Predictive modelling of transport decisions and resources optimisation in pre-hospital setting using machine learning techniques

BACKGROUND

The global evolution of pre-hospital care systems faces dynamic challenges, particularly in multinational settings. Machine learning (ML) techniques enable the exploration of deeply embedded data patterns for improved patient care and resource optimisation. This study's objective was to accurately predict cases that necessitated transportation versus those that did not, using ML techniques, thereby facilitating efficient resource allocation.

METHODS

ML algorithms were utilised to predict patient transport decisions in a Middle Eastern national pre-hospital emergency medical care provider. A comprehensive dataset comprising 93,712 emergency calls from the 999-call centre was analysed using R programming language. Demographic and clinical variables were incorporated to enhance predictive accuracy. Random Forest (RF), Support Vector Machine (SVM), Extreme Gradient Boosting (XGBoost), and Adaptive Boosting (AdaBoost) algorithms were trained and validated.

RESULTS

All the trained algorithm models, particularly XGBoost (Accuracy = 83.1%), correctly predicted patients' transportation decisions. Further, they indicated statistically significant patterns that could be leveraged for targeted resource deployment. Moreover, the specificity rates were high; 97.96% in RF and 95.39% in XGBoost, minimising the incidence of incorrectly identified "Transported" cases (False Positive).

CONCLUSION

The study identified the transformative potential of ML algorithms in enhancing the quality of pre-hospital care in Qatar. The high predictive accuracy of the employed models suggested actionable avenues for day and time-specific resource planning and patient triaging, thereby having potential to contribute to pre-hospital quality, safety, and value improvement. These findings pave the way for more nuanced, data-driven quality improvement interventions with significant implications for future operational strategies.

Factors Associated With the Ability of US Nursing Homes to Accept Residents With Severe Obesity

OBJECTIVES

Severe obesity in nursing home (NH) residents is associated with specialized care needs, limited mobility, and challenges in daily living. The COVID-19 pandemic strained NH resources and exacerbated staffing shortages. This study aimed to assess the ability of US NHs to accept and care for residents with severe obesity post-COVID, as well as associated NH factors.

DESIGN

Cross-sectional nationwide survey of NH administrators (2021-2022).

SETTING AND PARTICIPANTS

290 NHs from a national sample (n = 224) and a targeted sample in Massachusetts and New Jersey (n = 66).

METHODS

A survey designed to assess how NHs approach admitting and caring for people with severe obesity before and after COVID was fielded from 2021 to 2022. Responses were linked to facility information from the Certification and Survey Provider Enhanced Reports, Minimum Data Set, Nursing Home Compare, Area Health Resources File, and US Diabetes Surveillance System. Multivariable logistic regression was used to assess the effect of organizational and survey response variables.

RESULTS

Of the 2503 surveys sent to US NHs, 1923 were sent to the national NH stratified sample, and 580 were sent to the MA/NJ sample. Overall, 12% (301 of 2503) of NHs surveyed responded. The response rates were similar between the 2 samples. Of 290 NHs with complete data, 34% reported being unlikely to accept residents with severe obesity after COVID-19, compared with 25% before the pandemic (P < .001). The main barriers to acceptance were staffing shortages and difficulties meeting equipment and space needs. NHs with higher proportions of Black residents were more likely to admit individuals with severe obesity.

CONCLUSIONS AND IMPLICATIONS

The decline in acceptance of residents with severe obesity during and after COVID-19 highlights potential challenges that this population faces in accessing care. Our results also raise concerns that an intersection of disparities may exist in Black patients with severe obesity.

Exploring factors influencing time from dispatch to unit availability according to the transport decision in the pre-hospital setting: an exploratory study

BACKGROUND

Efficient resource distribution is important. Despite extensive research on response timings within ambulance services, nuances of time from unit dispatch to becoming available still need to be explored. This study aimed to identify the determinants of the duration between ambulance dispatch and readiness to respond to the next case according to the patients' transport decisions.

METHODS

Time from ambulance dispatch to availability (TDA) analysis according to the patients' transport decision (Transport versus Non-Transport) was conducted using R-Studio™ for a data set of 93,712 emergency calls managed by a Middle Eastern ambulance service from January to May 2023. Log-transformed Hazard Ratios (HR) were examined across diverse parameters. A Cox regression model was utilised to determine the influence of variables on TDA. Kaplan-Meier curves discerned potential variances in the time elapsed for both cohorts based on demographics and clinical indicators. A competing risk analysis assessed the probabilities of distinct outcomes occurring.

RESULTS

The median duration of elapsed TDA was 173 min for the transported patients and 73 min for those not transported. The HR unveiled Significant associations in various demographic variables. The Kaplan-Meier curves revealed variances in TDA across different nationalities and age categories. In the competing risk analysis, the 'Not Transported' group demonstrated a higher incidence of prolonged TDA than the 'Transported' group at specified time points.

CONCLUSIONS

Exploring TDA offers a novel perspective on ambulance services' efficiency. Though promising, the findings necessitate further exploration across diverse settings, ensuring broader applicability. Future research should consider a comprehensive range of variables to fully harness the utility of this period as a metric for healthcare excellence.

Epidemiology of prehospital emergency calls according to patient transport decision in a middle eastern emergency care environment: Retrospective cohort-based

Background and Aim

Though emergency medical services (EMS) respond to all types of emergency calls, they do not always result in the patient being transported to the hospital. This study aimed to explore the determinants influencing emergency call-response-based conveyance decisions in a Middle Eastern ambulance service.

Methods

This retrospective quantitative analysis of 93,712 emergency calls to the Hamad Medical Corporation Ambulance Service (HMCAS) between January 1 and May 31, 2023, obtained from the HMCAS electronic system, was analyzed to determine pertinent variables. Sociodemographic, emergency dispatch-related, clinical, and miscellaneous predictors were analyzed. Descriptive, bivariate, ridge logistic regression, and combination analyses were evaluated.

Results

23.95% (N = 21,194) and 76.05% (N = 67,285) resulted in patient nontransport and transportation, respectively. Sociodemographic analysis revealed that males predominantly activated EMS resources, and 60% of males (n = 12,687) were not transported, whilst 65% of females (n = 44,053) were transported. South Asians represented a significant proportion of the transported patients (36%, n = 24,007). "Home" emerged as the primary emergency location (56%, n = 37,725). Bivariate analysis revealed significant associations across several variables, though multicollinearity was identified as a challenge. Ridge regression analysis underscored the role of certain predictors, such as missing provisional diagnoses, in transportation decisions. The upset plot shows that hypertension and diabetes mellitus were the most common combinations in both groups.

Conclusions

This study highlights the nuanced complexities governing conveyance decisions. By unveiling patterns such as male predominance, which reflects Qatar's expatriate population, and specific temporal EMS activity peaks, this study accentuates the importance of holistic patient assessment that transcends medical histories.

Enhancing Patient Safety in Prehospital Environment: Analyzing Patient Perspectives on Non-Transport Decisions With Natural Language Processing and Machine Learning

OBJECTIVE

This research explored the experiences and perspectives of patients declining hospital transportation after receiving prehospital emergency care using advanced computational techniques.

METHOD

Between 15th June and 1st August 2023, 210 patients in Qatar, treated by Hamad Medical Corporation Ambulance Service (HMCAS) but refusing transportation to hospital, were interviewed. Key outcome variables stratified by demographics included "reasons for refusing transport," "satisfaction with HMCAS service," and "postrefusal actions." Responses underwent sentiment analysis and topic modeling using latent Dirichlet allocation. Machine learning models, such as Naïve Bayes, K-nearest neighboring, random forest, and support vector machine, were used to predict patients' subsequent actions.

RESULTS

Participants had an average age of 38.61 ± 19.91 years. The chief complaints were primarily chest and abdominal pains (18.49%; n = 39). Sentiment Analysis revealed a generally favorable perception of HMCAS-provided service. Latent Dirichlet allocation identified two main topics pertaining to refusal reasons and service satisfaction. Naïve Bayes and support vector machine algorithms were most effective in predicting postrefusal actions with an accuracy rate of 81.58%.

CONCLUSIONS

This study highlighted the utility of Natural Language Processing and ML in enhancing our understanding of patient behaviors and sentiments in prehospital settings. These advanced computational methodologies allowed for a nuanced exploration of patient demographics and sentiments, providing insights for Quality Improvement initiatives. The study also advocates for continuously integrating automated feedback mechanisms to improve patient-centered care in the prehospital context. Continuous integration of automated feedback systems is recommended to improve prehospital patient-centered care.

Perspectives on Preparedness for Chemical, Biological, Radiological, and Nuclear Threats in the Middle East and North Africa Region: Application of Artificial Intelligence Techniques

Over the past 3 decades, the diversity of ethnic, religious, and political backgrounds worldwide, particularly in countries of the Middle East and North Africa (MENA), has led to an increase in the number of intercountry conflicts and terrorist attacks, sometimes involving chemical and biological agents. This warrants moving toward a collaborative approach to strengthening preparedness in the region. In disaster medicine, artificial intelligence techniques have been increasingly utilized to allow a thorough analysis by revealing unseen patterns. In this study, the authors used text mining and machine learning techniques to analyze open-ended feedback from multidisciplinary experts in disaster medicine regarding the MENA region's preparedness for chemical, biological, radiological, and nuclear (CBRN) risks. Open-ended feedback from 29 international experts in disaster medicine, selected based on their organizational roles and contributions to the academic field, was collected using a modified interview method between October and December 2022. Machine learning clustering algorithms, natural language processing, and sentiment analysis were used to analyze the data gathered using R language accessed through the RStudio environment. Findings revealed negative and fearful sentiments about a lack of accessibility to preparedness information, as well as positive sentiments toward CBRN preparedness concepts raised by the modified interview method. The artificial intelligence analysis techniques revealed a common consensus among experts about the importance of having accessible and effective plans and improved health sector preparedness in MENA, especially for potential chemical and biological incidents. Findings from this study can inform policymakers in the region to converge their efforts to build collaborative initiatives to strengthen CBRN preparedness capabilities in the healthcare sector.

A Virtual Inner Ear Model Selects Ramped Pulse Shapes for Vestibular Afferent Stimulation

Bilateral vestibular deficiency (BVD) results in chronic dizziness, blurry vision when moving the head, and postural instability. Vestibular prostheses (VPs) show promise as a treatment, but the VP-restored vestibulo-ocular reflex (VOR) gain in human trials falls short of expectations. We hypothesize that the slope of the rising ramp in stimulation pulses plays an important role in the recruitment of vestibular afferent units. To test this hypothesis, we utilized customized programming to generate ramped pulses with different slopes, testing their efficacy in inducing electrically evoked compound action potentials (eCAPs) and current spread via bench tests and simulations in a virtual inner model created in this study. The results confirmed that the slope of the ramping pulses influenced the recruitment of vestibular afferent units. Subsequently, an optimized stimulation pulse train was identified using model simulations, exhibiting improved modulation of vestibular afferent activity. This optimized slope not only reduced the excitation spread within the semicircular canals (SCCs) but also expanded the neural dynamic range. While the model simulations exhibited promising results, in vitro and in vivo experiments are warranted to validate the findings of this study in future investigations.

Paying A Heavy Price: Costs of Care for People with Severe Obesity in Nursing Homes

BACKGROUND AND OBJECTIVES

The prevalence of resident obesity in nursing homes has increased dramatically from 22% to 28% between 2005 and 2015. To provide care for people with obesity, nursing homes have changed their admissions, staffing, and equipment, but underlying these changes are increased resources and financial costs of care. The purpose of this study is to describe nursing home organizational aspects of caring for older adults with obesity, with a focus on economic factors, from the perspective of nursing home staff and leadership.

RESEARCH DESIGN AND METHODS

This qualitative study used descriptive approaches; data were collected through semi-structured telephone interviews. Of 77 nursing home staff and leaders identified as potential study participants, 6 were ineligible, and 71 participated in the study through interviews conducted from 2019 to 2022.

RESULTS

Four primary themes described the issues surrounding cost of care for obesity in nursing homes: inefficient and risky use of staff time in a setting of persistent staff shortage, expensive and unique equipment needs, inadequate general reimbursement with an absence of obesity-specific reimbursement supplements, and competing short and long-term management solutions.

DISCUSSION AND IMPLICATIONS

This qualitative study of nursing home staff and leadership underscores a need for improved approaches to funding obesity care within existing nursing payment models. The increasing prevalence of obesity and the burden of the costs of obesity care for nursing homes will escalate this need over the coming decade.

Environmental and structural factors driving poor quality of care: An examination of nursing homes serving Black residents

BACKGROUND

Poor quality of care in nursing homes (NHs) with high proportions of Black residents has been a problem in the US and even more pronounced during the COVID-19 pandemic. Federal and state agencies are devoting attention to identifying the best means of improving care in the neediest facilities. It is important to understand environmental and structural characteristics that may have led to poor healthcare outcomes in NHs serving high proportions of Black residents pre-pandemic.

METHODS

We conducted a cross-sectional observational study using multiple 2019 national datasets. Our exposure was the proportion of Black residents in a NH (i.e., none, <5%, 5%-19.9%, 20-49.9%, ≥50%). Healthcare outcomes examined were hospitalizations and emergency department (ED) visits, both observed and risk-adjusted. Structural factors included staffing, ownership status, bed count (0-49, 50-149, or ≥150), chain organization membership, occupancy, and percent Medicaid as a payment source. Environmental factors included region and urbanicity. Descriptive and multivariable linear regression models were estimated.

RESULTS

In the 14,121 NHs, compared to NHs with no Black residents, NHs with ≥50% Black residents tended to be urban, for-profit, located in the South, have more Medicaid-funded residents, and have lower ratios of registered-nurse (RN) and aide hours per resident per day (HPRD) and greater ratios of licensed practical nurse HPRD. In general, as the proportion of Black residents in a NH increased, hospitalizations and ED visits also increased.

DISCUSSION/IMPLICATIONS

As lower use of RNs has been associated with increased ED visits and hospitalizations in NHs generally, it is likely low RN use largely drove the differences in hospitalizations and ED visits in NHs with greater proportions of Black residents. Staffing is an area in which state and federal agencies should take action to improve the quality of care in NHs with larger proportions of Black residents.

Finite Element Modeling of Residual Hearing after Cochlear Implant Surgery in Chinchillas

Cochlear implant (CI) surgery is one of the most utilized treatments for severe hearing loss. However, the effects of a successful scala tympani insertion on the mechanics of hearing are not yet fully understood. This paper presents a finite element (FE) model of the chinchilla inner ear for studying the interrelationship between the mechanical function and the insertion angle of a CI electrode. This FE model includes a three-chambered cochlea and full vestibular system, accomplished using µ-MRI and µ-CT scanning technologies. This model's first application found minimal loss of residual hearing due to insertion angle after CI surgery, and this indicates that it is a reliable and helpful tool for future applications in CI design, surgical planning, and stimuli setup.

Retrospective identification of medication related adverse events in the emergency medical services through the analysis of a patient safety register

Adverse drug events encompass a wide range of potential unintended and harmful events, from adverse drug reactions to medication errors, many of which in retrospect, are considered preventable. However, the primary challenge towards reducing their burden lies in consistently identifying and monitoring these occurrences, a challenge faced across the spectrum of healthcare, including the emergency medical services. The aim of this study was to identify and describe medication related adverse events (AEs) in the out-of-hospital setting. The medication components of a dedicated patient safety register were analysed and described for the period Jan 2017–Sept 2020. Univariate descriptive analysis was used to summarize and report on basic case and patient demographics, intervention related AEs, medication related AEs, and AE severity. Multivariable logistic regression was used to assess the odds of AE severity, by AE type. A total of 3475 patient records were assessed where 161 individual medication AEs were found in 150 (4.32%), 12 of which were categorised as harmful. Failure to provide a required medication was found to be the most common error (1.67%), followed by the administration of medications outside of prescribed practice guidelines (1.18%). There was evidence to suggest a 63% increase in crude odds of any AE severity [OR 1.63 (95% CI 1.03–2.6), p = 0.035] with the medication only AEs when compared to the intervention only AEs. Prehospital medication related adverse events remain a significant threat to patient safety in this setting and warrant greater widespread attention and future identification of strategies aimed at their reduction.

Nursing Home Satisfaction Surveys: Differences by Race, Age, and Gender

Nursing home satisfaction information has gained substantial traction as a quality indicator representing the consumers perspective. However, very little research has examined differences in satisfaction related to race, age and gender. As a quality metric, satisfaction measures are variously used for quality improvement, benchmarking, public reporting, and for adjustment to payments. As such, valid comparisons among facilities are important. To our knowledge, no adjustment to satisfaction scores are currently used for nursing homes. However, in many other settings this is a common practice. In this research, nursing home resident, family, and discharge satisfaction scores were examined from >4,000 participants. The data were collected in 2020 and come from 420 facilities. Satisfaction information came from the CoreQ surveys, which include 23 individual questions four of which can be combined to produce an overall satisfaction score. These CoreQ nursing home surveys are endorsed by NQF. Generally lower overall satisfaction scores were found for family members compared to current residents or discharged residents. Minorities (Black, Asian, Hispanic) had lower overall satisfaction scores compared to whites; however, the differences were not significant at conventional levels. Participants of the lowest age (<65 years) were significantly (p=<.05) less satisfied than older participants (>75 years) and males were significantly (p=<.05) less satisfied than females. The findings indicate that some case-mix adjustment may be applicable for nursing home satisfaction scores.

Women with Obesity Are More Likely to Have Long-Term Indwelling Bladder Catheterization in U.S. Nursing Homes

Reducing indwelling catheters and increasing clean intermittent catheterization is a key element of effective infection control and maintaining functional independence in nursing homes. Nursing care is often more difficult as obesity increases, leading to more nursing care or equipment to provide care. We hypothesized that nursing homes are more likely to use indwelling catheters for people with obesity because indwelling catheterization likely eases the nursing burden of toileting and personal hygiene care for residents with obesity. The study design was a retrospective cohort study of U.S. nursing home female residents in Minimum Data Set in 2013. Obesity and normal weight (the reference group) were categorized using National Institutes of Health criteria. Indwelling and intermittent bladder catheterization was defined during periodic assessment of residents. We modeled the outcomes using logistic regression using a robust variance estimator. Model covariates included obesity category, resident age, dementia status, comatose status, Stage 3 or 4 pressure ulcers, and the number of activities of daily living deficits. The study cohort included 1,068,388 female residents in 15,230 nursing homes. Obesity (BMI ≥ 30 kg/m2) prevalence was 31.9%. The prevalence of indwelling catheterization was 5.2% and of intermittent catheterization was 0.4%. The odds ratio of indwelling catheter use for obese residents varied from 1.05 to 1.74 (all with p-values <0.001), whereas the odds ratio. of intermittent catheter use varied from 0.84 to 0.46 (all with p-values <0.01) compared to residents of normal weight. Increasing obesity is independently associated with increased long-term indwelling bladder catheterization and decreased intermittent catheterization.

Application of a Healthcare Failure Modes and Effects Analysis to Identify and Mitigate Potential Risks in the Implementation of a National Prehospital Pediatric Rapid Sequence Intubation Program

INTRODUCTION

Rapid sequence intubation (RSI) has become the de facto airway method of choice in the emergency airway management of adult and pediatric patients. There is significant controversy regarding pediatric RSI in the prehospital setting, given not only the complexities inherent in both the procedure and patient population, but in variations in emergency medical service models, prehospital qualifications, scope of practice, and patient exposure too.

METHODS

A Healthcare Failure Mode and Effects Analysis was conducted to identify and mitigate potential hazards in the national implementation of a prehospital pediatric RSI program. A process map and potential failure points were developed and identified. Probabilities, severity, and hazards scores were calculated for each failure point, and actions items developed to address these.

RESULTS

One hundred four potential failure points were identified among 44 subprocesses, divided between nine major processes. In terms of severity, most were classified as either major (n = 39 [37.5%]) or catastrophic (n = 35 [33.7%]) with just more than half falling within the uncommon category (n = 56 [53.9%]) in terms of probability. Five strategic actions items were identified to mitigate against the failure points meeting criteria for action. To monitor the success of these, 11 quality and performance indicators were developed for concurrent implementation.

CONCLUSIONS

The Healthcare Failure Mode and Effects Analysis represents a simple yet comprehensive first step toward risk analysis of complex procedures within the prehospital emergency care setting. Application of the methodology provided guidance for the consensus identification of hazards associated with prehospital pediatric RSI and appropriate actions to mitigate them.

Brine-driven destruction of clay minerals in Gale crater, Mars

Mars' sedimentary rock record preserves information on geological (and potential astrobiological) processes that occurred on the planet billions of years ago. The Curiosity rover is exploring the lower reaches of Mount Sharp, in Gale crater on Mars. A traverse from Vera Rubin ridge to Glen Torridon has allowed Curiosity to examine a lateral transect of rock strata laid down in a martian lake ~3.5 billion years ago. We report spatial differences in the mineralogy of time-equivalent sedimentary rocks <400 meters apart. These differences indicate localized infiltration of silica-poor brines, generated during deposition of overlying magnesium sulfate-bearing strata. We propose that destabilization of silicate minerals driven by silica-poor brines (rarely observed on Earth) was widespread on ancient Mars, because sulfate deposits are globally distributed.

Qualitative Assessment of Resident Obesity in Nursing Homes by Medical Providers

We present qualitative themes from an ongoing five-year AHRQ-funded project (R01HS026943) examining the various ways nursing homes provide care for residents with obesity to determine the most effective way to prevent adverse safety events for residents with obesity. Obesity is a common diagnosis among short- and long-stay residents, and in the past, nursing home administrators have reported concerns from admissions issues to negative resident outcomes. No studies have examined the medical provider’s perspective on health of residents with obesity. In this abstract, we present three emergent themes from semi-structured interviews of medical providers (n=6) (nursing home medical directors, staff physicians, nurse practitioners) across the U.S. First, residents with obesity often have several complex and challenging medical conditions that require more services and health monitoring than most residents. Significant medical issues include diabetes, hypertension, cardiovascular disease, arthritis, and sleep apnea. Second, medical providers observe that it is difficult to provide daily custodial and nursing care, but the actual medical harm from substandard care is hard to quantify. Third, medical providers would like to help residents with obesity to lose weight and live healthier lives. There is, however, not an easy way to facilitate weight loss, due to limited resident physical activity, concerns about unhealthy weight loss, and difficulty changing established dietary habits of residents. These findings are limited by sample size, though themes have been consistent within the current participants. Comparing and contrasting these themes with other stakeholder groups (residents, nurse aides, administrators) interviews in the future will strengthen these findings.

Barriers to the implementation of prehospital thrombolysis in the treatment of ST-segment elevation myocardial infarction in South Africa: An exploratory inquiry

INTRODUCTION

Evidence-based guidelines advocate percutaneous coronary intervention (PCI) as the mainstay reperfusion strategy for ST-segment elevation myocardial infarction (STEMI). However, the South African health system is not well positioned to provide PCI as a 'mainstay strategy'. In response, the Health Professions Council of South Africa approved the use of prehospital thrombolysis (PHT) for emergency care practitioners in 2009. However, since its approval, prehospital thrombolysis has failed to reach a level of systematic uptake indicative of successful implementation. The current study aimed to explore, through a qualitative inquiry, barriers to PHT for the treatment of myocardial infarction within a South African context.

METHODS

A qualitative single-case study design was used where a series of semi-structured interviews were conducted involving purposefully selected participants. The case comprised a nationalised private emergency medical service, and participants were selected in view of relevant experience and knowledge. Requisite data was conceptualised through the consolidated framework for implementation research, and thematic analysis outlined the data coding procedures of the study.

RESULTS

The study identified potential barriers to the implementation of PHT. These comprised cost, logistics, inter-professional collaboration, leadership engagement, and beliefs or scepticism associated with PHT.

CONCLUSION

A lack of strategic implementation has resulted in a poor introduction of evidenced-based prehospital cardiac care, affecting vulnerable populations who may have otherwise benefited from receiving this level of care. Given the time-sensitive nature of STEMI management, and severely limited access to 'primary reperfusion', PHT resembles not only a logical but also appealing solution in the South African context.

Evidence for Multiple Diagenetic Episodes in Ancient Fluvial-Lacustrine Sedimentary Rocks in Gale Crater, Mars

The Curiosity rover's exploration of rocks and soils in Gale crater has provided diverse geochemical and mineralogical data sets, underscoring the complex geological history of the region. We report the crystalline, clay mineral, and amorphous phase distributions of four Gale crater rocks from an 80-m stratigraphic interval. The mineralogy of the four samples is strongly influenced by aqueous alteration processes, including variations in water chemistries, redox, pH, and temperature. Localized hydrothermal events are evidenced by gray hematite and maturation of amorphous SiO2 to opal-CT. Low-temperature diagenetic events are associated with fluctuating lake levels, evaporative events, and groundwater infiltration. Among all mudstones analyzed in Gale crater, the diversity in diagenetic processes is primarily captured by the mineralogy and X-ray amorphous chemistry of the drilled rocks. Variations indicate a transition from magnetite to hematite and an increase in matrix-associated sulfates suggesting intensifying influence from oxic, diagenetic fluids upsection. Furthermore, diagenetic fluid pathways are shown to be strongly affected by unconformities and sedimentary transitions, as evidenced by the intensity of alteration inferred from the mineralogy of sediments sampled adjacent to stratigraphic contacts.

LACK OF POLICIES, TRAINING, AND SPECIAL CARE UNITS FOR OBESITY CARE IN PENNSYLVANIA NURSING HOMES

It is unclear how nursing homes in the U.S. prepare for the specific needs of residents with obesity at a population level in terms of equipment availability, policies, staff training, and special care units. Using a mail survey of Directors of Nursing (DON) to 420 Pennsylvania Nursing Homes in 2017 and 2018, we examined the reported presence of obesity-specific equipment availability, organizational policies, staff training, and special care units. We compared the presence of these adaptation approaches by whether the DON strongly agreed that obesity was a problem for resident and staff safety using χ2 tests. One hundred fifty-one surveys were returned and included in the analysis (response rate of 36%). 80.7% of respondents were, on average, very concerned when asked about 11 resident medical, functional, relational, and staff-related safety outcomes (e.g., pressure ulcers, hospital readmissions, social isolation, and staff injury). DONs reported reduced equipment availability in nursing homes for obesity-specific beds (66%), walkers (34%), bedside commodes (30%), and gowns (28%). The presence of obesity-specific organizational policies (44%), staff training (26%), and special care units (7%) was limited. DON strong agreement with obesity-related resident and staff safety issues was significantly associated with obesity-specific bed availability (p=0.04) but was not significantly associated with obesity-specific organizational policies (p=0.17), staff training (p=0.51), and special care units (p=0.09). Despite a high concern for resident and staff safety related to obesity care expressed by DONs, there is little appropriate nursing home organizational response as measured by policies, staff training or special care units.

THE INFLUENCE OF STAFF RETENTION ON NURSING HOME QUALITY

The association of retention of Nurse Aides (NAs) with nursing home quality of care is examined. Retention is defined as staff continuously employed in the same facility for a defined period of time. Deficiency citations were used as quality indicators. Data used came from a survey of nursing home administrators, the Certification and Survey Provider Enhanced Reporting (CASPER) data, and the Area Resource File. All of the data was from 2015, and included 3,550 facilities. Analyses included negative binomial regression and multivariate logistic regression models (using GEE). The analytic modeling included staffing variables (turnover, agency use, staffing levels), facility factors (size, ownership, occupancy rate), and market characteristics (competition, Medicaid rates). The average number of deficiency citations was significantly lower (p<.01) in facilities with the higher levels of NAs consistently employed for one year or more. The same was found for facilities with the higher levels of NAs consistently employed for two years or more. While the average number of deficiency citations, the quality of care grouping of deficiency citations, and J, K, L deficiency citations were all significantly lower (p<.01) in facilities with the higher levels of NAs consistently employed for three years or more. Staff retention has been promoted as potentially influential based on little empirical evidence. The findings provide some justification for the importance of NA retention.

CONSISTENT ASSIGNMENT: AN UPDATE ON THE QUALITY IMPACT

The association of consistent assignment of Nurse Aides (NAs) with nursing home quality indicators is examined. Consistent assignment is defined as the same caregivers consistently caring for the same residents almost (80% of their shifts) every time they are on duty. Data used came from a survey of nursing home administrators, Nursing Home Compare, the Certification and Survey Provider Enhanced Reporting (CASPER) data, and the Area Resource File. All of the data was from 2015, and included 3,550 facilities. Several multivariate logistic regression models (using GEE) were used, including staffing variables (turnover, agency use, staffing levels), facility factors (size, ownership, occupancy rate), and market characteristics (competition, Medicaid rates). An average of 77% of nursing homes reported using at least some level of consistent assignment; although some were at low levels. In the multivariate analyses, accepted levels of consistent assignment were used. Turnover and family satisfaction quality were significantly (p<.01) better in facilities with the highest levels of consistent NA assignment. 7 of the 9 Quality Measures and 3 of the 5 Five-Star measures examined were significantly (p<.01) better in facilities with the highest levels of consistent NA assignment. Consistent assignment has developed as a preferred practice in nursing homes based on little empirical evidence. The findings presented here provide substantial justification for the use of this staffing practice for NAs.

USING A UNIVERSAL SATISFACTION SCORE IN LONG-TERM CARE SETTINGS

The CoreQ (not an acronym) consists of a limited number of satisfaction items (3-4 items, depending on setting) that are used to create an overall satisfaction score for long-term care facilities. This measure has been used in assisted living (AL) and skilled nursing facilities (SNFs) and has been endorsed by the National Quality Forum (NQF). Briefly, the development and psychometric testing of the CoreQ will be described, including the rationale for producing an overall satisfaction score and correlation with important quality indicators like Five-Star. Using data collected over the past 3 years, comprising more than 100,000 respondents, the use of the CoreQ measure will be described. For example, the CoreQ scores are used in MA to allow providers to benchmark their performance. The use of the scores in this way will be discussed including how providers have used the scores for quality improvement. Some states have elected to use CoreQ in pay for performance and other state initiatives. A case study of how New Jersey uses CoreQ with SNFs will be presented, including distribution of scores and addressing data collection challenges. CoreQ can be utilized as a short customer satisfaction measure to allow providers to benchmark their performance, residents and families in decision-making, and states and others to use for accountability.

Improving the prehospital management of ST elevation myocardial infarction: a national quality improvement initiative

ST elevation myocardial infarction (STEMI) is a time-dependent clinical emergency. Early recognition and intervention in the clinical course of STEMI are key to reducing mortality and morbidity. As a result, the benefits of the prehospital management of patients presenting with STEMI are well supported by the literature. Given these benefits, much of the focus on the development of quality and performance measures for Emergency Medical Services has focused on STEMI care. Historically, within Qatar, however, no measures of prehospital STEMI care have previously existed and as such, little is understood regarding the quality of prehospital care delivered to patients with STEMI. The overall aim of this national initiative was to improve the effectiveness of the prehospital care of patients with STEMI, to a minimum compliance of 75%, as measured by four process measures and one bundle measure, over a 12-month period. Initial efforts were aimed at the development of relevant indicators to guide assessment and identifying an appropriate patient cohort to test improvement efforts. Using these measures and criteria, the project team highlighted several areas for potential improvement centred on three key domains within the service: clinical practice, training and clinical equipment/medication. There was significant and sustained improvement across all measures recorded. For the bundle measure, the median proportional compliance increased from 39% pre-improvement activities to 76% post-improvement activities and remained sustained at 12 months post-implementation. The initiative was successful in meeting all of its aims and furthermore showed sustained compliance at 12 months post-implementation, thanks in part to what were designed to be changes that were simple, yet pragmatic, and readily producible at scale. While a formal cost analysis was not conducted, the improvement activities capitalised on existing organisational structures and processes with the resultant cost perceived to be negligible.

Evolution of The Qatar Trauma System: The Journey from Inception to Verification

Traumatic injuries accounted for substantial burden of morbidity and mortality (M and M) worldwide. Despite better socioeconomic conditions and living standards, the incidence of trauma is rising in the Eastern Mediterranean Region (EMR). Road traffic injuries are the leading cause of the high fatality rate in young economically productive adults in our region. The provision of trauma care at high-volume, accredited trauma center by a team of dedicated full-time professional health-care providers has been shown to improve the quality of care and the outcomes for trauma victims. With persistent hard work and effective leadership, in Qatar, the Trauma Section has evolved into a well-reputed and internationally recognized Center of Excellence in Trauma Care, Hamad Level 1 Trauma Center. In 2014, Qatar Trauma System was accredited with Trauma Distinction Award by the Accreditation Canada International, for high-quality trauma care of severely injured patients; first in the Middle East. The Hamad Trauma Center is committed to the advancement of trauma care in different aspects right from the immediate prehospital care to the subsequent hospital-based care, involving diagnosis, treatment, support, rehabilitation, and community reintegration of the patients and injury prevention. Our trauma system has gradually embedded with a structured and matured research unit with dedicated clinicians and academic researchers. The trauma team embodies the 21^st-century paradigm of translational research and injury prevention by going well beyond the bedside, out into the populations that need it most. The trauma system's future vision relies on the evidence-based health-care service and better outcomes; state-of-the-art infrastructure and multidimensional collaborations with health care and governmental services to minimize the burden of M and M caused by traumatic injury in the State of Qatar and to fulfill the population health enhancement strategy.

Changing culture through conversation: An action research inquiry on the adverse incident review process

Background: Clinical governance requires having a process for adverse incident review and management to ensure the organisation ‘learns from its mistakes’ to prevent repetition. How leadership implements this system may enhance learning and patient safety, or have the unintended consequence of raising alarm, possible demotivation, and staff becoming risk-averse. The impact of the existing Ambulance Service incident management process was assessed from an organizational culture aspect.

Methods: Action research uses iterative and collaborative cycles of study, action, and reflection to not only understand a complex situation by holding an attitude of inquiry but also to bring about positive change. Dialogue and narrative enquiry were used to collect data using a grounded theory approach for data interpretation. Dialogue was used both for reflection and for initiating change at various levels within the Service.

Results: Initial data indicated a moderate fear culture in the Service, with staff becoming risk averse in the clinical environment due to concerns of being called for investigation. Dialogue sessions were held with key role players highlighting the experiences of staff. The impact of these conversations were reflected on and the outcomes of this reflection was used to frame further dialogue. Narrative (stories) of staff experiences were collected and used in the dialogue to highlight the impact of the adverse incident review system on staff morale. Based on these conversations, leadership made changes, including developing new incident review process with peer involvement, changing leaders of the process and an increased focus on communicating feedback to staff. As one staff member noted the mood in the corridors is much lighter.

Conclusion: Action research provides an effective method for leaders, working in the real world environment, in dealing with the complex issues to bring about positive change, both in quality and patient safety, and staff satisfaction point of view.

Evidence-based medicine (EBM) in pre-hospital care: Our 4-year experience in designing and implementing Clinical Practice Guidelines (CPG)

Background: In 2011, HMCAS designed new Evidence-Based CPG. The previous protocols were not fit for purpose and not best practice. The service had multiple tiers of clinical practice among staff without standardization of care. CPG development is a knowledge management process to ensure standardization of care and a safer patient experience. This research sets out learning from two rounds of CPG development over 4 years.

Methods: The guidelines development process was mapped prior to starting in January 2015. CPG development and implementation went through 5 steps: 1. Scoping the guidelines: defining the purpose, the scope of service, and the end users of the guidelines. We conducted a staff survey to understand their views on presentation and purpose. 2. Establishing a working group to identify specific guidelines, clinical outcomes desired, and develop a writing template. 3. Conducting evidence reviews to draft the guidelines and then consulting with all role players to ensure guidelines are best practice and practical, and aligned to clinical pathways. 4. Guidelines publication considering ease of use, clarity, and balance between details and practicality. Finally, guidelines approval. 5. Guidelines implementation: Identifying champions to action alignment to systems (logistics/governance/management) and to redesign the corresponding educational curriculum.

Results: The development and implementation of the guidelines has resulted in significant changes within the Ambulance Service over 4 years. Reducing multiple tiers of care down to two tiers, standardized education of 900 existing and new clinical staff around guidelines, implementation of standardized pre-packed equipment within the ambulances, and standardized care to the community. This project was recognized by the MD's Stars of Excellence award 2013.

Conclusions: To implement standardized care and EBM, CPG are required. Guidelines development and implementation needs expertise, collaborative development, and champions who will undertake deliberate alignment of service activities and education to the guidelines.

Infection Prevention and Control Programs in US Nursing Homes: Results of a National Survey

OBJECTIVES

The objectives of this study were to (1) obtain a national perspective of the current state of nursing home (NH) infection prevention and control (IPC) programs and (2) examine differences in IPC program characteristics for NHs that had and had not received an infection control deficiency citation.

DESIGN

A national cross-sectional survey of randomly sampled NHs was conducted and responses were linked with Certification and Survey Provider Enhanced Reporting (CASPER) and NH Compare data.

SETTING

Surveys were completed and returned by 990 NHs (response rate 39%) between December 2013 and December 2014.

PARTICIPANTS

The person in charge of the IPC program at each NH completed the survey.

MEASUREMENTS

The survey consisted of 34 items related to respondent demographics, IPC program staffing, stability of the workforce, resources and challenges, and resident care and employee processes. Facility characteristics and infection control deficiency citations were assessed using CASPER and NH Compare data.

RESULTS

Most respondents had at least 2 responsibilities in addition to those related to infection control (54%) and had no specific IPC training (61%). Although many practices and processes were consistent with infection prevention guidelines for NHs, there was wide variation in programs across the United States. Approximately 36% of responding facilities had received an infection control deficiency citation. NHs that received citations had infection control professionals with less experience (P = .01) and training (P = .02) and were less likely to provide financial resources for continuing education in infection control (P = .01).

CONCLUSION

The findings demonstrate that a lack of adequately trained infection prevention personnel is an important area for improvement. Furthermore, there is a need to identify specific evidence-based practices to reduce infection risk in NHs.

Do Recipients of an Association-Sponsored Quality Award Program Experience Better Quality Outcomes Compared With Other Nursing Facilities Across the United States?

BACKGROUND

This study explores the relationship between recipients of an association-sponsored Quality Award Program and select measures of quality in U.S. nursing facilities, examined both cross-sectionally and over time.

METHOD

Data used came from Quality Award Program recipients over 9 years (2003-2011) and a set of quality indicators from the Online Survey Certification and Reporting (OSCAR) database. These data were analyzed using a variety of multivariate regression techniques.

RESULTS

Cross-sectionally, the award recipients demonstrated higher performance on most of the quality indicators, compared with both the broader field of nursing facilities and also a more stringent comparison group of facilities. Comparing quality from the 4 years before the award was received to the 4 years after the award, the majority of quality indicators demonstrated improvement in those facilities receiving an award.

CONCLUSION

These results indicate that, in general, the nursing facilities that participate in and receive the Silver or Gold American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) National Quality Award perform at a higher level of quality for residents and sustain that heightened performance over a period of time.

Resident Aggression and Abuse in Assisted Living

This article estimates the prevalence and identifies risk factors of resident aggression and abuse in assisted living facilities. We conducted multivariate analyses of resident-level data from an analytic sample of 6,848 older Americans in the 2010 National Survey of Residential Care Facilities. Nationwide, 7.6% of assisted living residents engaged in physical aggression or abuse toward other residents or staff in the past month, 9.5% of residents had exhibited verbal aggression or abuse, and 2.0% of resident engaged in sexual aggression or abuse toward other residents or staff. Dementia and severe mental illness were significant risk factors for all three types of resident aggression and abuse. Resident aggression and abuse in assisted living facilities is prevalent and warrants greater attention from policy makers, researchers, and long-term care providers. Future research is needed to support training and prevention efforts to mitigate this risk.

Satisfaction of Discharged Nursing Home Residents

The psychometric properties of The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Nursing Home survey: Discharged Resident Instrument (NHCAHPS-D) are examined. A random sample of 550 nursing homes was selected from across the United States and 365 agreed to participate (participation rate = 66%). From 7,020 surveys sent to discharged residents, 4,926 were returned (response rate = 70%). The psychometric properties of the resident responses and the survey items were robust. Confirmatory factor analyses model fit statistics met the criterion for good conformance. Five of the initial NHCAHPS-D instrument domains were identified (environment, care, communication and respect, autonomy, and activities), along with a sixth (transitions) added by the authors. The standardization and reliability that NHCAHPS-D provides could facilitate the same benefits we have seen in other industries for the CAHPS family of instruments (i.e., quality improvement, reimbursement, public reporting, and benchmarking) and also become an industry standard.

Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set

Objective: This research examined resident and facility-specific factors associated with a diagnosis of a urinary tract infection (UTI) in the nursing home setting. Method: Minimum Data Set and Online Survey, Certification and Reporting system data were used to identify all nursing home residents in the United States on April 1, 2006, who did not have a UTI ( n = 1,138,418). Residents were followed until they contracted a UTI (9.5%), died (8.3%), left the nursing home (33.2%), or the year ended (49.0%). A Cox proportional hazards model was estimated, controlling for resident and facility characteristics and for the state of residence. Result: The presence of an indwelling catheter was the primary predictor of whether a resident contracted a UTI (adjusted incidence ratio = 3.35, p < .001), but only 6.1% of the residents in the sample had such a catheter. Therefore, only one eighth of the UTIs were contracted by residents with a catheter. Thus, subsequent analysis examined the populations with and without catheters separately. Demographic characteristics (such as age) have a much greater association with incidence among residents without catheters. The association with facility factors such as percentage of Medicaid residents, for-profit, and chain status was less significant. Estimates regarding staffing levels indicate that increased contact hours with more highly educated nursing staff are associated with less catheter use. Discussion: Several facility-specific risk factors are of significance. Of significance, UTIs may be reduced by modifying factors such as staffing levels.

THE IMPORTANCE AND VALUE OF PROFESSIONAL MEMBERSHIP OF NURSING HOME ADMINISTRATORS

This study examines the association between nursing home administrators (NHAs) professional membership, certification, and fellow status with quality indicators in nursing homes. Membership, certification, and fellow information (representing increasing levels of participation) originated from the American College of Health Care Administrators (ACHCA). ACHCA is a professional association which represents long-term care administrators. The Quality Measures reported on the Nursing Home Compare web-site, and facility information from the On-line Survey Certification of Automated Records (OSCAR) were used. The period of interest was 2010 and a total of 19 quality indicators were examined. Data were analyzed through multivariate analyses using negative binomial regression. The results indicate NHAs who are members of ACHCA are associated with better quality in 6 of the 19 quality indicators examined; ACHCA certified member fellows are associated with better quality in 7 of the 19 quality indicators examined; ACHCA fellows are associated with better quality in 10 of the 19 quality indicators examined; and, ACHCA members (excluding certified, certified fellows, and fellows) are associated with better quality in 13 of the 19 quality indicators examined. These findings support the value of professional membership, as well as voluntary certification or fellow credentialing of NHAs with respect to quality improvement.

Hand Hygiene Practices Reported by Nurse Aides in Nursing Homes

Information from nurse aides describing their opinions of hand hygiene practices in nursing homes including perceived barriers to hand hygiene is presented. The information comes from a questionnaire developed for this investigation, with items addressing compliance, facility guidelines and protocols, training, hand washing facilities and materials, and hand washing barriers. Information from 4,211 nurse aides (response rate of 56%) working in a nationally representative sample of 767 nursing homes (participation rate = 51%) is used. We find that 57.4% of nurse aides comply with hand washing when caring for residents most of the time, while 21.7% always comply. With facilities, 43.3% sometimes check that hand washing is performed. In summary, self-reported compliance was poor, and facilities and materials were often lacking. These findings are useful in identifying issues and interventions, including the need for further initiatives to address hand hygiene practices.

Elder abuse in residential long-term care: an update to the 2003 National Research Council report

A synthesis of the last decade of literature on elder abuse in residential long-term care (i.e., Nursing Homes and Assisted Living) is discussed. Presented are definitions of abuse, theoretical and conceptual models, prevalence rates of abuse, outcomes and costs, and sources of abuse. The synthesis represents an update to the literature in the influential 2003 National Research Council report. We identify many of the same issues and concerns exist that were surfaced in this prior report. Many theoretical and conceptual models need further elaboration. Conflicting definitions of abuse are pervasive. Rates of abuse are generally inaccurate, and probably under-reported. However, we also identify progress in many areas. An increase in empirical studies that exist in this area (although very few in Assisted Living). Other forms and types of abuse have also been identified as important, such as resident-to-resident abuse. These areas are discussed, along with potential suggestions for additional research.

Hand hygiene deficiency citations in nursing homes

Hand hygiene (HH) is recognized as an effective way to decrease transmission of infections. Little research has been conducted surrounding HH in nursing homes (NHs). In this research, deficiency citations representing potential problems with HH practices by staff as identified in the certification process conducted at almost all US NHs were examined. The aims of the study were to identify potential relationships between these deficiency citations and characteristics of the NH and characteristics of the NH environment. We used a panel of 148,900 observations with information primarily coming from the 2000 through 2009 Online Survey, Certification, And Reporting data (OSCAR). An average of 9% of all NHs per year received a deficiency citation for HH. In the multivariate analyses, for all three caregivers examined (i.e., nurse aides, Licensed Practical Nurses, and Registered Nurses) low staffing levels were associated with receiving a deficiency citation for HH. Two measures of poor quality (i.e., [1] Quality of care deficiency citations and [2] J, K, or L deficiency citations, that is deficiency citations with a high extent of harm and/or more residents affected) were also associated with receiving a deficiency citation for HH. Given the percentage of NHs receiving deficiency citations for potential problems with HH identified in this research, more attention should be placed on this issue.

Why do nursing homes close? An analysis of newspaper articles

Using Non-numerical Unstructured Data Indexing Searching and Theorizing (NUD'IST) software to extract and examine keywords from text, the authors explored the phenomenon of nursing home closure through an analysis of 30 major-market newspapers over a period of 66 months (January 1, 1999 to June 1, 2005). Newspaper articles typically represent a careful analysis of staff impressions via interviews, managerial perspectives, and financial records review. There is a current reliance on the synthesis of information from large regulatory databases such as the Online Survey Certification And Reporting database, the California Office of Statewide Healthcare Planning and Development database, and Area Resource Files. Although such databases permit the construction of studies capable of revealing some reasons for nursing home closure, they are hampered by the confines of the data entered. Using our analysis of newspaper articles, the authors are able to add further to their understanding of nursing home closures.

Insertion of six different supraglottic airway devices whilst wearing chemical, biological, radiation, nuclear-personal protective equipment: a manikin study

Six different supraglottic airway devices: Combitube™, laryngeal mask airway, intubating laryngeal mask airway (Fastrach™), i-gel™, Laryngeal Tube™ and Pro-Seal™ laryngeal mask airway were assessed by 58 paramedic students for speed and ease of insertion in a manikin, whilst wearing either chemical, biological, radiation, nuclear-personal protective equipment (CBRN-PPE) or a standard uniform. All devices took significantly longer to insert when wearing CBRN-PPE compared with standard uniform (p < 0.001). In standard uniform, insertion time was shorter than 45 s in 90% of attempts for all devices except the Combitube, for which 90% of attempts were completed by 53 s. Whilst wearing CBRN-PPE the i-gel was the fastest device to insert with a mean (SD (95% CI)) insertion time of 19 (8 (17-21))s, p < 0.001, with the Combitube the slowest with mean (65 (23 (59-71))s. Wearing of CBRN-PPE has a negative impact on supraglottic airway insertion time.

Elder abuse in assisted living

Assisted Living (AL) currently represents one of the most numerous institutional care settings for elders. Very little information exists on abuse in AL. Descriptive information on elder abuse reported by nurse aides working in AL is presented from a survey sent to nurse aides. The questionnaire had items addressing verbal, physical, psychological, caregiving, medication, material, and sexual abuse. The responses to the questions included in the verbal abuse, physical abuse, psychological abuse, caregiving abuse, medication abuse, and material exploitation abuse sections (28 questions) show that suspected abuse is not uncommon. We could not objectively verify the cases of abuse described in the survey, still, they give a first indication that staff abuse may occur in AL. This may be significant given the large number of ALs in the United States and may influence the health, quality of life, and safety of many residents.