Patient flow in burn care: a population-based analysis of hospital admissions and transfers in Norway, a Western European healthcare system

Assertive community treatment (ACT) is an intensive and comprehensive treatment for clients with severe mental illness (SMI) who do not readily benefit from clinic-based services. Monitoring the implementation of such programs is critical, because better-implemented programs have been found to be effective in improving client outcomes. We tested the hypothesis that fidelity to the ACT model would be positively correlated with improved client outcomes, as measured by reduction in psychiatric hospital use. A scale measuring fidelity of program implementation, the Dartmouth ACT Scale, was examined in 10 newly formed ACT teams. Using the team as the unit of measure, the mean reduction in state hospital days for a 1-year period before and after program admission was calculated. Mean effect size in reduction in hospital days was used as the outcome measure in a correlational design. Pre/post comparisons showed a 43 percent reduction in hospital days for 317 clients (t=8.61, P<.001). The Pearson correlation between DACTS fidelity and reduction of state hospital days was .49, P=.08, one-tailed. Several possible reasons are offered for why the study hypothesis was not confirmed. However, even if predictive validity of the Dartmouth ACT Scale is limited, it continues to be a useful tool for program monitoring and for providing corrective feedback.

Introduction We reviewed the trends in referrals, admissions, treatment and outcomes for the burn patients managed in a National Burn Center (NBC) over a 17-year period since the center opened in 2006. Nationwide, there are four burn centres which care for patients who fulfil the American Burn Association criteria for a referral to a burn center. The NBC is located in the largest metropolitan area, and takes additional referrals of “severe” burn injuries (e.g. &amp;gt;30% total burn surface area (TBSA)). We will explore the burden of referrals and present the evolving models of care over the time period. Our total catchment population of 5.1 million people spread over 268, 021 km2 compares to the average population of a US state of 5.7 million over 182, 949 km2. Methods Patient data was extracted from the departmental database which has been prospectively recorded since the center opened in 2006. All inpatients received multidisciplinary team care. Results Between 2006-2023 there were 6279 admissions, of which 307 were burns &amp;gt;30% TBSA. We observed an over-representation of some ethnic groups with burn injury relative to the population, specifically Māori and Pasifika. Reviewing the admissions trends, there was a 12% increase in admissions comparing the three-year period of 2006-2009 to 2020-2023. Admissions increased by 21% in patients with &amp;lt; 10% TBSA from an average of 289 patient per year in 2006-2009, to 348 patients per year in 2020-2023. Admissions for patients with &amp;gt;10% TBSA decreased from an average of 59 per year in 2006-2009 to 43 per year in 2020-2023. Despite the overall increase in admission numbers, the average percentage of total admissions that were from national/out-of-region decreased slightly from 6.2% in 2006-2009 compared to 4.7% in 2020-2023. This is a result of being outweighed by a much larger contribution from the local catchment area. The average length of stay for patients increased slightly from 7.29 days (2006-09) to 7.76 days (2020-2023). There was a 19% increase in average operations from 1378 to 1633 year, and a 34% increase in average operating minutes per year (2006-09 vs 2020-23), indicating an increased operative burden on the unit. Conclusions Centralisation of care is reported to improve the standard of care in complex burns. From 2006-2023, our team has observed increasing numbers of patients accepted that do not meet the threshold for the agreed National Burn referral criteria, suggesting increasing reliance on referring services. Our findings have also shown that increased demand for a service can result from the demand generated from the local population independent of referring services, therefore the location of a NBC should take into account not only geographical distance and accessibility, but also local population changes. Applicability of Research to Practice This paper reflects the changing practice in burns management following the establishment of a National Burn Center/centralised burn care model, and the evolving models of care in burns.

Introduction The centralization of burn care involves consolidating specialized burn treatment services into a few highly equipped centers, aimed at improving patient outcomes by concentrating expertise and resources in specific locations. The National Burn Center (NBC) was created in 2006 to serve a population of 4.185 million people. Our current total catchment population is 5.1 million people spread over 268, 021 km2, compared to the average population of a US state of 5.7 million over 182, 949 km2. The NBC is located in the largest metropolitan area and in addition to loco-regional smaller burn injuries also accepts referrals of “severe” burn injuries (e.g. &amp;gt;30% total burn surface area (TBSA) from across the country. Challenges include geographic access, particularly for patients from rural or underserved areas, ensuring equitable access, and resource management when balancing the National Center needs with the loco-regional burns service provision. The “hub and spoke” model was implemented to overcome some of these challenges. This model involves centralizing complex and resource-intensive healthcare services at a “ hub” facility (NBC), and maintaining a network of “ spoke” facilities, (regional burns units - RBUs), and relies on strong collaboration between the hub and spoke facilities including clear referral pathways and support/training for regional centers. Methods We reviewed the 7255 admissions to the NBC over a 17-year period, and identified changes in the trends of referrals, treatment approaches and outcomes. All patients received a multi-disciplinary team approach throughout their stay. Results A significant changes in the burn treatment model was the regular use of a biodegradable temporizing matrix (BTM) introduced in 2018, which has contributed to the noted increase in survivability of burns &amp;gt;70% TBSA but also the increased length of hospital stay in 30-50% TBSA group. There was a decrease in the percentage of annual out-of-region transfers to the NBC, in keeping with a tighter referral criterion, and improved support and expertise in the RBUs. We also noted a persistent over-representation of Maori and Pasifika patients in our cohort compared to the population. Conclusions In conclusion, this model provides significant benefits, including improved outcomes, specialized multidisciplinary care, and a focus on research and innovation. However, addressing challenges related to equitable access remains crucial. By optimizing these systems, centralized burn care can significantly enhance both the immediate and long-term recovery outcomes for individuals with burn injuries. Applicability of Research to Practice This paper explores the evolving practices in burn management that have emerged since the establishment of a centralized National Burn Center, as well as the ongoing development of new models of care for burn treatment. Funding for the Study N/A

BackgroundThoracic trauma accounts for 10%–15% of all trauma admissions. Rib fractures are the most common injury following blunt thoracic trauma. Epidural analgesia improves patient outcomes but is not without problems. The use of continuous intercostal nerve blockade (CINB) may offer superior pain control with fewer side effects. This study’s objective was to compare the rate of pulmonary complications when traumatic rib fractures were treated with CINB vs epidurals.MethodsA hospital trauma registry provided retrospective data from 2008 to 2013 for patients with 2 or more traumatic rib fractures. All subjects were admitted and were treated with either an epidural or a subcutaneously placed catheter for continuous intercostal nerve blockade. Our primary outcome was a composite of either pneumonia or respiratory failure. Secondary outcomes included total hospital days, total ICU days, and days on the ventilator.Results12.5% (N=8) of the CINB group developed pneumonia or had respiratory failure compared to 16.3% (N=7) in the epidural group. No statistical difference (P=0.58) in the incidence of pneumonia or vent dependent respiratory failure was observed. There was a significant reduction (P=0.05) in hospital days from 9.72 (SD 9.98) in the epidural compared to 6.98 (SD 4.67) in the CINB group. The rest of our secondary outcomes showed no significant difference.ConclusionThis study did not show a difference in the rate of pneumonia or ventilator-dependent respiratory failure in the CINB vs epidural groups. It was not sufficiently powered. Our data supports a reduction in hospital days when CINB is used vs epidural. CINB may have advantages over epidurals such as fewer complications, fewer contraindications, and a shorter time to placement. Further studies are needed to confirm these statements.

In 2011, the Department of Health of the Western Cape Province, South Africa, requested a review of current burn services in the province, with a view to formulating a more efficient and cost-effective service. This article considers the findings of the review and presents strategies to improve delivery of appropriate burn care at primary and secondary levels. Surveys were conducted at eight rural and urban hospitals, two outreach workshops on burn care, four regional hospitals and at least 60 clinics in Cape Town and in the Western Cape as far as Ladismith. A survey on community management of paediatric burns was also included in the study. The incidence of burns was highest in the winter months, more than half of those affected were children, and the majority of burns were scalds from hot liquids. Most burn injuries managed at primary level were minor, with 75% of patients treated by nurse practitioners and discharged. The four regional secondary hospitals managed the majority of moderate to severe burns. There is room for improvement in terms of treatment facilities and consumables at all levels, regional hospitals being particularly restricted in terms of outdated equipment, a shortage of intensive care unit beds, and difficulties in transferring patients with major burns to a burns unit when indicated. The community management of paediatric burns was satisfactory, although considerable delays in transfer and insufficient pain control hampered appropriate care. A great need for ongoing education at all levels was identified. Ten strategies are presented that could, if implemented, lead to tangible improvements in the management of burn patients at primary and secondary levels in the Western Cape.

Bimonthly Medical Visits Reduce Sickle Cell Admissions

BackgroundAn integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs (\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\ge$$\\end{document}8 ED visits per 6 months) vs. high frequency SUs (4–7 ED visits per 6 months).MethodsWe assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU.ResultsThere was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs.ConclusionsOur study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients.Trial RegistrationIRB201500212. Retrospectively registered.

Effect of PACT on Inpatient Psychiatric Treatment for Adolescents With Severe Mental Illness: A Preliminary Analysis

This study examined whether inpatient psychiatric treatment and forensic treatment and incarceration were reduced among adolescents and young adults with severe and persistent mental illness after they received services in the Program of Assertive Community Treatment (PACT). The pre-post evaluation compared length of inpatient treatment and forensic treatment or incarceration for the year before and after PACT enrollment. Participants (N=15) were their own controls. Annual psychiatric hospitalization fell from 66.2 days before enrollment to 8.7 days in the first year of PACT (p=.025, Cohen's d=.54). Similarly, combined days of inpatient psychiatric treatment and forensic treatment or incarceration fell from 104.1 in the year before enrollment to 24.1 days in the year after (p=.015, Cohen's d=.61). PACT services significantly reduced time in inpatient psychiatric treatment. These preliminary results may have implications for long-term treatment, service delivery, and cost of care for adolescents and young adults with severe and persistent mental illness.

Is HCFA's reimbursement policy controlling quality of care for end-stage renal disease patients?

BackgroundTo assess the development of and variation in lengths of stay in Dutch hospitals and to determine the potential reduction in hospital days if all Dutch hospitals would have an average length of stay equal to that of benchmark hospitals.MethodsThe potential reduction was calculated using data obtained from 69 hospitals that participated in the National Medical Registration (LMR). For each hospital, the average length of stay was adjusted for differences in type of admission (clinical or day-care admission) and case mix (age, diagnosis and procedure). We calculated the number of hospital days that theoretically could be saved by (i) counting unnecessary clinical admissions as day cases whenever possible, and (ii) treating all remaining clinical patients with a length of stay equal to the benchmark (15th percentile length of stay hospital).ResultsThe average (mean) length of stay in Dutch hospitals decreased from 14 days in 1980 to 7 days in 2006. In 2006 more than 80% of all hospitals reached an average length of stay shorter than the 15th percentile hospital in the year 2000. In 2006 the mean length of stay ranged from 5.1 to 8.7 days. If the average length of stay of the 15th percentile hospital in 2006 is identified as the standard that other hospitals can achieve, a 14% reduction of hospital days can be attained. This percentage varied substantially across medical specialties. Extrapolating the potential reduction of hospital days of the 69 hospitals to all 98 Dutch hospitals yielded a total savings of 1.8 million hospital days (2006). The average length of stay in Dutch hospitals if all hospitals were able to treat their patients as the 15th percentile hospital would be 6 days and the number of day cases would increase by 13%.ConclusionHospitals in the Netherlands vary substantially in case mix adjusted length of stay. Benchmarking – using the method presented – shows the potential for efficiency improvement which can be realized by decreasing inputs (e.g. available beds for inpatient care). Future research should focus on the effect of length of stay reduction programs on outputs such as quality of care.

Epidemiology and outcome of burns: Early experience at the country's first national burns Centre

The COVID-19 pandemic had a huge global impact on healthcare systems that affected all medical services, including burn care facilities. This paper analyzes the effects of this medical crisis on pediatric burn injuries by comparing patient data from 2019 (pre-pandemic) and 2020 (during the pandemic) at a national burn center in Romania. The study included, overall, 676 patients, out of which 412 were admitted in 2019. In 2020, the admissions decreased by 35.9% (n = 264). However, moderate and severe burns remained constant and burn severity increased in 2020, with a larger total body surface area affected on average. Surgical management rates and hospital stay duration increased in 2020 from 18% to 39% and from 7 days to 11 days, respectively. Admissions to the intensive care unit and mortality rates remained similar between 2019 and 2020. Scalds were the leading cause of burns in both years; however, in 2020, they affected a larger total body surface area. Contact burns decreased significantly in 2020 from 10.9% to 5.2%, likely due to reduced outdoor activities. The concomitant presence of SARS-CoV-2 infection and burn injuries did not have a negative impact on complication rates, surgical management approaches, or duration of hospitalization. These findings emphasize the need to preserve dedicated burn care human and material resources during global health crises in order to offer access to the best quality of care, thus ensuring optimal patient outcomes, regardless of fluctuations in admission rates.

Reduction in Hospital Days Using a Multidisciplinary Approach for Pediatric Patients with Sickle Cell Disease

Assertive community treatment (ACT) is an extensively studied and widely imitated community support treatment model for severely mentally ill individuals. Several previous reviews have documented its favourable effects on clients and their families. This is the first review to focus on economic outcomes. Nineteen randomized studies and 15 nonrandomized studies describing ACT programs were identified based on 2 criteria: 1) provision of services primarily in the community and 2) shared caseloads. Percentage reduction in hospital days was calculated for the 34 study sites where reported data allowed it. Multiple-regression methods were used to relate reduction in hospital days to program fidelity and other contextual factors. The impacts of ACT on emergency-room use, use of outpatient services, housing, costs, and other economic outcomes were also examined. Higher-fidelity programs appear to reduce hospital days by about 23 percentage points more than lower-fidelity programs (95% CI = -41.2, -5.2). The estimated regression coefficients imply that a high-fidelity program reduces hospitalizations by about 58% over 1 year if the alternative involves some type of case management and by 78% if it does not. ACT appears to increase the proportion of clients who live in independent housing situations, but the effect on use of supervised housing, and therefore on housing costs, is ambiguous. The effects on use of most other resources are inconsistent across studies. Overall, ACT appears to result in somewhat lower costs, whatever the perspective of analysis adopted. The most reliable cost offset to ACT treatment costs appears to be reduced hospital use. Using Quebec costs, an ACT program must enroll people with prior hospital use of about 50 days yearly, on average, to break even. As care systems evolve to reduce their reliance on hospitalization as a care modality with or without ACT, this threshold will become increasingly difficult to achieve. The primary justification for implementing ACT services will then become their clinical benefits.