Filling the Gap between Metropoles and Peripheries: Insights about Hospital Standardization from the British Columbia Hospital Association Conferences, 1918-30.

A prospective study was undertaken from 1969 to 1974 to evaluate a program establishing coronary care units in small community hospitals. Crude mortality rates from acute myocardial infarction in these small hospitals were 14.5%, slightly higher but not statistically different from concurrently collected data in three larger comparision hospitals (11.5%). Mutivariate discriminate analysis of clinical characteristics was used to calculate a risk score for each patient admitted. Observed deaths exceeded expected deaths (134 versus 119) (P greater than 0.30) in small hospitals but observed deaths were less than expected (55 versus 77)(P less than 0.05) in comparison hospitals. Mortality was significantly greater in those units admitting fewer than 60 patients with infarctions yearly (20.9%) than in those admitting more than 60 (10.7%) (P less than 0.001). These data suggest that coronary care units in small community hospitals can provide adequate coronary care, but their level of performance drops when fewer than 60 patients with infarctions are admitted yearly.

To investigate whether hospital characteristics not readily susceptible to change (i.e. hospital size, university status, and geographic location) are associated with specific self-reported nurse outcomes. Research often focuses on factors within hospitals (e.g. work environment), which are susceptible to change, rather than on structural factors in their own right. However, numerous assumptions exist about the role of structural factors that may lead to a sense of pessimism and undermine efforts at constructive change. Data was derived from survey questions on assessments of work environment and satisfaction, intention to leave, quality of care and burnout (measured by the Maslach Burnout Inventory), from a population-based sample of 11 000 registered nurses in Sweden. Mixed model regressions were used for analysis. Registered nurses in small hospitals were slightly more likely to rank their working environment and quality of nursing care better than others. For example 23% of staff in small hospitals were very satisfied with the work environment compared with 20% in medium-sized hospitals and 21% in large hospitals. Registered nurses in urban areas, who intended to leave their job, were more likely to seek work in another hospital (38% vs. 32%). While some structural factors were related to nurse-reported outcomes in this large sample, the associations were small or of questionable importance. The influence of structural factors such as hospital size on nurse-reported outcomes is small and unlikely to negate efforts to improve work environment.

PurposeAlthough many new patients are seen at small hospitals, there are few reports of new health problems from such hospitals in Japan. Therefore, we investigated the reasons for encounter (RFE) and diagnoses of new outpatients in a small hospital to provide educational resources for teaching general practice methods.MethodsThis observational study was conducted at the Department of General Internal Medicine in a small community hospital between May 6, 2010 and March 11, 2011. We classified RFEs and diagnoses according to component 1, “Symptoms/Complaints”, and component 7, “Diagnosis/Diseases”, of the International Classification of Primary Care, 2nd edition (ICPC-2). We also evaluated the differences between RFEs observed and common symptoms from the guidelines Model Core Curriculum for Medical Students and Goals of Clinical Clerkship.ResultsWe analyzed the data of 1,515 outpatients. There were 2,252 RFEs (1.49 per encounter) and 170 ICPC-2 codes. The top 30 RFE codes accounted for 80% of all RFEs and the top 55 codes accounted for 90%. There were 1,727 diagnoses and 196 ICPC-2 codes. The top 50 diagnosis codes accounted for 80% of all diagnoses, and the top 90 codes accounted for 90%. Of the 2,252 RFEs, 1,408 (62.5%) included at least one of the 36 symptoms listed in the Model Core Curriculum and 1,443 (64.1%) included at least one of the 35 symptoms in the Goals of Clinical Clerkship. On the other hand, “A91 Abnormal result investigation”, “R21 Throat symptom/complaint”, and “R07 Sneezing/nasal congestion”, which were among the top 10 RFEs, were not included in these two guidelines.ConclusionWe identified the common RFEs and diagnoses at a small hospital in Japan and revealed the inconsistencies between the RFEs observed and common symptoms listed in the guidelines. Our findings can be useful in improving the general practice medical education curricula.

Time and personnel requirements for antimicrobial stewardship in small hospitals in a rural area in Germany

Most hospitals in British Columbia have fewer than 200 beds, yet the clinical pharmacy services provided and factors influencing their delivery in this context are unknown. To describe on-site clinical pharmacy services and associated contextual barriers and enablers in small BC hospitals. Between January and April 2022, an internet-based survey questionnaire was deployed to all pharmacy licence holders at BC hospitals with fewer than 200 beds (n = 23 licence holders representing 58 hospitals). Site characteristics, clinical activities, and barriers to and enablers of clinical pharmacy services (according to the Consolidated Framework for Implementation Research [CFIR]), as well as free-text responses, were captured. Of the 23 licence holders invited to participate, 18 (78%) responded, representing 37 (64%) of the small hospitals. Provision of clinical pharmacy services was reported at 27 (73%) of the 37 hospitals. Resolution of drug therapy problems and patient education were delivered at all of these hospitals. Conversely, the comprehensive patient care bundle and discharge medication reconciliation were never performed at 15 (56%) and 11 (41%), respectively, of these 27 hospitals. Of the 9 CFIR barriers, insufficient external networking and insufficient resources were reported by 17 (94%) and 16 (89%), respectively, of the 18 respondents. Funding and staffing barriers were reported, using free text, by 14 (78%) and 13 (72%), respectively, of the 18 respondents. Of the 21 CFIR enablers, the following 5 were reported by all respondents: agreement that clinical services are supported by adequate evidence, that such services will improve quality, that they will meet patient needs, that they will satisfy patients, and that a strong need exists for these services. On-site clinical pharmacy services were delivered at most small BC hospitals; however, opportunities exist to expand clinical services. Pharmacy leaders should implement change strategies that overcome contextual barriers and enhance enablers.

Between 1972 and 1973, Britt and colleagues conducted 1-day infection prevalence surveys in 18 hospitals each with fewer than 75 beds and all located in the rural intermountain west. The lessons learned from that study were incorporated into a book chapter entitled “Infection Control in Small Hospitals” by Dr. Britt. Since that study no substantial nor systematic review of nosocomial infections in small community or rural hospitals has been reported. A recent editorial in Infection Control posed four questions that still needed to be answered for the smaller (less than 100-bed) hospital:1. Given the statistical realities of small hospitals, what types of surveillance methods—periodic prevalence surveys, general surveillance, focused surveillance, etc.—are the most reliable? Are any of them necessary?2. Which of the many infection control practices recommended by the CDC, the Joint Commission on Accreditation of Hospitals, and others are applicable to small hospitals?3. What resource sharing of existing expertise, from larger hospitals, health departments, groups such as the Association of Practitioners of Infection Control and the Society of Hospital Epidemiologists of America, and others can be developed for smaller hospitals in cost effective and realistic ways?4. Should smaller hospitals be required to have the same type of multidisciplinary infection control committees required of larger hospitals or can the responsibilities of the committee be delegated to a smaller group such as one nurse and one staff physician?The purpose of this report is to provide detailed infection control information obtained from 15 hospitals located in rural areas of Southwestern Wisconsin. This article will focus on data derived from an initial comprehensive prevalence survey that replicated the Britt study in the Wisconsin sites in 1983. Additional data were derived from ongoing bi-monthly prevalence studies done over 6 consecutive months in each of the 15 rural hospitals. Data from 6 months of ongoing comprehensive surveillance from each of the 15 hospitals and final conclusions from the project will be the subject of a subsequent paper.

Acute Coronary Syndromes and Heart Failure Critical Care Units Utilization and Outcomes in Teaching and Community Hospitals: A National Population-Based Analysis

This survey was undertaken to identify knowledge and performance level of MRSA infection control among medium and small hospital nurses. The subjects of the study were 261 medium and small hospital nurses. The collected data were analyzed by using SPSS WIN 18.0. The total mean values of the knowledge and performance on the MRSA infection control were <TEX>$9.51{\pm}1.67$</TEX> and <TEX>$2.26{\pm}.47$</TEX> respectively. the Knowledge about the general characteristics according to work department, MRSA infection control department presence, MRSA infection control guidelines presence, MRSA infection control education experience, MRSA infection control education method according to the statistically significant differences were observed. The performance about general characteristics according to age, work experience, work department, MRSA infection control department presence, MRSA infection control guidelines presence, MRSA infection control education experience and MRSA infection control education methods according to the statistically significant differences were observed. It is having sufficient various facilities, to enhance nurses knowledge about management of MRSA infection. If the continuous education of professional infection control is offered, it contributes to protect MRSA infection in the medium and small hospitals.

Antibiotic use and misuse is driving drug resistance. Much of US healthcare takes place in small community hospitals (SCHs); 70% of all US hospitals have <200 beds. Antibiotic use in SCHs is poorly described. We evaluated antibiotic use using data from the National Healthcare and Safety Network antimicrobial use option from the Centers for Disease Control and Prevention. We used Intermountain Healthcare's monthly antibiotic use reports for 19 hospitals from 2011 to 2013. Hospital care units were categorized as intensive care, medical/surgical, pediatric, or miscellaneous. Antibiotics were categorized based on spectrum of coverage. Antibiotic use rates, expressed as days of therapy per 1000 patient-days (DOT/1000PD), were calculated for each SCH and compared with rates in large community hospitals (LCHs). Negative-binomial regression was used to relate antibiotic use to predictor variables. Total antibiotic use rates varied widely across the 15 SCHs (median, 436 DOT/1000PD; range, 134-671 DOT/1000PD) and were similar to rates in 4 LCHs (509 DOT/1000PD; 406-597 DOT/1000PD). The proportion of patient-days spent in the respective unit types varied substantially within SCHs and had a large impact on facility-level rates. Broad-spectrum antibiotics accounted for 26% of use in SCHs (range, 8%-36%), similar to the proportion in LCHs (32%; range, 26%-37%). Case mix index, proportion of patient-days in specific unit types, and season were significant predictors of antibiotic use. There is substantial variation in patterns of antibiotic use among SCHs. Overall usage in SCHs is similar to usage in LCHs. Small hospitals need to become a focus of stewardship efforts.

Not much appears in the published literature describing pharmacy practice in small and rural hospitals.1–4 Pharmacy practice in such settings can prove professionally satisfying, and living in a rural area can prove personally rewarding. The terms small hospital and rural hospital often evoke the image of a one-pharmacist operation in the middle of nowhere. The Indian Health Service may designate such a facility as an “isolated duty station.”5 The Health Resources and Services Administration defines small hospitals as having no more than 49 licensed beds and critical access hospitals as having no more than 25 beds.6 The 2006 American Hospital Association database of U.S. hospitals revealed that just under one third of the 6280 respondent hospitals in the United States officially qualified as small hospitals, while just over half of the hospitals in the country had fewer than 100 beds and might consider themselves “small.”7 Rural has been defined several ways,8 none of which is entirely accurate. The designation of rural versus nonrural is often a matter of personal perspective.

Purpose: The purpose of this study was to identify moderating effects of work-family conflict in the relationship between job, organizational, career characteristics and turnover intention among nurses working in small and medium-sized hospitals. Methods: A self report questionnaire survey was completed by 286 nurses working in five small or medium-sized hospitals in P city. Data were gathered during October, 2014 and analyzed using the SPSS 21.0 program. Results: Work-family conflict had significant moderating effects between job, organizational, career characteristics and turnover intention of nurses working in small or medium-sized hospitals. Career commitment was the biggest factor in reducing turnover intention. Conclusion: The results of the study indicate that work-family conflict and career commitment are important factors in turnover intention among nurses working in small and medium-sized hospitals. Therefore, to understand job and organizational career characteristics of nurses in small and medium hospitals, consideration must be given to the role of conflict in the nurses' workplace and homes. Support from the organization focusing on career development, and provision of an innovative system for the environment of small hospitals are needed.

Purpose: The purpose of this study was to compare perception of patient safety culture and safety care activities between university hospital nurses (group A) and small hospital nurses (group B). Methods: Using a structured questionnaire, data were collected from 246 university hospital nurses and 223 small hospital nurses working in Seoul or Gyeonggi Province. Descriptive statistics, x-test, ANCOVA, t-test, ANOVA with the SPSS package were used for data analysis. Results: Total score for perception of patient safety culture and 3 subcategories of perception of patient safety culture were statistically significantly higher for group B compared to group A. Operation room nursing, falls, and bed sore scores in patient safety care activities were statistically significantly higher for group A than for group B. Conclusion: The study findings suggest that the specific characteristics by size should be considered when developing effective patient safety culture in hospitals.

Leading cancer hospitals have increasingly shared their 'brand' with smaller hospitals through affiliations. Because each brand evokes a distinct reputation for the care provided, 'brand-sharing' has the potential to impact the public's ability to differentiate the safety and quality within hospital networks. The general public was surveyed to determine the perceived similarities and differences in the safety and quality of complex cancer surgery performed at top cancer hospitals and their smaller affiliate hospitals. A national, web-based KnowledgePanel (GfK) survey of American adults was conducted. Respondents were asked about their beliefs regarding the quality and safety of complex cancer surgery at a large, top-ranked cancer hospital and a smaller, local hospital, both in the presence and absence of an affiliation between the hospitals. A total of 1010 surveys were completed (58.1% response rate). Overall, 85% of respondents felt 'motivated' to travel an hour for complex surgery at a larger hospital specializing in cancer, over a smaller local hospital. However, if the smaller hospital was affiliated with a top-ranked cancer hospital, 31% of the motivated respondents changed their preference to the smaller hospital. When asked to compare leading cancer hospitals and their smaller affiliates, 47% of respondents felt that surgical safety, 66% felt guideline compliance, and 53% felt cure rates would be the same at both hospitals. Approximately half of surveyed Americans did not distinguish the quality and safety of surgical care at top-ranked cancer hospitals from their smaller affiliates, potentially decreasing their motivation to travel to top centers for complex surgical care.

Inadequate access to anesthesia and surgical services is often considered to be a problem of low- and middle-income countries. However, affluent nations, including Canada, Australia, and the United States, also face shortages of anesthesia and surgical care in rural and remote communities. Inadequate services often disproportionately affect indigenous populations. A lack of anesthesia care providers has been identified as a major contributing factor to the shortfall of surgical and obstetrical care in rural and remote areas of these countries. This report summarizes the challenges facing the provision of anesthesia services in rural and remote regions. The current landscape of anesthesia providers and their training is described. We also explore innovative strategies and emerging technologies that could better support physician-led anesthesia care teams working in rural and remote areas. Ultimately, we believe that it is the responsibility of specialist anesthesiologists and academic health sciences centers to facilitate access to high-quality care through partnership with other stakeholders. Professional medical organizations also play an important role in ensuring the quality of care and continuing professional development. Enhanced collaboration between academic anesthesiologists and other stakeholders is required to meet the challenge issued by the World Health Organization to ensure access to essential anesthesia and surgical services for all.

To the editor: Clostridium difficile-associated diarrhea (CDAD) is an important nosocomial infection in Canadian hospitals and an emerging public health problem. CDAD causes significant morbidity and can be associated with high all-cause mortality (1). Recent Ontario guidelines have emphasized housekeeping and case-management strategies to control CDAD (2). Although antibiotic stewardship has been suggested by many experts as useful in CDAD control (3–5), this strategy has not been included in the Ontario recommendations. We describe a persistent outbreak of CDAD in a small hospital that appears to have been controlled by a simple antibiotic stewardship program. Campbellford Memorial Hospital (CMH) is a small (34 bed) community hospital in rural eastern Ontario. CMH does not perform dialysis or operate a true intensive care unit (ie, no ventilators or invasive hemodynamic monitoring). Patient care areas were built in 1953, most rooms have shared toilets and occupancy rates were close to 100% throughout the outbreak period. Before April 2007, CMH experienced sporadic incident nosocomial cases of CDAD (frequent loose stools and stool positive for C difficle toxin with either onset of symptoms >72 h after hospital admission or a history of hospital admission within the previous four weeks) (6). The average infection rate was 0.3/1000 patient days (approximately one case every three months) over the 21 months before April 2007. Beginning in April 2007, CMH experienced much higher rates of incident nosocomial CDAD. Over a 15-month period (April 2007 to June 2008), CMH had 49 incident nosocomial cases of CDAD with an average infection rate of 3.2/1000 patient days (Figure 1). This was a very high rate compared with other Ontario hospitals (average Ontario CDAD infection rate in August 2008 was 0.39/1000 patient days/month) (7). Forty-seven cases (88%) had a history of hospital antibiotic use, 35 (71%) fluoroquinolone use and 28 (57%) moxifloxicin use. Figure 1) Clostridium difficile-associated diarrhea outbreak at Campbellford Memorial Hospital (Trent Hills, Ontario) April 2007 to May 2008 CMH followed expert advice and implemented a series of housekeeping and patient management measures without controlling the outbreak (Table 1). On June 17, 2008 the CMH instituted several additional measures. These included double cleaning of CDAD patient rooms seven days a week (previously five days a week), disposable bedpans for CDAD cases and an antibiotic stewardship program. The latter consisted of two elements. First, memos were sent to physicians and notices were posted requesting that they avoid the use of fluoroquinolones for inpatients. There was special emphasis on reducing moxifloxacin use because of the particularly strong association with this antibiotic (8). Second, all orders for moxifloxacin for inpatients were automatically reviewed by the hospital pharmacist and consultant internist, and alternative antibiotics recommended to the most responsible physician (9). TABLE 1 Clostridium difficile-associated diarrhea (CDAD) control interventions The use of moxifloxacin declined from an average of 87 doses per month during the 14 months of the outbreak to an average of 12 doses per month – an 87% decrease – in the first six months after implementation of the antibiotic stewardship program. CMH has had one incident case of nosocomial CDAD in the 24 months from June 17, 2008 until July, 2010. This was a significant decrease in the CDAD rate from 3.2/1000 patient days/month (before implementation of antibiotic stewardship) to 0.04/1000 patient days/month (over the 24 months with antibiotic stewardship) (incidence rate ratio associated with the intervention 0.013 [95% CI 0.018 to 0.093]; P<0.0001 [χ2 test]). CMH’s simple antibiotic stewardship program was effective at changing antibiotic use and may have played a decisive role in ending a persistent CDAD outbreak. Additional environmental measures, adopted at the same time as antibiotic stewardship, may have also contributed. Antibiotic stewardship deserves more attention as a CDAD control strategy. A particularly strong link between moxifloxacin and CDAD has been proposed by other observers (8). This association could be related to moxifloxacins’s activity against anaerobes, unique among the currently available fluoroquinolones (10). The apparent association between CDAD and moxifloxacin use deserves further investigation.