. presentation of review results (input), 2. modification of DFH characteristics and rating of their relevance in smaller working groups, 3. discussion of group results in plenary and 4. questionnaire for prioritization and rating of feasibility. The data were analyzed in MAXQDA using content analysis and descriptive statistics.

RESULTS

A total of 16 professional dementia experts working in hospitals participated in the workshop. All the previously identified characteristics of a DFH were rated as relevant or very relevant for patients with dementia, their relatives and health care professionals from the professional dementia experts' perspective. They made a few modifications of the six characteristics at the level of subcategories, aspects, and descriptions. The feasibility of the characteristics in hospitals was critically discussed regarding resources, hospital structures and processes, the role of nurses, and the current care situation of people with dementia in hospitals. More than half of the subcategories of the characteristics were considered very difficult or difficult to implement by most professional dementia experts.

CONCLUSION

The involvement of professional dementia experts helped us contextualize our review findings within the German hospital setting. These results highlight the need to consider resources, funding options, influencing factors, and the current situation and culture of care provided by hospitals before implementing DFH characteristics. Beside the involvement of professional dementia experts and various health care professionals, the involvement of other stakeholders, such as people with dementia and their relatives, is necessary in future research for the development of a DFH.

Outcomes and cost analysis of patients with dementia in the intensive care unit: a population-based cohort study

BACKGROUND

Dementia is a neurological syndrome affecting the growing elderly population. While patients with dementia are known to require significant hospital resources, little is known regarding the outcomes and costs of patients admitted to the intensive care unit (ICU) with dementia.

METHODS

We conducted a population-based retrospective cohort study of patients with dementia admitted to the ICU in Ontario, Canada from 2016 to 2019. We described the characteristics and outcomes of these patients alongside those with dementia admitted to non-ICU hospital settings. The primary outcome was hospital mortality but we also assessed length of stay (LOS), discharge disposition, and costs.

RESULTS

Among 114,844 patients with dementia, 11,341 (9.9%) were admitted to the ICU. ICU patients were younger, more comorbid, and had less cognitive impairment (81.8 years, 22.8% had ≥ 3 comorbidities, 47.5% with moderate-severe dementia), compared to those in non-ICU settings (84.2 years, 15.0% had ≥ 3 comorbidities, 54.1% with moderate-severe dementia). Total mean LOS for patients in the ICU group was nearly 20 days, compared to nearly 14 days for the acute care group. Mortality in hospital was nearly three-fold greater in the ICU group compared to non-ICU group (22.2% vs. 8.8%). Total healthcare costs were increased for patients admitted to ICU vs. those in the non-ICU group ($67,201 vs. $54,080).

CONCLUSIONS

We find that patients with dementia admitted to the ICU have longer length of stay, higher in-hospital mortality, and higher total healthcare costs. As our study is primarily descriptive, future studies should investigate comprehensive goals of care planning, severity of illness, preventable costs, and optimizing quality of life in this high risk and vulnerable population.

Virtual Acute Psychiatric Ward: Evaluation of Outcomes and Cost Savings

OBJECTIVE

The COVID-19 pandemic motivated rapid expansion of virtual care. In Winnipeg, Canada, the authors launched a virtual psychiatric acute care ward (vWARD) to divert patients from hospitalization through daily remote treatment by a psychiatry team using telephone or videoconferencing. This study examined vWARD patient characteristics, predictors of transfer to a hospital, use of acute care postdischarge, and costs of the vWARD compared with in-person hospitalization.

METHODS

Data for all vWARD admissions from March 23, 2020, to April 30, 2021, were retrieved from program documents and electronic records. Emergency department visits and hospitalizations in the 6 months before admission and the 30 days after discharge were documented. Logistic regression identified factors associated with transfer to a hospital. Thirty-day acute care use after discharge was modeled with Kaplan-Meier curves. A break-even cost analysis was generated with data for usual hospital-based care.

RESULTS

The 132 vWARD admissions represented a diverse demographic and clinical population. Overall, 57% involved suicidal behavior, and 29% involved psychosis or mania. Seventeen admissions (13%) were transferred to a hospital. Only presence of psychosis or mania significantly predicted transfer (OR=34.2, 95% CI=3.3-354.6). Eight individuals were hospitalized in the 30 days postdischarge (cumulative survival=0.93). vWARD costs were lower than usual care across several scenarios.

CONCLUSIONS

A virtual ward is a feasible, effective, and potentially cost-saving intervention to manage acute psychiatric crises in the community and avoid hospitalization. It has benefits for both the health system and the individual who prefers to receive care at home.

Stroke systems of care in South-East Asia Region (SEAR): commonalities and diversities

The Southeast Asia Region (SEAR) accounts for nearly 50% of the developing world's stroke burden. With various commonalities across its countries concerning health services, user awareness, and healthcare-seeking behavior, SEAR still presents profound diversities in stroke-related services across the continuum of care. This review highlights the numerous systems and challenges in access to stroke care, acute stroke care services, and health care systems, including rehabilitation. The paper has also attempted to compile information on the availability of stroke specialized centers, Intravenous thrombolysis (IVT) ready centers, Endovascular therapy (EVT) ready centers, rehabilitation centers, and workforce against a backdrop of each country's population. Lastly, the efforts of WHO (SEARO)-CMCL (World Health Organization-South East Asia region, Christian Medical College & Hospital Ludhiana) collaboration towards improving stroke services and capacity among the SEAR have been described.

The implementation and impacts of national standards for comprehensive care in acute care hospitals: An integrative review

Objectives

To synthesise current evidence addressing implementation approaches, challenges and facilitators, and impacts of national standards for comprehensive care in acute care hospitals.

Methods

Using Whittemore & Knafl's five-step method, a systematic search was conducted across five databases, including Medline (EBSCO), CINAHL (EBSCO), Cochrane Library, Web of Science, and Scopus, to identify primary studies and reviews. In addition, grey literature (i.e., government reports and webpages) was also searched via Google and international government/organisation websites. All searches were limited to January 1, 2000 to January 31, 2023. Articles relevant to the implementation or impacts of national standards for comprehensive care in acute care hospitals were included. Included articles underwent a Joanna Briggs Institute quality review, followed by qualitative content analysis of the extracted data adhering to PRISMA reporting guidelines.

Results

A total of 16 articles were included in the review (5 primary studies, 5 government reports, and 6 government webpages). Three countries (Australia, Norway, and the United Kingdom [UK]) were identified as having a national standard for comprehensive care. The Australian standard contains a unique component of minimising patient harm. Norway does not have a defined implementation framework for the standard, whereas Australia and the UK do. Limited research suggests that challenges in implementing a national standard for comprehensive care in acute care hospitals include difficulties in implementing governance processes, end-of-life care actions, minimising harms actions, and developing comprehensive care plans with multidisciplinary teams, the absence of standardised care plans and patient-centred goals in documentation, and excessive paperwork. Implementation facilitators include a new care plan template using the Identify, Situation, Background, Assessment and Recommendation framework for handover, promoting efficient documentation, clinical decision-making and direct patient care, and proactivity among patients and care professionals with collaboration skills. Limited research suggests introducing the Australian standard demonstrated some positive effects on patient outcomes.

Conclusion

The components and implementation approaches of the national standards for comprehensive care in Australia, Norway and the UK were slightly different. The scarcity of studies found during the review highlights the need for further research to evaluate the implementation challenges and facilitators, and impacts of national standards for comprehensive care in acute care hospitals.

[Comparison of acute stroke care pathways-A qualitative multicenter study in three referring hospitals of a stroke network]

BACKGROUND

In stroke networks, hospitals that do not provide thrombectomy (referring hospitals) refer patients to specialized hospitals (receiving hospitals) for this specific intervention. In order to improve the access and management of thrombectomy, the focus of research needs to be not only on the receiving hospitals but also on the prior stroke care pathways in referring hospitals.

OBJECTIVE

The purpose of this study was to investigate the stroke care pathways in different referring hospitals as well as the advantages and disadvantages associated with these pathways.

METHODS

A qualitative multicenter study was carried out in three referring hospitals of a stroke network. Stroke care was assessed and analyzed by using non-participant observations and 15 semi-structured interviews with employees in various health professions.

RESULTS

The following aspects were reported as advantageous within the stroke care pathways: (1) a structured and personal prenotification of the patient by the emergency medical service (EMS) members; (2) a more efficiently organized teleneurology workflow; (3) the provision of the secondary referral to thrombectomy by the same EMS members of the primary referral and (4) the integration of external neurologists into in-house structures.

CONCLUSION

The study provides insights into different stroke care pathways of three different referring hospitals of a stroke network. The results can be used to derive potentials for improvement of other referring hospitals; however, this study is too small to provide reliable information about their potential effectiveness. Future studies should investigate whether implementation of these recommendations actually leads to improvements and under which conditions they are successful. To ensure patient-centeredness, the perspectives of patients and relatives should also be included.

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective

BACKGROUND

The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements.

METHODS

Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis.

RESULTS

An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care.

CONCLUSIONS

To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.

Colorectal neoplastic emergencies in immunocompromised patients: preliminary result from the Web-based International Register of Emergency Surgery and Trauma (WIRES-T trial)

Association of advanced age, neoplastic disease and immunocompromission (IC) may lead to surgical emergencies. Few data exist about this topic. Present study reports the preliminary data from the WIRES-T trial about patients managed for colorectal neoplastic emergencies in immunocompromised patients. The required data were taken from a prospective observational international register. The study was approved by the Ethical Committee with approval n. 17575; ClinicalTrials.gov Identifier: NCT03643718. 839 patients were collected; 753 (80.7%) with mild-moderate IC and 86 (10.3%) with severe. Median age was 71.9 years and 73 years, respectively, in the two groups. The causes of mild-moderate IC were reported such malignancy (753-100%), diabetes (103-13.7%), malnutrition (26-3.5%) and uremia (1-0.1%), while severe IC causes were steroids treatment (14-16.3%); neutropenia (7-8.1%), malignancy on chemotherapy (71-82.6%). Preoperative risk classification were reported as follow: mild-moderate: ASA 1-14 (1.9%); ASA 2-202 (26.8%); ASA 3-341 (45.3%); ASA 4-84 (11.2%); ASA 5-7 (0.9%); severe group: ASA 1-1 patient (1.2%); ASA 2-16 patients (18.6%); ASA 3-41 patients (47.7%); ASA 4-19 patients (22.1%); ASA 5-3 patients (3.5%); lastly, ASA score was unavailable for 105 cases (13.9%) in mild-moderate group and in 6 cases (6.9%) in severe group. All the patients enrolled underwent urgent/emergency surgery Damage control approach with open abdomen was adopted in 18 patients. Mortality was 5.1% and 12.8%, respectively, in mild-moderate and severe groups. Long-term survival data: in mild-moderate disease-free survival (median, IQR) is 28 (10-91) and in severe IC, it is 21 (10-94). Overall survival (median, IQR) is 44 (18-99) and 26 (20-90) in mild-moderate and severe, respectively; the same is for post-progression survival (median, IQR) 29 (16-81) and 28, respectively. Univariate and multivariate analyses showed as the only factor influencing mortality in mild-moderate and severe IC is the ASA score. Colorectal neoplastic emergencies in immunocompromised patients are more frequent in elderly. Sigmoid and right colon are the most involved. Emergency surgery is at higher risk of complication and mortality; however, management in dedicated emergency surgery units is necessary to reduce disease burden and to optimize results by combining oncological and acute care principles. This approach may improve outcomes to obtain clinical advantages for patients like those observed in elective scenario. Lastly, damage control approach seems feasible and safe in selected patients.

Testing an Intervention to Improve Posthospital Outcomes in Persons Living With Dementia and Their Family Care Partners

Background and Objectives

Hospitalized persons living with dementia are at risk for functional decline, behavioral symptoms of distress, and delirium, all persisting in the postacute period. In turn, family care partners (FCPs) experience increased anxiety and lack of preparedness for caregiving, compounding existing strain and burden. Family-centered Function-focused Care (Fam-FFC) purposefully engages FCPs in assessment, decision-making, care delivery, and evaluation of function-focused care during and after hospitalization (within 48 hours of discharge, weekly telephone calls for a total of 7 additional weeks, then monthly for 4 months). The objective of this study was to test the efficacy of Fam-FFC.

Research Design and Methods

A cluster randomized controlled trial included 455 dyads of persons living with dementia and FCPs in 6 medical units in 3 hospitals. Patient outcomes included return to baseline physical function, behavioral symptoms of distress, depressive symptoms, and delirium severity. Family care partner measures included preparedness for caregiving, anxiety, strain, and burden.

Results

Multilevel level modeling demonstrated that the likelihood of returning to baseline function across time for Fam-FFC participants was twice that of the control group by the end of 6 months (OR = 2.4, p = .01, 95% CI 1.2-4.7). Family-centered Function-focused Care was also associated with fewer symptoms of distress (b = -1.1, SE = 0.56, p = .05) but no differences in the amount of moderate physical activity, depressive symptoms, and delirium severity. Preparedness for caregiving increased significantly only from 2 to 6 months (b = 0.89, SE = 0.45, d = 0.21, overall p = .02) in the intervention group, with no group differences in anxiety, strain, and burden.

Discussion and Implications

Family-centered Function-focused Care may help prevent some of the postacute functional decline and behavioral symptoms in hospitalized persons living with dementia. Further research is needed to promote sustained improvements in these symptoms with more attention to the postacute needs of the care partner.