Role of a rapid response system and code status discussion as determinants of prognosis for critical inpatients: An observational study in a Japanese urban hospital

Rapid response systems (RRS) have been introduced worldwide to reduce unpredicted in-hospital cardiac arrest (IHCA) and in-hospital mortality. The role of advance care planning (ACP) in the management of critical patients has not yet been fully determined in Japan.We retrospectively assessed the characteristics of all inpatients with unpredicted IHCA in our hospital between 2016 and 2018. Yearly changes in the number of RRS activations and the incidence of unpredicted IHCA with or without code status discussion were evaluated from 2014 to 2018. Hospital standardized mortality ratios were assessed from the data reported in the annual reports by the National Hospital Organization.A total of 81 patients (age: 70.9 ± 13.3 years) suffered an unpredicted IHCA and had multiple background diseases, including heart disease (75.3%), chronic kidney disease (25.9%), and postoperative status (cardiovascular surgery, 18.5%). Most of the patients manifested non-shockable rhythms (69.1%); survival to hospital discharge rate was markedly lower than that with shockable rhythms (26.8% vs 72.0%, P < .001). The hospital standardized mortality ratios was maintained nearly constant at approximately 50.0% for 3 consecutive years. The number of cases of RRS activation markedly increased from 75 in 2014 to 274 patients in 2018; conversely, the number of unpredicted IHCA cases was reduced from 40 in 2014 to 18 in 2018 (P < .001). Considering the data obtained in 2014 and 2015 as references, the RRS led to a reduction in the relative risk of unpredicted IHCA from 2016 to 2018 (ie, 0.618, 95% confidence interval 0.453-0.843). The reduction in unpredicted IHCA was attributed partly to the increased number of patients who had discussed the code status, and a significant correlation was observed between these parameters (R2 = 0.992, P < .001). The reduction in the number of patients with end-stage disease, including congestive heart failure and chronic renal failure, paralleled the incidence of unpredicted IHCA.Both RRS and ACP reduced the incidence of unpredicted IHCA; RRS prevents progression to unpredicted IHCA, whereas ACP decreases the number of patients with no code status discussion and thus potentially reducing the patient subgroup progressing to an unpredicted IHCA.

Seroprevalence of SARS-CoV-2 antibodies among 925 staff members in an urban hospital accepting COVID-19 patients in Osaka prefecture, Japan: A cross-sectional study

The subclinical severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection rate in hospitals during the pandemic remains unclear. To evaluate the effectiveness of our hospital's current nosocomial infection control measures, we conducted a serological survey of anti-SARS-CoV-2 antibodies (immunoglobulin [Ig] G) among the staff of our hospital, which is treating coronavirus disease 2019 (COVID-19) patients.The study design was cross-sectional. We measured anti-SARS-CoV-2 IgG in the participants using a laboratory-based quantitative test (Abbott immunoassay), which has a sensitivity and specificity of 100% and 99.6%, respectively. To investigate the factors associated with seropositivity, we also obtained some information from the participants with an anonymous questionnaire. We invited 1133 staff members in our hospital, and 925 (82%) participated. The mean age of the participants was 40.0 ± 11.8 years, and most were women (80.0%). According to job title, there were 149 medical doctors or dentists (16.0%), 489 nurses (52.9%), 140 medical technologists (14.2%), 49 healthcare providers (5.3%), and 98 administrative staff (10.5%). The overall prevalence of seropositivity for anti-SARS-CoV-2 IgG was 0.43% (4/925), which was similar to the control seroprevalence of 0.54% (16/2970) in the general population in Osaka during the same period according to a government survey conducted with the same assay. Seropositive rates did not significantly differ according to job title, exposure to suspected or confirmed COVID-19 patients, or any other investigated factors.The subclinical SARS-CoV-2 infection rate in our hospital was not higher than that in the general population under our nosocomial infection control measures.

Healthcare Failure Mode and Effect Analysis (HFMEA) as an Effective Mechanism in Preventing Infection Caused by Accompanying Caregivers During COVID-19-Experience of a City Medical Center in Taiwan

BACKGROUND AND OBJECTIVES

In response to the COVID-19 pandemic outbreak and to ensure the safety of epidemic prevention in the hospital, the hospital has established mitigation strategies in advance including risk assessment and effect analysis to control hospital visitors and accompanying persons. The study aims to assess the effectiveness of mitigation strategies implemented to effectively prevent the invasion and spread of the virus.

METHOD

Conduct a status analysis in accordance with the Healthcare Failure Mode and Effect Analysis (HFMEA) 4-step model, construct a response workflow, confirm the failure mode and potential causes, perform hazard matrix analysis and decision tree analysis, and formulate risk control management measures.

RESULTS

For the 4 main processes and 9 subprocesses of the accompanying carers and contract caregivers entering the hospital, 26 potential failure modes and 42 potential causes of failure were analyzed. Following implementing improvement measures including strategies targeting the accompanying person, mitigation workflow failure rates decreased from 42 to 13 items, the pass rate for the maximum body temperature cutoff increased from 53.1% to 90.8%, and the compliance rate of hand washing increased from 89.5% to 100%.

CONCLUSION

The HFMEA model can effectively implement preventive risk assessment and workflow management of high-risk medical procedures. The model can adjudicate the health of hospital visitors during the epidemic/pandemic, provide epidemic/pandemic education training and preventive measure health education guidance for hospital visits, and improve their epidemic prevention cognition. When combined, these strategies can prevent nosocomial infection to achieve the best anti-epidemic effect.

Acute Care Surgery Service Is Essential During a Nonsurgical Catastrophic Event, the COVID-19 Pandemic

BACKGROUND

The role of an acute care surgery (ACS) service during the COVID-19 pandemic is not well established.

METHODS

A retrospective review of the ACS service performance in an urban tertiary academic medical center. The study was performed between January and May 2020. The demographics, clinical characteristics, and outcomes of patients treated by the ACS service 2 months prior to the COVID surge (pre-COVID group) and during the first 2 months of the COVID-19 pandemic (surge group) were compared.

RESULTS

Trauma and emergency general surgery volumes decreased during the surge by 38% and 57%, respectively; but there was a 64% increase in critically ill patients. The proportion of patients in the Department of Surgery treated by the ACS service increased from 40% pre-COVID to 67% during the surge. The ACS service performed 32% and 57% of all surgical cases in the Department of Surgery during the pre-COVID and surge periods, respectively. The ACS service managed 23% of all critically ill patients in the institution during the surge. Critically ill patients with and without confirmed COVID-19 infection treated by ACS and non-ACS intensive care units during the surge did not differ in demographics, indicators of clinical severity, or hospital mortality:13.4% vs. 13.5% (P = .99) for all critically ill patients; and 13.9% vs. 27.4% (P = .12) for COVID-19 critically ill patients.

CONCLUSION

Acute care surgery is an "essential" service during the COVID-19 pandemic, capable of managing critically ill nonsurgical patients while maintaining the provision of trauma and emergent surgical services.

LEVEL OF EVIDENCE

III.

STUDY TYPE

Therapeutic.

Acute Kidney Injury in COVID-19 Patients: An Inner City Hospital Experience and Policy Implications

BACKGROUND

Although diffuse alveolar damage and respiratory failure are the key features of coronavirus disease 2019 (COVID-19), the involvement of other organs such as the kidney has also been reported. The reports of the incidence of acute kidney injury (AKI) in COVID-19 patients vary widely. In this study, we report our unique experience with AKI in COVID-19 patients in a low socioeconomic and predominantly ethnic minority group and provide its incidence, risk factors, and prognosis to expand the current understanding of this complication.

METHODS

In this single-center, retrospective cohort study, we analyzed the data of 469 COVID-19 patients admitted to the Brookdale University Hospital in Brooklyn, NY, from March 18 through April 23, 2020. Information regarding demographics, comorbidities, medications, clinical and laboratory data, and outcomes was collected from the electronic medical records. Both univariate and multivariate analyses were performed to determine the association of AKI with in-hospital mortality.

RESULTS

The median age was 66 years (interquartile range [IQR] 25-75; range 19-101 years), and 268 (57.14%) patients were male. Estimated glomerular filtration rate (eGFR) as determined by the Modification of Diet in Renal Disease Study Equation was low (<60 mL/min/1.73 m2) in 207 (44.1%) patients. During hospitalization, 128 (27.3%) patients developed AKI, and the incidence was significantly higher in those patients presenting with a low eGFR (N = 81, 39.1%; p < 0.001). Male sex, hypertension, the use of angiotensin-converting enzyme inhibitors and non-steroidal anti-inflammatories, hemodynamic instability, mechanical ventilation, acute respiratory distress syndrome, and admission elevated ferritin, creatinine kinase, brain natriuretic peptide, and troponin 1 were identified as the risk factors for in-hospital AKI. Ninety-seven (28.45%) patients died in the non-AKI group versus 91 (71.1%) in the AKI group (p < 0.001). The Cox proportional hazard model after adjusting for age, gender, comorbidities, hemodynamic status, and PF ratio (arterial oxygen partial pressure [PaO2]/fractional inspired oxygen [FiO2]) determined that on admission, an elevated blood urea nitrogen (hazard ratio [HR]: 1.75; 95% confidence interval [CI] 1.23-2.48), a low eGFR (HR 1.43; CI 1.1-2.03), AKI stage 1 (HR 1.14; CI 0.64-2.03), AKI stage 2 (HR 1.86; CI 1.03-3.56), and AKI stage 3 (HR 2.1; CI 1.3-2.81) were independent risk factors for in-hospital mortality. Renal replacement therapy (RRT) did not improve survival in stage III AKI.

CONCLUSION

AKI in our hospitalized COVID-19 patients was common and carried a high mortality, especially in patients with AKI stage 3. RRT did not improve survival. Policy changes and planning for this high incidence of AKI in COVID-19 patients and its associated high mortality are necessary at the local and national levels.

Oral status of HIV-infected children aged 12 years or younger who attended a Paediatric Infectious Diseases Clinic in Cape Town

BACKGROUND

Children continue to suffer from the impact of the human immunodeficiency virus-acquired immunodeficiency syndrome (HIV/AIDS) pandemic. In Cape Town, these children receive medical care including antiretroviral therapy from facilities like Tygerberg Hospital's Paediatric Infectious Diseases Clinic. HIV-infected children may experience an increased caries experience when compared with their healthy peers.

AIM

The aim of this study was to determine the oral health status of HIV-infected children younger than 12 years receiving antiviral drugs at the Paediatric Infectious Diseases Clinic.

DESIGN

A cross-sectional survey was conducted among children aged between 2 and 12 years presenting at this clinic. Caregivers were interviewed to obtain information regarding health seeking behaviour, oral hygiene practices and dietary habits. A single clinician undertook a standardized clinical intraoral examination according to the World Health Organization guidelines, with modifications.

RESULTS

Sixty-six children were recruited. A high prevalence of dental caries (78.8%) and an unmet treatment need of 90.4% were recorded among the participants. Most children had never visited the dentist, and those who did had mainly received emergency dental care.

CONCLUSION

The high prevalence of severe dental caries in this population highlights the need for oral health awareness and the inclusion of oral health care in the comprehensive care of children with HIV.

WHY THIS PAPER IS IMPORTANT TO PAEDIATRIC DENTISTS

The study highlights the importance of collaborating with health professions outside of dentistry. Doctors and nurses are often the first health professionals to come into contact with children with special needs. They should therefore be made aware of the early signs of decay so that these patients can be referred for dental treatment timeously. Holistic management of children with special healthcare needs is essential to improve their overall well-being.

Status of healthcare workers after comprehensive reform of urban public hospitals in Beijing, China: sustainable supply, psychological perception, and work outcomes

BACKGROUND

Healthcare reform in China has attracted worldwide interest and reached a new juncture. In an attempt to improve healthcare quality and patient satisfaction, the government of Beijing introduced comprehensive reform of urban public hospitals in 2016 and implemented new policies on personnel, compensation, management, and diagnosis and treatment. As the agents of healthcare service, and a target of reform measures, healthcare workers were greatly affected by these reforms but have not been carefully studied.

METHODS

This study used mean value analysis, variance analysis, and qualitative content analysis to investigate the status of healthcare workers after comprehensive reform of urban public hospitals in Beijing.

RESULTS

We found a gradual but constant increase in the number of healthcare workers in poor health in Beijing public hospitals. After the reforms, this population reported high challenge stress, public service motivation, job satisfaction, job performance and quality of healthcare, moderate presenteeism, and low hindrance stress and turnover intention. The status of healthcare workers differed by subgroup and changed during the reform process.

CONCLUSIONS

Our study provides data useful for policy recommendations regarding the implementation and extension of future reforms and offers important lessons for developing and developed countries that are reforming public hospitals to improve efficiency and reduce costs.

Relationship of Staff Information Sharing and Advice Networks to Patient Safety Outcomes

OBJECTIVE

The aim of this study was to compare information sharing and advice networks' relationships with patient safety outcomes.

BACKGROUND

Communication contributes to medical errors, but rarely is it clear what elements of communication are key.

METHODS

We investigated relationships of information-sharing and advice networks to patient safety outcomes in 24 patient care units from 3 hospitals over 7 months. Web-based questionnaires completed via Android tablets provided data to create 2 networks using ORA, a social network analysis application. Each hospital provided nurse-sensitive patient safety outcomes.

RESULTS

In both networks, medication errors correlated positively with node count and average distance and negatively with clustering coefficient. Density and weighted density negatively correlated with medication errors and falls in both networks. Eigenvector and total degree centrality correlated negatively with both safety outcomes, whereas betweenness centrality positively related to falls in the information-sharing network.

CONCLUSION

Technology-enabled social network analysis data collection is feasible and can provide managers actionable system-level information.

Rural Rotations at Core: Rarefied Exposure or Real Experience?

OBJECTIVE

Surgical rotations involving rural General Hospitals (rGH) are frequently associated with recruitment challenges, partly because of adverse perceptions regarding distances from social support networks and training opportunities. The aim of this study was to determine the outcomes of core surgical training rotations involving rGHs when compared with urban hospitals in a single UK Deanery.

DESIGN

Online Intercollegiate Surgical Curriculum Programme portfolios from 163 core surgical trainees (CST) were examined related to postlocation, operative experience, workplace-based assessments, and academic achievement. Of the 163 CSTs, 27 had completed at least 50% of their 2-year training posts at rGHs and were compared with 136 control CSTs completing rotations in urban general and teaching hospitals (uGH). The primary outcome measures were MRCS pass rate and success at national ST3 selection.

SETTING

A core surgical training program serving a single UK Deanery.

PARTICIPANTS

Consecutive 177 CSTs appointed to a single UK Deanery between 2010 and 2016.

RESULTS

Success at MRCS and national ST3 selection were similar for CSTs from rGH vs uGH rotations-MRCS success: 70.4 vs 72.8% (p = 0.816), and ST3 success: 22.2% vs 27.0% (p = 0.811). Median rGH vs uGH curriculum-based outcomes were operative case load: 378 vs 422 (p = 0.300); workplace-based assessments completed: 79 vs 94 (p = 0.499); audits performed: 4 vs 4 (p = 0.966); learned society communications: 1 vs 2 (p = 0.020); and scientific publications: 0 vs 0 (p = 0.478).

CONCLUSION

CST rotations including rGHs produced a different spectrum of training experience compared with uGH rotations but overall primary outcomes were similar.

Impact of health workforce availability on health care seeking behavior of patients with diabetes mellitus in China

BACKGROUND

China has a high burden of diabetes mellitus (DM), and a large proportion of DM patients remain untreated for various reasons, including low availability of primary health care providers. DM patient management is one of the priorities in China's national essential public health programs. Shortage of health workforce has been a major barrier to improving access to health care for DM patients. This study examines the impact of the health workforce on outpatient utilization of DM patients.

METHODS

Data were collected from China National Health Service Surveys in 2008 and 2013, covering 94 rural counties and 156 urban districts, respectively, with a total of 15,984 DM patients. Household data and facility-based data at county/district level were merged. The health workforce was measured by number of physicians per 1,000 population in county hospitals and primary health centers (PHCs), respectively. Health care seeking behavior was measured by health care utilization and distribution of health providers of the DM patients. Multilevel zero-inflated negative binomial regression was used to analyze the impact of the health workforce on outpatient visits by DM patients, and a multilevel, multinomial logit model was used to examine the impact of the health workforce on choice of health providers by DM patients.

RESULTS

An increase in the number of physicians at both county hospitals and PHCs was associated with increased outpatient visits by DM patients, particularly more physicians at PHCs. With increased numbers of physicians at PHCs, outpatient visits among residents with DM in rural and western areas of China increased more than those in urban and eastern areas. More physicians at PHCs had a positive impact on improving the likelihood of outpatient visits at PHCs. The positive influence of increasing the number of physicians available to DM patients in rural and western areas was greater than that for urban and eastern DM patients.

CONCLUSIONS

The health workforce is a key component of any healthcare system and is critical in improving health care accessibility. Strategies to increase coverage of health workforce at PHCs are crucial to achieving adequate levels of health services for DM patients. Allocation of health workforce should focus on PHCs in rural and low-income areas.

Referral to treatment for hospitalized medical patients with an alcohol use disorder: A proof-of-concept brief intervention study

Substance misuse intervention in healthcare settings is becoming a US national priority, especially in the dissemination and implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT). Yet, the referral to treatment component of SBIRT is understudied. This proof-of-concept investigation tested an enhanced coordinated hospital-community two session brief intervention designed to facilitate the referral to treatment of hospitalized medical patients with an alcohol use disorder. Participants (N = 9) attended the second session of the brief intervention held in the community in most cases (56%), while one out of three (33%) received some level of post-brief intervention alcohol and/or other drug treatment. Alcohol use and alcohol-related problems also statistically improved. Based, in part, on the results plus the widespread dissemination of SBIRT, next step investigations of brief interventions to help bridge hospitalized medical patients in need to community substance abuse treatment are warranted.

Studer Group® ' s evidence-based leadership initiatives

PURPOSE

The purpose of this paper is to analyze the implementation of an organizational change initiative--Studer Group®'s Evidence-Based Leadership (EBL)--in two large, US health systems by comparing and contrasting the factors associated with successful implementation and sustainability of the EBL initiative.

DESIGN/METHODOLOGY/APPROACH

This comparative case study assesses the responses to two pairs of open-ended questions during in-depth qualitative interviews of leaders and managers at both health systems. Qualitative content analysis was employed to identify major themes.

FINDINGS

Three themes associated with success and sustainability of EBL emerged at both health systems: leadership; culture; and organizational processes. The theme most frequently identified for both success and sustainability of EBL was culture. In contrast, there was a significant decline in salience of the leadership theme as attention shifts from success in implementation of EBL to sustaining EBL long term. Within the culture theme, accountability, and buy-in were most often cited by interviewees as success factors, while sense of accountability, buy-in, and communication were the most reported factors for sustainability.

ORIGINALITY/VALUE

Cultural factors, such as accountability, staff support, and communication are driving forces of success and sustainability of EBL across both health systems. Leadership, a critical factor in several stages of implementation, appears to be less salient as among factors identified as important to longer term sustainability of EBL.

Security's role in supporting a hospital's Early Intervention Program for inner city children

The availability of an Early Intervention Program for at-risk children in New Jersey's city with the highest crime rate and poverty level has been enhanced several fold by a volunteer escort service provided by security officers of hospitals which serve the community. In this article, the lead author and contributors explain in detail how an Early Intervention Program works and the key contribution to its success by hospital security escorts.

Availability of Lactation Counseling Services Influences Breastfeeding among Infants Admitted to Neonatal Intensive Care Units

Purpose.

To assess the association between the presence of international board-certified lactation consultant (IBCLC) services at a delivery hospital and the breastfeeding practices of women whose infants required neonatal intensive care unit (NICU) admission.

Design.

Cross-sectional study using population-level data.

Setting.

Philadelphia, Pennsylvania.

Subjects.

2132 infants admitted to the NICU.

Measures.

Breastfeeding at hospital discharge was measured with the question, “Is the infant being breastfed?” Delivery hospitals were dichotomized as to the presence or absence of an IBCLC on staff.

Analysis.

Logistic regression was used to assess the relationship between breastfeeding at discharge and the presence of an IBCLC at the delivery facility while adjusting for maternal characteristics and birth outcomes.

Results.

Among mothers of infants admitted to the NICU, breastfeeding rates among mothers who delivered at hospitals with an IBCLC were nearly 50% compared with 36.9% among mothers who delivered at hospitals without an IBCLC. The adjusted odds of breastfeeding initiation prior to hospital discharge were 1.34 (95% confidence interval = 1.03, 1.76) times higher for women who delivered at a facility with an IBCLC.

Conclusions.

To increase breastfeeding rates among the NICU population, these findings support the need for universal availability of IBCLCs at delivery facilities that have NICUs.

Market Structure and Technical Efficiency in the Hospital Services Industry: A DEA Approach

This article uses data envelopment analysis and multiple regression analysis to examine empirically the impact of various market-structure elements on the technical efficiency of the hospital services industry in various metropolitan areas of the United States. Market-structure elements include the degree of rivalry among hospitals, extent of HMO activity, and health insurer concentration. The DEA results show the typical hospital services industry experienced 11 percent inefficiency in 1999. Moreover, multiple regression analysis indicates the level of technical efficiency varied directly across metropolitan hospital services industries in response to greater HMO activity and private health insurer concentration in the state. The analysis suggests the degree of rivalry among hospitals had no marginal effect on technical efficiency at the industry level. Evidence also implies that the presence of a state Certificate of Need law was not associated with a greater degree of inefficiency in the typical metropolitan hospital services industry.

A Pragmatic Randomized Evaluation of a Nurse-Initiated Protocol to Improve Timeliness of Care in an Urban Emergency Department

STUDY OBJECTIVE

Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow.

METHODS

This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay.

RESULTS

Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296 minutes) and the median time to troponin for patients presenting with suspected ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length of stay was reduced by 224 minutes (95% CI -19 to 467 minutes) by implementing a suspected fractured hip protocol. A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes).

CONCLUSION

Targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce ED length of stay. A cooperative and collaborative interdisciplinary group is essential to success.

Development of a New Graduate Perioperative Nursing Program at an Urban Pediatric Institution

In 2012, perioperative personnel from Boston Children's Hospital began the process of planning for perioperative staff member attrition and retirement by developing a new graduate perioperative nursing program geared toward our pediatric urban academic institution. We selected two cohorts of new graduate nurses to begin the program in 2013. To date, two cohorts of six graduate nurses have completed the program and have been hired. Our new perioperative nurse retention rate is 100%. All of these nurses are currently practicing in the main OR at our facility. In one year, we recovered the initial program costs, which included the expenses incurred by hiring 12 full-time employees to replace more highly paid tenured RNs lost to attrition or retirement and training costs for new graduates. We believe the program has reduced overall long-term staffing costs and has prevented disruption to services as a result of unexpected vacancies from retirements and resignations.

Hospital Health Promotion: Swimming or Sinking in an Upstream Business?

Healthy People 2000 (HP 2000) calls on hospitals to offer health promotion programs addressing priority health needs of the community. Historically, this upstream initiative has not been present in health care. With the increasing provision of these programs, this case study examined their content to further understand potential public health impact. The health promotion programs offered to the community–both the general public and corporate employees–by an urban Midwest hospital were assessed over 1 year. This article presents a content analysis of 216 programs that was conducted by measuring seven variables: target group, presentation format, fee, health focus, program providers, contact frequency, and activity. Based on this single case study, hospitals appear to be addressing objectives set forth by HP 2000 for community hospitals. Although moving upstream with health promotion, an analysis of program content suggests modifications may be necessary in order to serve as effective interventions for health priorities.

The social practice of rescue: the safety implications of acute illness trajectories and patient categorisation in medical and maternity settings

The normative position in acute hospital care when a patient is seriously ill is to resuscitate and rescue. However, a number of UK and international reports have highlighted problems with the lack of timely recognition, treatment and referral of patients whose condition is deteriorating while being cared for on hospital wards. This article explores the social practice of rescue, and the structural and cultural influences that guide the categorisation and ordering of acutely ill patients in different hospital settings. We draw on Strauss et al.'s notion of the patient trajectory and link this with the impact of categorisation practices, thus extending insights beyond those gained from emergency department triage to care management processes further downstream on the hospital ward. Using ethnographic data collected from medical wards and maternity care settings in two UK inner city hospitals, we explore how differences in population, cultural norms, categorisation work and trajectories of clinical deterioration interlink and influence patient safety. An analysis of the variation in findings between care settings and patient groups enables us to consider socio-political influences and the specifics of how staff manage trade-offs linked to the enactment of core values such as safety and equity in practice.

[THE ROLE OF DEVELOPMENT OF MATERIAL AND TECHNICAL RESOURCES OF MULTIFIELD HOSPITAL AND ITS IMPACT ON EFFECTIVENESS OF INSTITUTION FUNCTIONING]

The role of development of material and technical resources of Moscow multifield hospital within the framework of program of modernization of capital health care and its impact on effectiveness offunctioning of institution. The comparison was implemented between capital investment level of physicians related to medical equipment and corresponding target indicators in Moscow. The correlation is established between indicators of capital investment level ofphysicians, average bed stay and clinical efficiency.

The Long-Term Effect of an Independent Capacity Protocol on Emergency Department Length of Stay: A before and after Study

PURPOSE

In this study, we determined the long-term effects of the Independent Capacity Protocol (ICP), in which the emergency department (ED) is temporarily used to stabilize patients, followed by transfer of patients to other facilities when necessary, on crowding metrics.

MATERIALS AND METHODS

A before and after study design was used to determine the effects of the ICP on patient outcomes in an academic, urban, tertiary care hospital. The ICP was introduced on July 1, 2007 and the before period included patients presenting to the ED from January 1, 2005 to June 31, 2007. The after period began three months after implementing the ICP from October 1, 2007 to December 31, 2010. The main outcomes were the ED length of stay (LOS) and the total hospital LOS of admitted patients. The mean number of monthly ED visits and the rate of inter-facility transfers between emergency departments were also determined. A piecewise regression analysis, according to observation time intervals, was used to determine the effect of the ICP on the outcomes.

RESULTS

During the study period the number of ED visits significantly increased. The intercept for overall ED LOS after intervention from the before-period decreased from 8.51 to 7.98 hours [difference 0.52, 95% confidence interval (CI): 0.04 to 1.01] (p=0.03), and the slope decreased from -0.0110 to -0.0179 hour/week (difference 0.0069, 95% CI: 0.0012 to 0.0125) (p=0.02).

CONCLUSION

Implementation of the ICP was associated with a sustainable reduction in ED LOS and time to admission over a six-year period.

A novel configuration of a traditional rapid response team decreases non-intensive care unit arrests and overall hospital mortality

BACKGROUND

In-hospital cardiopulmonary arrest (CPA) accounts for substantial morbidity and mortality. Rapid response teams (RRTs) are designed to prevent non-intensive care unit (ICU) CPA through early detection and intervention. However, existing evidence has not consistently demonstrated a clear benefit.

OBJECTIVE

To explore the effectiveness of a novel RRT program design to decrease non-ICU CPA and overall hospital mortality.

METHODS

This study was conducted from the start of fiscal year 2005 to 2011. In November 2007, our hospitals implemented RRTs as part of a novel resuscitation program. Charge nurses from each inpatient unit underwent training as unit-specific RRT members. Additionally, all inpatient staff received annual training in RRT concepts including surveillance and recognition of deterioration. We compared the incidence of ICU and non-ICU CPA from first complete preimplementation year 2006 to postimplementation years 2007 to 2011. Overall hospital mortality was also reported.

RESULTS

The incidence of non-ICU CPA decreased, whereas the incidence of ICU CPA remained unchanged. Overall hospital mortality also decreased (2.12% to 1.74%, P < 0.001). The year-over-year change in RRT activations was inversely related to the change in Code Blue activations for each inpatient unit (r = -0.68, P < 0.001).

CONCLUSION

Our novel RRT program was associated with a decreased incidence of non-ICU CPA and improved hospital mortality.

[Project for the Creation of a Medical or Hospital Ethical Committee at a Local Level in the San Miguel Arcangel Hospital, District of San Miguelito, Province of Panama. Year 2013]

The next project was based on the design on the creation of a medical ethical Committee at a hospital. It was developed at the San Miguel Arcangel Hospital, District of San Miguelito, Province of Panama, in 2013. Insomuch as the creation of social projects requires unified international parameters, format is taken from the Unesco's guides for the establishing and working of bioethics committees; adapted to the socio-economic, political and cultural context of the San Miguelito District, Panama Province. Furthermore to adapting to socio-ecological aspect where the research project is carried out, the theoretical aspect includes from the ontological personalistic bioethics, where the cornerstone is the dignity of the human person. A study of perceptions of medical staff and nursing was developed on the management of the most common ethical dilemmas in the Hospital San Miguel Arcángel. The instrument used was a previously validated perception survey through a pilot test. Reliability was measured using Cronbach's alpha coefficient, and validity was obtained from the content. Satisfactory statistical results, that verify the working hypotheses on the recognition of the importance of autonomy, confidentiality, protection of vulnerable population, occupational health staff welfare and integration of bioethics at the institutional agenda, were obtained. However, there were particular aspects that indicate some doubt as to the management of some realities that are presented in the context of health care.

Development and implementation of an emergency medicine graduate training program at Addis Ababa University School of Medicine: challenges and successes

BACKGROUND

Ethiopians experience high rates of acute illness and injury that have been sub-optimally addressed by the existing health care system. High rates of patient morbidity and mortality prompted the Federal Ministry of Health (FMOH) and the Addis Ababa University School of Medicine (AAU-SM) to prioritize the establishment of emergency medicine (EM) as a medical specialty in Ethiopia to meet this acute health system need.

OBJECTIVES

To review the EM residency training program developed and implemented at AAU-SM in partnership with the University of Wisconsin (UW), the University of Toronto (UT) and University of Cape Town (UCT) and to evaluate the progress and challenges to date.

METHODS

An EM Task Force (EMTF) at AAU-SM developed a context-specific three-year graduate EM curriculum with UW input. This curriculum has been co-implemented by faculty teachers from AAU-SM, UT and UW. The curriculum together with all documents (written, audio, video) are reviewed and used as a resource for this article.

RESULTS

Seventeen residents are currently in full-time training. Five residents research projects are finalized and 100% of residents passed their year-end exams.

CONCLUSION

A novel graduate EM training program has been successfully developed and implemented at AAU-SM. Interim results suggest that this curriculum and tri-institutional collaboration has been successful in addressing the emergency health needs of Ethiopians and bolstering the expertise of Ethiopian physicians. This program, at the forefront of EM education in Africa, may serve as an effective model for future EM training development throughout Africa.

Emergency medicine and its development in Ethiopia with emphasis on the role of Addis Ababa University, School of Medicine, Emergency Medicine Department

INTRODUCTION

Globally Emergency Medicine (EM) is young discipline and even in developed countries it is about five decades old. In Ethiopia formal pre-hospital care or hospital based Emergency department (ED) development is a recent phenomenon and this article describes development of Emergency Medicine care in Ethiopia before, around and after Ethiopia millennium.

METHODOLOGY

Documents related to emergency medicine development and implementation from different government and nongovernmental data sources are used as a resource for this article.

RESULTS

Emergency Medicine task force (EMTF) has been established in Addis Ababa University (AAU) school of Medicine (SOM) in June 2006 and the taskforce has closely worked with Federal Ministry of Health (FMOH) and Addis Ababa city council Health Bureau (AACCHB). In addition to the main actors many partners have contributed significantly to this initiative. Some of the developments were establishment of emergency departments in Tikur Anbessa Specialized Hospital (TASH) and the restructuring of EM service by FMOH. Emergency care has been considered as a crucial service in hospitals' service along with outpatient and inpatient services. Furthermore, Pre-hospital care initiatives have been commenced in Addis Ababa and expanded to the regions with a arrangement of one or two ambulances to small districts having 100,000 population. There have also been key achievement in human resource development, notably the establishment of EM residency and MSC in EM and critical care nursing. Prehospital care givers training programs in order to produce emergency medicine technicians (EMT) have been started in various regional health professionals training centers. Furthermore, EM module has been included in the current undergraduate medical education. The Ethiopian society of emergency professionals (ESEP) has been established with members from different categories of emergency medicine professionals. In all these developments the emergency medicine training center in the emergency department of AAU has played key role in the training of human resources in different categories.

DISCUSSION AND CONCLUSION

The recent successes in EM development is due to concerted efforts of the FMOH, AAU SOM and AACCHB along with committed partners. Hence, it is concluded that consistent local efforts and relevant stakeholders support in EM has resulted in successful development of the field in the country.

Infection prevention needs assessment in Colorado hospitals: rural and urban settings

BACKGROUND

The purpose of our study was to conduct a needs assessment for infection prevention programs in both rural and urban hospitals in Colorado.

METHODS

Infection control professionals (ICPs) from Colorado hospitals participated in an online survey on training, personnel, and experience; ICP time allocation; and types of surveillance. Responses were evaluated and compared based on hospital status (rural or urban). Additionally, rural ICPs participated in an interview about resources and training.

RESULTS

Surveys were received from 62 hospitals (77.5% response); 33 rural (75.0% response) and 29 urban (80.6% response). Fifty-two percent of rural ICPs reported multiple job responsibilities compared with 17.2% of urban ICPs. Median length of experience for rural ICPs was 4.0 years compared with 11.5 years for urban ICPs (P = .008). Fifty-one percent of rural ICPs reported no access to infectious disease physicians (0.0% urban) and 81.8% of rural hospitals reported no antimicrobial stewardship programs (31.0% urban). Through the interviews it was revealed that priorities for rural ICPs were training and communication.

CONCLUSIONS

Our study revealed numerous differences between infection prevention programs in rural versus urban hospitals. An infection prevention outreach program established in Colorado could potentially address the challenges faced by rural hospital infection prevention departments.

Family planning needs of women experiencing severe maternal morbidity in Accra, Ghana: another missed opportunity?

Women with severe maternal morbidity represent an important group to target for increasing contraceptive uptake. Our objective was to explore the future fertility intentions, use of family planning including methods and reasons for not wanting to use contraception among a group of women who had traumatic delivery experience at a tertiary teaching hospital in Accra, Ghana. Our results show that despite higher educational attainment, longer hospital stays and intention to limit or stop childbearing among women, there is a missed opportunity for family planning among women with severe maternal morbidity in this urban African hospital setting. Integrating postpartum family planning consultations by linking available services such as reproductive health clinics at the facilities rather than including additional tasks for the midwives and the doctors in the wards could be a sustainable solution in such urban, high-volume settings.

'Why must I wait?' The performance of legitimacy in a hospital emergency department

This article examines the processes of negotiation that occur between patients and medical staff over accessing emergency medical resources. The field extracts are drawn from an ethnographic study of a UK emergency department (ED) in a large, inner city teaching hospital. The article focuses on the triage system for patient prioritisation as the first point of access to the ED. The processes of categorising patients for priority of treatment and care provide staff with the opportunities to maintain control over what defines the ED as a service, as types of work and as particular kinds of patients. Patients and relatives are implicated in this categorical work in the course of interactions with staff as they provide reasons and justifications for their attendance. Their success in legitimising their claim to treatment depends upon self-presentation and identity work that (re)produces individual responsibility as a dominant moral order. The extent to which people attending the ED can successfully perform as legitimate is shown to contribute to their placement into positive or negative staff-constituted patient categories, thus shaping their access to the resources of emergency medicine and their experience of care.

Reducing hospital readmissions through primary care practice transformation

PURPOSE

To assess the impact of a multicomponent intervention on 30-day hospital readmissions in a group of primary care practices that undertook practice transformation, compared with rates in usual-care practices that admitted patients to the same hospital service.

METHODS

Four primary care clinics enhanced patient care coordination with care managers and inpatient care teams, and developed and used hospital readmission reports to monitor readmission rates. Patient readmissions to the hospital were analyzed over a 12-month period from May 2012 through April 2013, among patients who fell into 2 groups. Group 1 patients were those cared for by the primary care clinics that implemented transformation activities and who were admitted to the hospital associated with the practices. Group 2 patients were seen at clinics in the same catchment area that did not undertake any known practice redesign activities (usual care group).

RESULTS

A total of 961 patients were included in analyses; 685 (71.3%) were in Group 1, and 276 (28.7%) were in Group 2. Readmissions among Group 1 patients decreased from 27% to 7.1% (P=.02), and readmissions in Group 2 were variable with a nonsignificant trend (P=.53). The unadjusted regression model that compared the interaction between Group 1 and Group 2 patients found a significant difference in readmissions (P=.05).

CONCLUSION

Developing a multicomponent intervention appears to have a significant impact on reducing hospital readmissions. Primary care groups seeking to reduce hospital readmissions should consider implementing similar processes.

Can inbound and domestic medical tourism improve your bottom line? Identifying the potential of a U.S. tourism market

In large part due to current economic conditions and the political uncertainties of healthcare reform legislation, hospitals need to identify new sources of revenue. Two potentially untapped sources are inbound (international) and domestic (within the United States) medical tourists. This case study uses data from a large, urban healthcare system in the southeastern United States to quantify its potential market opportunities for medical tourism. The data were mined from electronic health records, and descriptive frequency analysis was used to provide a preliminary market assessment. This approach permits healthcare systems to move beyond anecdotal information and assess the relative market potential of their particular geographic area and the diagnostic services they offer for attracting inbound and domestic medical tourists. Implications for healthcare executives and guidance on how they can focus marketing efforts are discussed.

"Better pathways of care": suggested improvements to the emergency department management of people with advanced cancer

OBJECTIVE

It is difficult to provide optimal care to people with advanced cancer presenting to emergency departments (EDs). Recent data suggest that the ED environment, the skills and priorities of treating staff, and the lack of clear communication related to goals of care contribute to the difficulty. By exploring the views of emergency, palliative care (PC), and oncology clinicians on the care of these patients, this study aimed to describe potential solutions.

METHODS

This qualitative study involved focus groups with clinicians at two major hospitals and two community PC services in Melbourne, Australia, and semistructured telephone interviews with emergency clinicians from all other Australian states and territories. Discussions were recorded and transcribed verbatim. Thematic analysis identified ways to improve or enhance care.

RESULTS

Throughout discussions with 94 clinicians, a number of possible improvements to care were raised; these were broadly grouped into service areas: clinical care, pathways, information access, and education.

CONCLUSION

The provision of care to patients with advanced cancer in the ED occurs across sites, across disciplines, and across teams. To make improvements to care, we must address these complexities. The improvements suggested in this study place the patient (and the patient's family) at the centre of care.

[Analysis of civil hospitals in Pola (Pula) through a century of town history (1842-1947)]

The purpose of this study is to present the history of civil hospitals present in Pula through the 19th and the first half of the 20th century. All circumstances which are related to their founding and development have been analysed, together with a number of complex events which had influenced them through several decades. Careful archival and bibliographic research has made it possible to present the above mentioned material which explains the most important aspects of hospital care in the Province of Istria in the processed period. The first communal sanatorium in Pula was founded in 1842, while the first city hospital was built in 1875. The extraordinary urban development of Pula in the last decade of the 19th century had led to an urgent need of building a bigger hospital complex which was built on the hill of St. Mihovil and solemnly opened 6th October, 1896. On the day of 3rd January, 1904 the complete medical institution became the property of the Province of Istria thus establishing the Provincial hospital of Pula. The reconstruction of the history of the civil hospitals in Pula has made it possible to identify the chronic difficulties through which the health care system in the province had gone through. The reasons for the explained status are mainly the result of financial and organisational problems that inevitably affected the quality of medical care available to the population.

East meets West

A delegation from RCN Publishing and the RCN visited Beijing in September, where they saw how the city's hospitals integrate traditional Chinese and western medicine. Nursing schools in China are expanding their student intake to meet government targets. At the same time, nursing representatives are forging links and exchanging ideas with their counterparts in other countries, including the UK.

Priority queuing models for hospital intensive care units and impacts to severe case patients

This paper examines several different queuing models for intensive care units (ICU) and the effects on wait times, utilization, return rates, mortalities, and number of patients served. Five separate intensive care units at an urban hospital are analyzed and distributions are fitted for arrivals and service durations. A system-based simulation model is built to capture all possible cases of patient flow after ICU admission. These include mortalities and returns before and after hospital exits. Patients are grouped into 9 different classes that are categorized by severity and length of stay (LOS). Each queuing model varies by the policies that are permitted and by the order the patients are admitted. The first set of models does not prioritize patients, but examines the advantages of smoothing the operating schedule for elective surgeries. The second set analyzes the differences between prioritizing admissions by expected LOS or patient severity. The last set permits early ICU discharges and conservative and aggressive bumping policies are contrasted. It was found that prioritizing patients by severity considerably reduced delays for critical cases, but also increased the average waiting time for all patients. Aggressive bumping significantly raised the return and mortality rates, but more conservative methods balance quality and efficiency with lowered wait times without serious consequences.

Discharge phone calls: a technique to improve patient care during the transition from hospital to home

The discharge process is a transitional period when the patient's care is shifted from the hospital to the home and can be stressful for patients. One technique used to improve the quality and continuity of care is the discharge phone call (DPC). A large, metropolitan hospital implemented the DPC program to improve quality of care and decrease readmission rates. Qualitative interviews were performed with 24 hospital leaders, managers, and staff to determine the impact of the DPC program on the quality of care during the discharge process. Interviewees responded that the main benefits to the DPCs related to patient's medication management, follow-up appointment reminders, and answering questions. From a hospital perspective, the DPC can provide feedback to help improve the care delivery process related to discharge planning through improved discharge instructions and reinforcement of prescribed steps upon the patient's return home.

Enhancing the emergency department approach to pediatric sexual assault care: implementation of a pediatric sexual assault response team program

OBJECTIVES

The objectives of this study were to describe the experience of a novel pediatric sexual assault response team (SART) program in the first 3 years of implementation and compare patient characteristics, evaluation, and treatment among subpopulations of patients.

METHODS

This was a retrospective chart review of a consecutive sample of patients evaluated at a pediatric emergency department (ED) who met institutional criteria for a SART evaluation. Associations of evaluation and treatment with sex, menarchal status, and presence of injuries were measured using logistic regression.

RESULTS

One hundred eighty-four patients met criteria for SART evaluation, of whom 87.5% were female; mean age was 10.1 (SD, 4.6) years. The majority of patients underwent forensic evidence collection (89.1%), which varied by menarchal status among girls (P < 0.01), but not by sex. Evidence of acute anogenital injury on physical examination was found in 20.6% of patients. As per the Centers for Disease Control and Prevention guidelines for acute sexual assault evaluations in pediatric patients, menarchal girls were more likely to undergo testing for sexually transmitted infections and pregnancy (P < 0.01) and to be offered pregnancy, sexually transmitted infection, and HIV prophylaxis (P < 0.01).

CONCLUSIONS

In an effort to improve quality and consistency of acute sexual assault examinations in a pediatric ED, development of a SART program supported the majority of eligible patients undergoing forensic evidence collection. Furthermore, a substantial number of patients had evidence of injury on examination. These findings underscore the importance of having properly trained personnel to support ED care for pediatric victims of acute sexual assault.

[How to prescribe for patients with dysphagia: a review for the adaptation of the pharmaceutical guide in a socio-sanitary hospital]

PURPOSE

The aims of this paper are to review the pharmaceutical guide in order to include suitable dosage forms for patients with dysphagia and to establish specific recommendations for the drug administration.

METHODS

A comprehensive literature review was performed to develop general recommendations. Three topics were checked for every drug: a) alternative dosage forms suitable to patients with dysphagia; b) appropriateness of crushing tablets and opening capsules; and c) are these drugs suitable be mixed with food?

RESULTS

An algorithm was designed in order to help clinicians to select the best pharmaceutical form and its optimal administration method. The former pharmaceutical guide was modified and handling recommendations were made for each drug. Eleven dispersable, 26 liquid and 8 powder new forms were included.

CONCLUSIONS

This work has turned the pharmaceutical guide of the hospital in a useful tool for the prescription, validation and administration of medicines to patients with dysphagia.

Randomized controlled trial to evaluate screening and brief intervention for drug-using multiethnic emergency and trauma department patients

BACKGROUND

Screening and brief intervention (SBI) is a comprehensive, integrated public health approach to identify and deliver a spectrum of early detection and intervention services for substance use in general medical care settings. Although the SBI approach has shown promise for alcohol use, relatively little is known about its effectiveness for illicit drug use. We are evaluating the SBI approach for drug use using a rigorous randomized controlled trial. The purpose of the report is to describe the overall trial and its programmatic and methodological strengths with a focus on health educator (HE) selection and training. In addition, the baseline characteristics of the recently enrolled multiethnic cohort are described.

METHODS/DESIGN

A randomized two-group repeated measures design is being used in which drug-related outcomes of an intervention group will be compared with those of an attention-placebo control group. Selection of bicultural paraprofessional HEs-their training in research concepts, comorbid mental health issues, special treatment of marijuana use, and nonscripted enhanced motivational interviewing as well as their ongoing monitoring and evaluation-are among the features described. The HEs enrolled, consented, and conducted an intervention among 700 illicit drug users in two large hospital emergency departments/trauma units. To be eligible, a participant needed to be an adult (age ≥18 years), an English or Spanish speaker, awake and able to give consent, and reachable by telephone to schedule a six-month follow-up interview.

DISCUSSION

A comprehensive HE training protocol combined with rigorous, ongoing process measurement resulted in skill mastery in many areas and a successful participant recruitment period. Strengths and limitations of the study protocol are discussed as well as the characteristics of those recruited. This trial will be among the first to provide information about the effectiveness of SBI for illicit drug use. Outcome analysis has not yet been completed, but demonstrated programming and design successes have implications for future research and service delivery.

TRIAL REGISTRATION

http://NCT01683227.

Bouncers, brokers, and glue: the self-described roles of social workers in urban hospitals

Social workers delivering services in health care settings face unique challenges and opportunities. The purpose of this study was to solicit input from social workers employed in urban hospitals about their perceptions of the roles, contribution, and professional functioning of social work in a rapidly changing health care environment. Using qualitative methods, the university and hospital-based research team conducted seven focus groups (n = 65) at urban hospitals and analyzed the data using an interpretive framework with ATLAS.ti software. Seven major themes emerged from the participants' description of their roles: bouncer, janitor, glue, broker, firefighter, juggler, and challenger. Along with descriptions of the ways social workers fulfilled those roles, participants articulated differences in status within those roles, the increasing complexity of discharge planning, and expectations to provide secondary support to other health care professionals on their teams. Implications for practice and research are discussed.

"Nurses' training may be shifted": the story of Bellevue and Hunter College, 1942-1969

During the mid-20th century, nursing leaders advocated moving nursing education out of hospital-based programs and into colleges and universities for the purpose of preparing nurses to meet the demands of increasingly complex health care situations. Nursing leaders in New York City's municipal hospitals recognized the value of this change and sought to increase the number of baccalaureate-prepared nurses to fill the many vacancies within city hospitals. This article examines the political support New York gave to the expansion of Hunter College's baccalaureate program in nursing (a college within the City University of New York system) while closing the almost 100-year-old Bellevue and Mills Schools of Nursing diploma program. The efforts to change nursing at Bellevue started in the 1940s, but the transfer to Hunter College was not realized until 1967. Although the decision to close the diploma school met resistance among various stakeholders, the expansion ultimately succeeded. It was supported by the New York City Department of Hospitals and received approval from the Board of Estimates and Board of Higher Education. Both Bellevue and Hunter's leadership was ready to make this change and participated in this transformation.