[ENCOVUR-2 study: Analysis of the protocols of action, management and availability of intensive care resources for patients with severe COVID-19 attended in spanish Emergency Departments during the first peak of the pandemic.]

OBJECTIVE

During the first wave of the COVID-19 pandemic, the availability of a critical care bed was insufficient. The aim of this work was to evaluate the presence of protocols, management in the emergency department (ED) and the availability of intensive care unit (ICU) beds for severe COVID-19 patients attended in Spanish hospital EDs during the first peak of the 2020 pandemic.

METHODS

Questionnaire collecting data regarding ED care in March-April 2020 aimed at all Spanish public health care EDs. The respondents were the Chiefs of EDs. The variables of interest were: 1) Presence and of compliance with ED protocols for decision making and adequacy of therapeutic effort; 2) management of COVID-19 patients with non-invasive mechanical ventilation (NIMV) or high flow nasal cannula (HFNC) in the ED; and 3) ICU bed accessibility for ED patients. The results were compared based on the characteristics of the hospital, impact of the pandemic and autonomous community. A descriptive and inferential analysis of the variables studied was performed using the chi-square test and analysis of variance.

RESULTS

A total of 246 questionnaires (89%) were received. Protocols were available in 136 EDs (57.1%). Globally, the protocol was applied in >95% of the EDs, although this was less frequent (76%) in EDs with high impact of the pandemic. 53% of the EDs managed patients with severe COVID-19 with NIMV/HFNC in the ED itself, and 19.4% suffered from lack of ICU beds. The lack of ICU beds for severe COVID-19 patients in the ED significantly differed among periods, and more marked in hospitals with ICU and with high pandemic impact.

CONCLUSIONS

It is needed to generalize the implementation of protocols in EDs for the management of severe COVID-19 patients and improve the capacity of the ICUs to homogeneously adjust to the needs.

The Discharge Lounge: A Patient Flow Process Solution

BACKGROUND

Patient flow, from emergency department admission through to discharge, influences hospital overcrowding. We aimed to improve patient flow by increasing discharge lounge (DL) usage.

LOCAL PROBLEM

Patients need to receive a continuum of nursing care to encourage compliance with follow-up care after discharge from the acute care setting.

METHODS

Baseline data revealed inefficient use of the DL. We targeted the medical-surgical unit with the lowest DL use and trialed interventions over sequential Plan-Do-Study-Act cycles.

INTERVENTIONS

After surveying the nursing staff, we assessed the influence of 3 interventions on DL usage: educating staff on patient eligibility, engaging a recruitment scout, and displaying a visual cue notifying staff when a patient's discharge order was written.

RESULTS

The unit's average DL use increased from 18% to 36%, while hospital overcrowding and discharge turnaround time decreased.

CONCLUSION

The DL is an effective tool to improve patient flow and decrease hospital overcrowding.

Impact of Hospital Bed Shortages on the Containment of COVID-19 in Wuhan

The global outbreak of COVID-19 has caused worrying concern amongst the public and health authorities. The first and foremost problem that many countries face during the outbreak is a shortage of medical resources. In order to investigate the impact of a shortage of hospital beds on the COVID-19 outbreak, we formulated a piecewise smooth model for describing the limitation of hospital beds. We parameterized the model while using data on the cumulative numbers of confirmed cases, recovered cases, and deaths in Wuhan city from 10 January to 12 April 2020. The results showed that, even with strong prevention and control measures in Wuhan, slowing down the supply rate, reducing the maximum capacity, and delaying the supply time of hospital beds all aggravated the outbreak severity by magnifying the cumulative numbers of confirmed cases and deaths, lengthening the end time of the pandemic, enlarging the value of the effective reproduction number during the outbreak, and postponing the time when the threshold value was reduced to 1. Our results demonstrated that establishment of the Huoshenshan, Leishenshan, and Fangcang shelter hospitals avoided 22,786 people from being infected and saved 6524 lives. Furthermore, the intervention of supplying hospital beds avoided infections in 362,360 people and saved the lives of 274,591 persons. This confirmed that the quick establishment of the Huoshenshan, Leishenshan Hospitals, and Fangcang shelter hospitals, and the designation of other hospitals for COVID-19 patients played important roles in containing the outbreak in Wuhan.

Ethical aspects of the COVID-19 crisis: How to deal with an overwhelming shortage of acute beds

The current outbreak of SARS-CoV-2 has and continues to put huge pressure on intensive care units (ICUs) worldwide. Many patients with COVID-19 require some form of respiratory support and often have prolonged ICU stays, which results in a critical shortage of ICU beds. It is therefore not always physically possible to treat all the patients who require intensive care, raising major ethical dilemmas related to which patients should benefit from the limited resources and which should not. Here we consider some of the approaches to the acute shortages seen during this and other epidemics, including some guidelines for triaging ICU admissions and treatments.

Protecting patients: pressure ulcer prevention

John Tingle, Reader in Health Law, Nottingham Trent University, continues his discussion of Healthcare Improvement Scotland patient safety publications and its standards for management of pressure ulcers.

The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries

OBJECTIVE

Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries.

DESIGN

Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations.

SETTING

A total of 23 countries.

SUBJECTS

General practitioners and patients.

MAIN OUTCOME MEASURES

Diabetes-related avoidable hospitalizations.

RESULTS

Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications.

CONCLUSIONS

Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations.

KEY POINTS

Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization. Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications. Continuity of care was associated with lower rates of diabetes-related hospitalization. Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.

[Current situation of available back-up beds for terminal home care patients]

The Palliative Care Unit at Heiwa Hospital has 16 beds, and offers inpatient support in general wards, as well as back-up beds in emergencies in collaboration with local home care support clinics. For two years from January 2012 to December 2013, there were 1,213 cases where patients were seen for initial outpatient visits at the Department of Palliative Care. At the time of the initial visit, visiting medical care had been introduced for 25% of the cases. Although 59% of the patients who visited our department are hospitalized, 20% of inpatients have been hospitalized at the request of their home care physician. The availability of back-upbeds offers patients and their families, as well as related medical institutions, a sense of security, and enables home care to continue. The significance of back-upbeds will become even more important in the future.

Do more hospital beds lead to higher hospitalization rates? a spatial examination of Roemer's Law

BACKGROUND

Roemer's Law, a widely cited principle in health care policy, states that hospital beds that are built tend to be used. This simple but powerful expression has been invoked to justify Certificate of Need regulation of hospital beds in an effort to contain health care costs. Despite its influence, a surprisingly small body of empirical evidence supports its content. Furthermore, known geographic factors influencing health services use and the spatial structure of the relationship between hospital bed availability and hospitalization rates have not been sufficiently explored in past examinations of Roemer's Law. We pose the question, "Accounting for space in health care access and use, is there an observable association between the availability of hospital beds and hospital utilization?"

METHODS

We employ an ecological research design based upon the Anderson behavioral model of health care utilization. This conceptual model is implemented in an explicitly spatial context. The effect of hospital bed availability on the utilization of hospital services is evaluated, accounting for spatial structure and controlling for other known determinants of hospital utilization. The stability of this relationship is explored by testing across numerous geographic scales of analysis. The case study comprises an entire state system of hospitals and population, evaluating over one million inpatient admissions.

RESULTS

We find compelling evidence that a positive, statistically significant relationship exists between hospital bed availability and inpatient hospitalization rates. Additionally, the observed relationship is invariant with changes in the geographic scale of analysis.

CONCLUSIONS

This study provides evidence for the effects of Roemer's Law, thus suggesting that variations in hospitalization rates have origins in the availability of hospital beds. This relationship is found to be robust across geographic scales of analysis. These findings suggest continued regulation of hospital bed supply to assist in controlling hospital utilization is justified.

The effect of certificate-of-need laws on hospital beds and healthcare expenditures: an empirical analysis

OBJECTIVE

To estimate the effect of certificate-of-need legislation on hospital bed supply and healthcare expenditures.

STUDY DESIGN

This study uses state data on several variables, including healthcare expenditures, hospital bed supply, and the existence of a certificate-of-need program, from 4 periods (1985, 1990, 1995, and 2000).

METHODS

We estimate 2 multivariate regression equations. In the first equation, hospital bed supply is the dependent variable, and certificate of need is included as an independent variable. In the second equation, healthcare expenditures is the dependent variable, and hospital bed supply and certificate of need are included as independent variables.

RESULTS

Certificate-of-need laws have reduced the number of hospital beds by about 10% and have reduced healthcare expenditures by almost 2%. Certificate-of-need programs did not have a direct effect on healthcare expenditures.

CONCLUSION

Certificate-of-need programs have limited the growth in the supply of hospital beds, and this has led to a slight reduction in the growth of healthcare expenditures.

WOC nurses as advocates for patients who are morbidly obese: a case study promoting the use of bariatric beds

Wound, ostomy, and continence nurses and healthcare providers are encountering more than ever before patients who are morbidly obese. Patients who are immobile and morbidly obese are at increased risk for complications such as skin breakdown. Strategies to predict and prevent skin and wound complications should include properly sized bariatric beds. Bariatric beds greatly reduce the risk of pressure ulcers through pressure reduction. They also promote patient independence, improve clinical outcomes, decrease staff workload, and help control unnecessary healthcare costs. The purpose of this article is to increase wound, ostomy, and continence nurses' awareness about the benefits of bariatric beds and some important issues that surround their use.

SimCair: a simple mattress system to support pressure ulcer prevention

Assessing skin is a simple method of reducing pressure ulcer occurrence and is easily accomplished by both trained and untrained staff. The important issue, once the risk has been identified, is to supply equipment in the shortest time possible. A new mattress, SimCair, developed by Hill-Rom Ltd, is designed for just such a reason. It is a lightweight overlay that combines air and viscoelastic foam in order to redistribute the body weight and thus reduce risk. SimCair is easily transported and can be ready for instant and automatic inflation as soon as it is required. It is also durable and simple to clean between patients. A small evaluation was undertaken in one nursing home to assess the benefits to the residents.

Choosing the right support surface

PURPOSE

To provide the clinician with an overview of support surfaces used to manage tissue integrity as well as a review of how pressure ulcers develop.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in understanding how available support surfaces can impact the development and treatment of pressure ulcers.

OBJECTIVES

After reading the article and taking the test, the participant should be able to:

Using Support Surfaces to Manage Tissue Integrity

PURPOSE

To provide the clinician with an overview of support surfaces used to manage tissue integrity as well as a review of how pressure ulcers develop.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in understanding how available support surfaces can impact the development and treatment of pressure ulcers.

OBJECTIVES

After reading the article and taking the test, the participant should be able to:

Preventing pressure ulcers: choosing a mattress

The standard hospital mattress is not suitable for patients at risk of developing pressure ulcers. The type of mattress or overlay system they require will depend on their pressure ulcer risk, medical history and local practice. This article provides a guide to pressure-relieving mattresses.

An online ordering system for therapy beds and mattresses

Within this article, the authors have put forward a solution to keep track of pressure-relieving devices using internet-based secure online systems. In partnership with a therapy bed company they set up a system that was able to manage and monitor the requirements of their trust and ensure that products are used for patients who most need them. In using these systems they were also able to gather real-time data on usage and costs as well as time-dependent analysis. The system has also allowed a means of gathering outcome measurement of all products in use. Over a 6-month period the authors have shown how a forecasted 18% budget deficit has been turned into a 10% under spend of the overall budget. It is suggested that these systems could be one way of managing the pressure-relieving needs of hospital trusts ensuring both clinical effectiveness and cost-benefit.

Is bed rest an effective treatment modality for pressure ulcers?

Despite the well-documented medical, physical, and psychological complications associated with this care management option, bed rest remains a frequently prescribed treatment modality for conditions such as pressure ulcers. Cognitive and psychosocial complications of bed rest include depression, learned helplessness, perceptual changes, and fatigue. Physically, complications can include contractures, muscle atrophy, osteoporosis, pathologic fractures, urinary tract infections, decreased cardiac reserve, decreased stroke volume, resting and post-exercise tachycardia, orthostatic hypotension, pulmonary embolism, deep venous thrombosis, pneumonia, anorexia, constipation, and bowel impaction. Furthermore, the literature does not contain evidence supporting the use of bed rest to facilitate healing of pressure ulcers. More suitable approaches to pressure ulcer care include limiting bed rest, initiating occupational therapy, integrating meaningful tasks into daily activities, increasing outside stimulation, involving patients in care decisions and addressing their concerns, optimizing nutritional status, and managing pressure and shear throughout daily activities. Recommendations for implementing alternatives to bed rest are addressed.

Health inequalities in Thailand: geographic distribution of medical supplies in the provinces

The purpose of this study was to analyze the regional characteristics and geographic distribution of the medical staffs (physicians and nurses) and the patient beds in relation to the population and average death rates in each of the provinces in Thailand, by using the Lorenz curve and Gini coefficients. Those data were obtained from surveys conducted by the Ministry of Public Health and the Office of the National Education Commission. It was demonstrated that there are certain clear uneven distributions in medical personnel, especially physicians (Gini index = 0.433), by province. For physicians, nurses, and patient beds, approximately 39.6%, 25.8% and 20.6% are concentrated in the Bangkok Metropolis. Specific ideas to solve those problems are discussed in order to overcome this health care crisis by the year 2025.

The expected number of hospitalisations and beds needed due to pandemic influenza on a regional level in the Netherlands

In order to minimise the effects of a potential influenza pandemic on the population, regional authorities in the Netherlands are in the process of development of a plan to be prepared to cope with mass illness and to ensure health care services. The objective of this study is to calculate the expected numbers of hospitalisations and the maximum number of beds needed per day on a regional level. As many uncertainties are involved in this type of studies, we have performed a scenario analysis of the expected number of hospitalisations and beds needed during an influenza pandemic. The analysis gives insight into the impact of the pandemic in terms of how many will be hospitalised, how many beds are needed during the pandemic and in the effect of a possible intervention by therapeutic use of antivirals in terms of hospitalisations and beds needed. It can be concluded that our scenario analysis will be helpful in designing and planning on a regional level.

Provision of alternating air-pressure mattresses in the community

The presence of pressure ulcers is seen as a key indicator of quality (Department of Health, 1993) and they are both costly to the patient (Franks, 2001) and the NHS. It is important that resources are directed towards prevention rather than treatment, which makes the provision of pressure-relieving equipment an integral part of any strategy for the prevention and management of pressure ulcers.

'Immediate bedding' boosts patient satisfaction at California emergency department

For sick or injured patients, the average wait of nearly an hour to see a physician at Good Samaritan Hospital's ED must have seemed like an eternity. But since instituting a practice known as "immediate bedding", unhappy patients have almost disappeared and its patient satisfaction ratings have skyrocketed.

[Medical equipment. Tilting beds. Condition and perspectives]

Data are elucidated in the paper on the tilting beds available in the Russian market. There is a sufficiently detailed description of the discussed products manufactured by Russian and foreign companies. Prospective requirements of more comfort for the patient are outlined.

ProfiCare®: an alternating pressure-relieving mattress

Risk assessment tools should only act as a guide to patient status rather than definitive diagnosis. Emphasis must be placed on not using the Waterlow score in isolation but in conjunction with clinical judgment. We must therefore attempt to minimize opportunities for disagreement over pressure ulcer risk scores through the selection of appropriate support surfaces based on a thorough consideration of costs of pressure ulcers for the patient, institutions and healthcare professionals. This product focus advocates that ProfiCare® replacement mattresses are an option as they are designed for use on a hospital bed frame and provide alternating and static patient support surfaces.

TheraPulse ATP for preventing and treating pressure ulcers

In the modern healthcare environment where evidence-based best practice is key in seeking quality improvements for patient care, using treatment and therapies that have evidence of clinical efficacy is paramount. The current evidence bases supporting pulsating air suspension therapy is excellent and the improved lymphatic flow and enhanced microcirculation along with reduction of pressure ulcer potential (El-Habbal and Smith, 1996; Gunther and Brofeldt, 1996) ensures a firm place for TheraPulse ATP (KCI Medical) in reduction of oedema and pressure ulcers in the critically ill patient.

Beds Simulator 1.0: a software for the modelisation of the number of beds required for a hospital department

The determination of the number of beds needed for a hospital department is a complex problem that try to take into account efficiency, forecasting of needs, appropriateness of stays. Health authority used methods based on ratios that do not take into account local specificities and use rather to support an economic decision. On the other side, the models developed are too specific to be applied to all type of hospital department. Moreover, all the solutions depend on the LoS (Length of Stay). We have developed a non parametric method to solve this problem. This modelisation was successfully tested in teaching and non teaching hospitals, for an Intensive Care Unit, two Internal Medicine and a surgical departments. A software easy to use was developed, working on Windows available on our website www.sante.univ-nantes.fr/med/stat/.

Pressure relieving equipment selection in the community: rising to the challenge

Due to changes in health care provision district nurses are increasingly called on to assess for more specialized pieces of equipment from an ever-increasing choice of products. Eligibility criteria for the ordering of equipment have been developed in Leeds to assist district nurses in ensuring that the equipment they assess for is the most appropriate and suitable for its purpose and that it will be used safely and correctly. The use of the criteria is demonstrated through their application to pressure-relieving equipment. Use of the eligibility criteria will hopefully improve the overall quality of service for the patient and carers throughout the process of equipment provision, from assessment through to delivery and its subsequent use.