Acute Inpatient Care Research Articles

Association between Race and Social Deprivation in Patients with Hematologic Malignancies

Background: Recent therapeutic advances including biologics, immunomodulators, and cellular therapies have transformed management paradigms for hematologic malignancies. Nevertheless, disparities exist in terms of access to care, and non-White individuals are historically underrepresented in clinical trials. As it remains unknown whether there are inequalities in care related to adverse events of these therapeutic approaches, in this study we explored whether racial and social differences are related to outcomes of patients with hematologic malignancies. Methods: This was a retrospective chart review from January 2011 to December 2021 that included adult patients across our cancer center network with diagnostic codes for malignant neoplasms of lymphoid, myeloid, and hematopoietic origin who were receiving an immunologic therapy at the time of an emergency department visit. Data were compared according to White and non-White individuals. The non-White group comprised of Black or African American, Asian Indian, Chinese, Asian, or unspecified/other. Differences in continuous variables between groups were assessed using the Wilcoxon rank-sum test, and Chi-square or Fisher's exact test was used to compare categorical variables. Outcomes included time to admission, length of stay within the hospital, ICU admissions, and differences in social deprivation index (SDI). SDI is a composite measure of a geographic region's socioeconomic variation in health outcomes based on demographic characteristics collected by the U.S Census Bureau (www.census.gov/programs-surveys/acs). Higher SDI scores indicate more severe social deprivation. Results: 180 patients were identified with 142 patients meeting inclusion criteria. Among these, 43% were non-White patients. The median age for the White group was 71.6 and for the non-White group 65.8 (P=.001). The most common immunotherapies were lenalidomide (50%), pomalidomide (19.7%), daratumumab (12.7%), methotrexate (9.9%), and rituximab (8.5%). The main chief complaint that was statistically different between the two groups was musculoskeletal complaints; the incidence among the White group was 8.6% and 29.5% among the non-White group (P=0.001). Other reasons for presentation included neurological complaints (21)%, infection/sepsis (16%), respiratory issues (12%), and abnormal laboratory values (3.5%). There were no differences in time to hospitalization for White versus non-White patients (5 versus 6 hours, P=0.12). Differences in ICU admissions, 30 day-readmissions, and length of stay were also not statistically significant between the two groups. However, the median SDI for the White group was statically greater among the non-White group (p<0.001). Discussion: In this retrospective study, non-White patients with hematologic malignancies were found to have greater social deprivation than White patients, however this did not impact inpatient metrics. We found that non-White patients with hematologic malignancies were more likely to originate from socially disadvantaged backgrounds, although there were no differences in hospitalization outcomes among the two groups. Results suggest that social determinants may impact factors unrelated to access to acute care in patients with hematologic therapies receiving immunologic therapies.

Implementation of an Adult Sickle Cell Center Directly Correlates with Improved Patient Outcomes and Decreased Acute Care Utilization

Introduction: The lack of comprehensive care for adult patients with sickle cell disease (SCD) remains a major unmet need in the United States, leading to the noted increase acute care utilization, high morbidity and mortality as well as increased healthcare burden. By establishing a dedicated adult center, the delivery of SCD care will be moved from the acute to the outpatient setting where best practices of disease management and a trusting therapeutic relationship can be established. This will allow for timely detection of complications and address the psychosocial contributors to disease management. Here, we demonstrate how the establishment of a dedicated adult sickle cell results in direct and immediate improvement in acute care utilization and patient outcomes. With funding from our institution and health department, Inova Adult Sickle Cell Center (IASC) was established in March of 2022. After IASC opening, each provider's schedule allowed for frequent clinic visits to apply standard of care and address timely unmet needs, particularly those with highest disease burden and acute care use. Methods/ Results: With IASC opening, disease-modifying therapies, screening studies and individualized care plans (ICPs) were implemented for each patient. Equally important and perhaps a key factor for IASC funding was the degree of acute care utilization within our hospital system which comprises of five large hospitals including a 1000-bed tertiary care center as well as numerous standalone ED facilities. To standardize care across this large institution, we quickly developed ICPs for all IASC patients and provided education to ED and hospitalist colleagues. In line with other adult sickle cell centers, we eliminated use of parenteral diphenhydramine as well intermittent parenteral opioid bolus use. Instead, patient controlled anesthesia (PCA) pumps were utilized along with oral opioids. Upon admission, the care for each patient was closely coordinated between IASC and inpatient teams. We also identified several patients with frequent hospitalizations for comprehensive care plan meeting. The patients consisted of all sickle genotypes, males and females and predominately in the second and third decade of life. The care plan meeting consisted of IASC team, the patient and his or her identified caregiver(s). In this meeting, barriers to care including psychosocial support, food and housing insecurity and transportation needs were identified. Patient's sickle cell disease and comorbidities were reviewed and goals of care agreed upon. Patients were then seen weekly to continue ongoing discussions and management of underlying disease, psychosocial support and monitoring of acute care and opioid use. Within IASC's first year, interim analysis showed of the 1439 total hospital days saved from all service lines, 864 were predominately SCD. The total number of admission days across the system was continuously rising until opening of the IASC in March 2022 and within a year, we saw a reduction in total hospital days by 11% which equates to tremendous cost savings (Fig. 1). Moreover, for each of our identified highest acute care utilizing patients, we noted a dramatic reduction in hospitalization after clinic opening with aggressive disease management and frequent clinic visits (Fig. 2). With IASC opening, we were able to begin implementation of disease modifying therapies including enhanced hydroxyurea compliance as well as initiation of vaccinations and screening studies including nephropathy and iron overload. These changes were nearly a 100% increase from the year before given that patients were not receiving comprehensive care. Conclusion: Individuals with SCD without a ‘medical home’ face many barriers to care including access to regular clinic visits where ongoing education and gaps in care can be identified including physical, psychological, and social impact. It is important for sickle cell providers to account for all aspects of a patient's well-being when devising individual treatment strategies. Caring for a sickle cell patient is complex and time consuming and best done by sickle cell disease experts in a dedicated center. Using data from our center in our large healthcare system, we demonstrate that a dedicated adult sickle cell center allows for much improved overall patient outcomes and decreased healthcare burden by moving the delivery of care form the inpatient to outpatient setting.

Usage of mineralocorticoids and isotonic crystalloids in subarachnoid hemorrhage patients in the United States

BackgroundThe usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. MethodsWe surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites in 2023, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters from 2010 to 2020 in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20 % of all acute inpatient care in the United States. ResultsAlthough mineralocorticoids are used by 70 % of the NINDS StrokeNet sites, it is used in less than 20 % of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41 and 45 %, respectively. ConclusionsThe use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.

External validation of the M-CARS score for mortality risk in coronary intensive care units

Abstract Background The M-CARS (Mayo-CICU Admission Risk Score) score was recently developed and validated for coronary intensive care units (CICU) for the estimation of mortality risk at admission. Most existing scores were developed and validated for general intensive care unit patients with a distinct profile, and need a myriad of both clinical and laboratory data from the first 24 hours after admission and constant updates. The M-CARS is based on only 7 data points collected at admission: the presence of cardiac arrest, respiratory failure and/or any type of shock, the Branden score, blood urea nitrogen > 23mg/dL, anion gap > 14 and red blood cell distribution width (RDW) > 14.3. The scale varies from zero to 10 points and three risk categories were described: low (0 to 2 points), intermediate (from 2 to 4), and high (>4 points). Purpose To provide external validation of the M-CARS score. Methods Retrospective cohort of patients admitted to two CICUs in the same academic hospital. One is linked to the emergency ward and mainly admits acute cardiac care patients. The second one is linked to the cardiology clinical and surgical wards, the outpatient care center, and the interventional and surgical suites. Demographic, clinical, and laboratory data were collected during admission to obtain the M-CARS score. Our primary endpoint was death within 30 days of admission to CICU. Readmissions for the same time interval were also evaluated. Statistical analysis used parametric and non-parametric tests as needed to describe the data and for comparison between groups. P-value < 5% was established as significant. Results A total of 408 consecutive patients were included: 60% men, 81% white and the median age was 64 years. The mean stay duration was 6±6 days. The total mortality at 30 days was 9.8% (40 patients), with no age (62.4±14,6years - alive vs 66.4 ± 17.0years - dead; p=0.10), gender (p=0.31), and CICU location (10.9%- CICU linked to the emergency ward vs 8.3% - CICU linked to cardiology wards; p=0.38) differences. The M-CARS score was obtained in 363 patients, and the lack of blood chloride levels needed for anion gap calculation was the reason for the 45 patients not being included in this analysis. Within this group, 38 (10.5%) patients died. The M-CARS score was significantly higher in the group of patients who died within 30 days (4.4±2.6 vs 2.0±1,6; p<0.0001). Considering the risk categories, mortality was significantly distinct between all mortality risk categories (Low = 3.4%, Intermediate = 10.2%, and High =40.5%; p<0.0001, and P<0.0001 for all Bonferroni post-tests). Readmissions with 30 days had similar M-CARS score (P=0.64).CONCLUSIONS: The M-CARS score was adequate in identifying the mortality risk category in CICUs from outside the country it was developed. It could not predict readmissions. It may be incorporated into the admission proceedings and be used to guide medical care and instruct relatives about the risks of the patient.

Facilitating a hearing voices group on acute and psychiatric intensive care units to promote acceptance and hope: preliminary learning and reflections

Purpose Hearing voices can be a debilitating and traumatic experience, and psychiatric hospitals can feel unsafe and overstimulating to voice hearers. Research suggests this may prolong a service user’s admission time and lead to an unhelpful experience. Therefore, a hearing voices group (HVG) was developed to create a safe space where voice hearers could share their story with others with lived experience and access support. Design/methodology/approach The group was developed by the first author under the supervision of the inpatient psychology lead. Both a practice-based and expert by experience-based approach were considered during the development of the group structure. The group also aligned with the Hearing Voices Network and the Trust’s values. A questionnaire was developed to evaluate the effectiveness of the group using six five-point Likert scale questions and three open questions to collect the data, which was then analysed. Findings The themes from the qualitative data showed that staff and ward-based promotion of the group were paramount to ensuring patient engagement. The results also showed that voice hearers found the group therapeutic, and some found the coping skills shared to be beneficial and effective. Research limitations/implications A large percentage of women (76%) reported that they had attended a HVG before. This was not the case for service users from the male unit and psychiatric intensive care unit. This result is considered to reflect the fact that women in that unit had the opportunity to attend more than once during their admission, rather than that they had accessed these groups in other settings or in the community. Therefore, in the future, it would be useful to change this question to “have you attended any other HVGs in the past, prior to this admission?”, which might be more appropriate for data collection. Originality/value To the best of the authors’ knowledge, this is the original work of the first author, who is an expert by experience and an assistant psychologist. The results suggest that HVGs can be beneficial for patients in acute and intensive mental health care and highlight some necessary adaptations and the importance of adopting an MDT approach in promoting therapeutic groups.

The PaCES Study: Cost effectiveness of an early palliative care intervention in patients with advanced colorectal cancer.

20 Background: An early palliative care (PC) pragmatic trial conducted in outpatient cancer clinics for patients living with advanced colorectal cancer (CRC), led to a 17% increase in early referrals (more than 3 months before death). This study evaluates the cost effectiveness of this trial. A lack of timely palliative care is associated with poorer quality of life, poorer symptom control and fewer days spent at home. Improving on this time toxicity is an important part of early palliative care. Methods: This pragmatic controlled before-and-after study was performed in 18 outpatient cancer clinics in two tertiary cancer centers in neighboring metropolitan cities. Baseline phase was from April 2017 to December 2018 with intervention phase only occurring in 1 of the cities, from April 2019 to December 2020. Intervention consisted of systematically screening patients for unmet PC needs, adding a community-based PC nurse specialist and templated ‘shared care’ letters sent from oncologists to primary care providers. Effectiveness was defined as the number of days spent at home in the last 90 days of life, by subtracting days in hospital, residential hospice, emergency department and clinic. A healthcare system perspective was used to calculate total costs in all sectors including hospital, cancer care, home care, palliative care and physician visits. Healthcare outcomes and costs were analysed using a difference-in-differences (DID) method, while accounting for geographic variations and other covariates. Results: A total of 695 decedents were included. There was a 15% decrease in hospital stay and 18% decrease in chemotherapy days in last 90 days of life. The intervention was cost dominant with an overall DID increase of 2.3 community days with an average cost reduction of C$1,942.17 per patient day in the community. Adjusted analysis showed that this difference was not statistically significant. A non-parametric random resampling of the population with 1,000 reiterations (bootstrapping) showed that the likelihood of the program remaining dominant was 69%. The biggest cost contributors were inpatient acute care (53.6%) and residential hospice (33.6%). Conclusions: Integrating early palliative care services into the care of CRC patients’ shows potential for cost savings and more days spent in the community in the last 90 days of life. Measuring time toxicity is a potentially important outcome in early palliative care trials while examining impact on cost.

43 Application of the Moroccan Arabic Bedside Western Aphasia battery-Revised in Acute Stroke Care

Objective:Despite the prevalence of aphasia in Morocco, standardized quick assessment tools are not available for use with patients in acute stroke care. The present study set out to (1) describe the processes of linguistic adaptation of a Moroccan Arabic (MA) version of the Bedside Western Aphasia Battery-Revised (WAB-R), (2) examine the test’s sensitivity to the detection of aphasia in an acute clinical setting, and (3) measure the instrument’s ability to detect improvement in language ability in the acute period.Participants and Methods:To achieve the first objective, the English Bedside WAB-R was adapted to Moroccan Arabic by a group of linguists. The instrument’s psychometric properties were established by (1) ascertaining the test’s sensitivity to the presence of aphasia, and (2) verifying the tool’s validity and reliability. Participants included a group of age- and education-matched non-brain-damaged individuals (N = 106), a group of right hemisphere brain-lesioned patients (N = 20), and a group of left hemisphere aphasic patients (N = 52). To accomplish the second and third objectives, the Bedside MA-WAB-R was administered to a group of aphasic participants in the acute period (less than three months post-stroke), and a group of age- and education-matched participants (N = 20). Aphasic patients in the acute stage were tested twice on a seven-day interval (3 days and 10 days post-onset). All data were collected from the Neurology department at the University Medical Hospital Hassan II, and the study received approval from the ethics committee of the Faculty of Medicine and Pharmacy, Sidi Mohammed Ben Abdellah.Results:Regarding the first objective, the results indicated that the MA-WAB-R is sensitive to the presence of aphasia, as revealed by the significantly worse performance of the aphasic group on all subtests relative to matched normal and right-hemisphere participants (p = .000). Analyses revealed excellent content and construct validity (correlations between subtests and AQ ranging from .5 to .8) as well as high inter-rater reliability, intra-rater reliability and test-retest reliability (ICC (2,1) > .9). For the second and third objectives, the results supported the test’s sensitivity to the detection of aphasia in the acute phase, as confirmed by the significantly worse performance of aphasic patients relative to matched normal controls (p = .000). The instrument also proved as a reliable measure of language improvement in the acute period, as supported by better scores on the second testing point relative to the first across all subtests.Conclusions:The MA-WAB-R is the first standardized assessment tool that can be used for a quick but reliable screening of aphasia in both chronic and acute clinical settings. The test can inform the initial diagnosis of aphasia, and guide a more comprehensive assessment of patients’ spared and impaired linguistic abilities within a context receiving little attention in the aphasia literature.

Abstract 228: Suboptimal Door‐to‐Puncture Times: Challenges Faced in the Stroke Alert Workflow

Introduction Advances in stroke care have led to more patients eligible for thrombectomy. With these advances, it has become imperative to create a seamless workflow for thrombectomy candidates to ensure rapid door‐to‐puncture times and, ultimately, improve patient outcomes. We sought to determine what barriers are causing delays in patients’ door‐to‐puncture time. Methods A survey was distributed to all members of the Neurology PGY2, PGY3, PGY4 classes and vascular fellows at our single‐center, Comprehensive Stroke Center. The survey allowed participants to freely respond to questions regarding obstacles they encountered that led to delays in door‐to‐puncture times. All survey responses were anonymized. Results The survey was sent to 32 participants, with 26 responses. Of the 26 responses, 11 respondents (42%) noted that obtaining IV access for CTA/CTP scans was a significant cause of delay. Other responses included lack of availability of family for collateral (23%), CT scanner availability (15%), and length of time to decide if the patient is a thrombectomy candidate (15%). Conclusion The goal of this study was to collect data from the individuals involved in the direct care of acute stroke patients who are thrombectomy candidates. We used their experience to determine which points in the stroke alert workflow led to delays in door‐to‐puncture time. Our survey showed the most consistent delay is obtaining proper IV access for CTA and CTP imaging. This information was valuable and has led to the creation of a coalition between the neurology and emergency medicine departments, nursing, and CT technologists to create a “CODE IV” protocol to be implemented into the stroke alert workflow. We aim to report the change in door‐to‐puncture time after the implementation of this new protocol.

CE Workshop 06: The Cumulative Burden of Congenital Heart Disease Across the Lifespan: Implications for Neuropsychologists in Pediatrics Through Geriatrics

Abstract & Learning Objectives:The heart and the brain are inextricably linked across development by overlapping genetic programs and transacting physiologies that exist long before birth and endure throughout the lifespan. Congenital heart disease (CHD) refers to a diverse array of conditions in which structural heart development is atypical. Of the roughly 1 million babies born with CHD each year, some 40,000 are born with a “critical” form of CHD that will require intensive surgical intervention within the first year of life. As recently as the 1980s, children born with some forms of critical CHD did not survive; palliation was their only option. This has changed dramatically over the past 30-40 years. Driven by momentous breakthroughs in medical science and technology, approximately 80-95% of children born with CHD today will reach adulthood.But increased survival is only a part of the CHD story. Indeed, like extreme prematurity, leukemia, and many other previously fatal medical conditions with which neuropsychologists are familiar, increases in longevity among CHD survivors have come with increasing recognition of the many challenging transitions and cumulative medical, neurobehavioral, and psychosocial burdens inherent to “living with CHD.” CHD begins to alter expected brain development in utero with evidence of structural, volumetric, and metabolic differences documented as early as the second or third prenatal trimester. Brain dysmaturation, in turn, increases one’s risk for further acquired brain injury and gives rise to a range of neurobehavioral deficits and psychosocial difficulties that consistently rank among the most salient threats to quality of life among children, adolescents, and adults with CHD.More recently, as survival into adulthood has become increasingly common for individuals with CHD, we have also begun to more fully appreciate the cascading impact and cumulative neuropsychological burden of CHD across the lifespan, which impact a range of long-term outcomes such as educational and occupational attainment, living independently, and risk for dementia.In short, CHD can no longer reasonably be considered a child or pediatric condition, but rather a lifespan condition with the potential to adversely impact neurobehavioral and psychosocial outcomes in different ways and at different times across infancy, childhood, adolescence, and adulthood. Over a series of talks presented by a panel of recognized neuropsychologists and experts in CHD, this symposium aims to review the neuropsychology of CHD across the lifespan and to present an integrative lifespan developmental neuropsychological model of CHD that eschews prevailing “child” vs. “adult” distinctions. Each presentation will address a salient developmental epoch (prenatal-early childhood, school-age/adolescence, and adulthood/geriatric timeframes) and will include a comprehensive review of the extant literature pertaining to relevant neuroanatomical and neurodevelopmental/neuropsychological considerations for individuals with CHD during each epoch. Transitions, of which there are myriad for individuals living with CHD (e.g., from acute inpatient care to stepdown unit care; from inpatient to outpatient settings; from early intervention to the school system; from childhood to adolescence; from adolescence to young adulthood; from pediatric to adult CHD care), will feature prominently throughout the symposium, as will recommendations for competent, developmentally-informed clinical neuropsychological management and intervention planning throughout the lifespan. Upon conclusion of this course, learners will be able to:1.Describe the mechanisms by which congenital heart disease (CHD) impacts brain development and functioning across the lifespan (from infancy to older adulthood).2.Discuss neurodevelopmental/neuropsychological sequelae of CHD for children, adolescents, and adults.3.Explain the role of clinical neuropsychologists in evaluating, supporting, and optimizing the neuropsychological trajectories of individuals with CHD across the lifespan.

Evaluation of Bian Que Flying Rescue system in rescue and emergency care of acute stroke patients

Evaluation of Bian Que Flying Rescue system in rescue and emergency care of acute stroke patients

Hydration and nutrition care practices in stroke: findings from the UK and Australia

BackgroundDehydration and malnutrition are common in hospitalised patients following stroke leading to poor outcomes including increased mortality. Little is known about hydration and nutrition care practices in hospital to avoid dehydration or malnutrition, and how these practices vary in different countries. This study sought to capture how the hydration and nutrition needs of patients’ post-stroke are assessed and managed in the United Kingdom (UK) and Australia (AUS).AimTo examine and compare current in-hospital hydration and nutrition care practice for patients with stroke in the UK and Australia.MethodsA cross-sectional survey was conducted between April and November 2019. Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing post-stroke inpatient acute care or rehabilitation. Non-respondents were contacted up to five times.ResultsWe received 150/174 (86%) completed surveys from hospitals in the UK, and 120/162 (74%) in Australia. Of the 270 responding hospitals, 96% reported undertaking assessment of hydration status during an admission, with nurses most likely to complete assessments (85%). The most common methods of admission assessment were visual assessment of the patient (UK 62%; AUS 58%), weight (UK 52%; AUS 52%), and body mass index (UK 47%; AUS 42%). Almost all (99%) sites reported that nutrition status was assessed at some point during admission, and these were mainly completed by nurses (91%). Use of standardised nutrition screening tools were more common in the UK (91%) than Australia (60%). Similar proportions of hydration management decisions were made by physicians (UK 84%; AUS 83%), and nutrition management decisions by dietitians (UK 98%; AUS 97%).ConclusionDespite broadly similar hydration and nutrition care practices after stroke in the UK and Australia, some variability was identified. Although nutrition assessment was more often informed by structured screening tools, the routine assessment of hydration was generally not. Nurses were responsible for assessment and monitoring, while dietitians and physicians undertook decision-making regarding management. Hydration care could be improved through the development of standardised assessment tools. This study highlights the need for increased implementation and use of evidence-based protocols in stroke hydration and nutrition care to improve patient outcomes.

Hospital mortality after acute myocardial infarction- really an indicator of quality of acute care?

Abstract Introduction ‘AMI 30-day-mortality using unlinked data’ is reported by OECD as indicator for quality of acute care. It relates to hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22). AMI hospital mortality in Germany is among the highest in Europe - indicating major problems in quality of acute care. In contrast, Germany ranks high on health expenditure and availability of cardiologists and PCI facilities. We explain these contradictory findings. Methods Literature and public health reports on AMI patient characteristics, acute care, patient registration and healthcare organisation were reviewed. OECD indicators ‘AMI 30-day-mortality using unlinked data’ and ‘average length of stay after AMI’ for European countries were downloaded for 2000-2019. The trend in AMI hospital mortality was described graphically. The influence of average length of stay (LOS) on AMI mortality was assessed by linear regression. Results Since 2000, AMI hospital mortality fell strongly. In 2019, it was 2.9% in the Netherlands, 3.2% in Norway, but 8.5% in Germany. Different patient characteristics or therapies do not account for the differences in mortality, but health care organization: 1. Day cases are not always included in OECD source data; 2. Average LOS is associated with AMI hospital mortality (R2=0.58) and is itself influenced by patient transfer frequency and reimbursement policy; 3. In centralised health systems, AMI patient transfers are more frequent. These factors reduce the registered AMI deaths or increase the number of cases, all resulting in lower hospital mortality. Discussion AMI hospital mortality is highly influenced by factors that are not related to acute patient care, but to health care organization and patient registration rules. AMI registries reporting hospital mortality include selected AMI patient populations, which hampers valid comparisons. European sentinel registries are needed to validly describe quality of acute care and outcomes in AMI. Key messages • OECD indicator ‘AMI hospital mortality’ does not allow valid conclusions on quality of acute care. • AMI hospital mortality is strongly influenced by patient registration rules and healthcare organization, namely frequency of patient transfers and length of stay in hospital after AMI.

Trends of fall-related and other fatal injuries in older adults in Finland between 1998 and 2020.

The number of falls and fall-related injuries will likely increase as the number of older adults expands. Increases in total deaths due to falls have been observed over Europe. Less is known about other injuries leading to death. We analyzed open data from Statistics Finland's register on the causes of death of those aged ≥65 collected between 1998 and 2020 yielding a total of 32150 deaths due to injury using Poisson regression and distributional comparisons chi-squared tests. The most common injuries leading to death among people aged ≥65 in Finland were fall related. There has been an increase in the absolute number of fall-related and other injuries, but when adjusting for person-years in population, a significant decrease can be observed. The crude rates of deaths from fall-related injuries among males annually increased 1.1-4.4% from 1998 to 2020, while the changes in rates among females ranged between -2% and 1.6%. The crude rates of other injuries ranged between -0.5% to +3.8%. Recently (2018-20), nearly 40% of the cases in males and 25% of cases in females were not fall related but comprised other types of injury mechanisms such as traffic, poisoning and drowning. Strengthening the implementation of preventive strategies is essential to prevent injuries. To reduce injury-related mortality and disability, improvement of acute and post-acute care for injured older patients is warranted.

Acute care for burn patients: fluids, surgery, and what else?

Recently published initiatives spanning the burn care spectrum have substantially changed the standard of care in burn care. The purpose of this article is to describe new impactful concepts in burn first aid, triage, resuscitation, and treatment as well as their impact on future research. First aid after burn injury traditionally consists of extinguishing the burn and applying dressings. Recent evidence suggests that applying 20 min of cool tap water to the burn wound in the first 3 h postburn mitigates burn injury extent. National burn center transfer criteria have been updated, impacting patient initial transfer and management. The adverse effects of hydroxocobalamin, a commonly used antidote for cyanide toxicity, have been delineated. Initial burn resuscitation recommendations for both volume and potentially fluid type are being reexamined. The emergence of innovative skin substitutes may improve burn survival by providing a physiologically stabilizing intermediate dressing. Finally, formal clinical practice guidelines for early mobility in the ICU after burn injury have been defined. These changes in burn care, triage, resuscitation, and treatment have challenged traditional burn care standards, created new standards, and are the basis for future prospective randomized trials.

No Sex Differences in Mechanical Thrombectomy Time Metrics and Outcomes in Saskatchewan.

Numerous studies have shown longer pre-hospital and in-hospital workflow times and poorer outcomes in women after acute ischemic stroke (AIS) in general and after endovascular treatment (EVT) in particular. We investigated sex differences in acute stroke care of EVT patients over 5 years in a comprehensive Canadian provincial registry. Clinical data of all AIS patients who underwent EVT between January 2017 and December 2022 in the province of Saskatchewan were captured in the Canadian OPTIMISE registry and supplemented with patient data from administrative data sources. Patient baseline characteristics, transport time metrics, and technical EVT outcomes between female and male EVT patients were compared. Three-hundred-three patients underwent EVT between 2017 and 2022: 144 (47.5%) women and 159 (52.5%) men. Women were significantly older (median age 77.5 [interquartile range: 66-85] vs.71 [59-78], p < 0.001), while men had more intracranial internal carotid artery occlusions (48/159 [30.2%] vs. 26/142 [18.3%], p = 0.03). Last-known-well to comprehensive stroke center (CSC)-arrival time (median 232 min [interquartile range 90-432] in women vs. 230 min [90-352] in men), CSC-arrival-to-reperfusion time (median 108 min [88-149] in women vs. 102 min [77-141] in men), reperfusion status (successful reperfusion 106/142 [74.7%] in women vs. 117/158 [74.1%] in men) as well as modified Rankin score at 90 days did not differ significantly. This held true after adjusting for baseline variables in multivariable analyses. While women undergoing EVT in the province of Saskatchewan were on average older than men, they were treated just as fast and achieved similar technical and clinical outcomes compared to men.

Older Adults' Experiences With Participation and eHealth in Care Coordination: Qualitative Interview Study in a Primary Care Setting.

Owing to the demographic changes in the elderly population worldwide, delivering coordinated care at home to multimorbid older adults is of great importance. Older adults living with multiple chronic conditions need information to manage and coordinate their care. eHealth can be effective for gaining sufficient information, communicating, and self-managing chronic conditions. However, incorporating older adults' health preferences and ensuring active involvement remain challenging. More knowledge is needed to ensure successful participation and eHealth use in care coordination. This study aimed to explore multimorbid older adults' experiences with participation and eHealth in care coordination with general practitioners (GPs) and district nurses (DNs). The study had a qualitative explorative approach. Data collection included semistructured interviews with 20 older adults with multimorbidity receiving primary care services from their GPs and DNs. The participants were included by their GPs or nurses at a local intermunicipal acute inpatient care unit. The data analysis was guided by systematic text condensation. We identified 2 categories: (1) older adults in charge of and using eHealth in care coordination, and (2) older adults with a loss of control in care coordination. The first category describes how communication with GPs and DNs can facilitate participation, the importance of managing own medication, and how eHealth can support older adults' information needs. The second category focuses on older adults who depend on guidance and help from their GPs and DNs to manage their health, describing how a lack of capacity and system support to be involved makes these adults lose control of their care coordination. Being in charge of care coordination is important for older multimorbid adults. The results show that older adults are willing to use eHealth to be informed and to seek information, which ensures high levels of participation in care coordination. Future research should investigate how older adults can be involved in electronic information sharing with health care providers.

Perceived Risk of falls among Acute Care Patients

Purpose: In an effort to lower the number of falls that occur among hospitalized patients, several facilities have begun introducing various fall prevention programs. However, the efficacy of fall prevention programs is diminished if patients do not consider themselves to be at risk for falls and do not follow recommended procedures. The goal of this study was to characterize how patients in four different acute care specialist services felt about their risk of falling while in the hospital. Methods: One hundred patients admitted to the study hospital with a Morse Fall Scale score of 45 or higher were given the Patient Perception Questionnaire, a tool designed to assess a patient's perception of their own fall risk, fear of falling, and motivation to take part in fall prevention efforts. Scores on the Morse Fall Scale were gathered through a historical assessment of medical records. Descriptive statistics, Pearson's correlation coefficients, and independent sample t tests were used to examine the data. Results: The average age was 65, and around half (52%) were men and half (48%) were women. Based on their ratings on the Morse Fall Scale, all 100 participants were classified as being at high risk for falls. However, only 55.5% of the individuals agreed with this assessment. The likelihood that a patient would seek assistance and the degree to which they feared falling both declined as their faith in their mobility improved. Patients hospitalized after a fall exhibited considerably lower confidence scores and greater fear scores than patients who had not been injured in a fall. Conclusions: Patients who have a high fall risk assessment score may not believe they are at risk for falls and may not take any steps to reduce their risk. The prevalence of falls in hospitals might be mitigated by the creation of a fall risk assessment technique that takes into account both objective and subjective factors.

Advanced practice nurse competencies to practice in emergency and critical care settings: A scoping review.

Advanced Practice Nurses are expected to provide lifesaving care to patients with complex acute illnesses in emergency and critical care settings. However, little is known about their competencies and barriers to practice in emergency and critical care settings. This review investigated these nurses' competencies to practice. A scoping review was conducted in accordance with Arksey and O'Malley's framework. Extensive research searches were conducted using seven electronic databases: MEDLINE, CINAHL, Scopus, Web of Science, Ichushi Web, Mednar and GreyNet International. Definitions and explanations of Advanced Practice Nurse competencies were categorized into elements and grouped according to similarity. The database searches identified 2,483 studies, and data were extracted for 23 studies. Analysed studies were published between 2000 and 2021 and conducted in eight countries. Seven competencies were identified: performing advanced practice nursing, acute patient care, diagnostic assessment, interdisciplinary collaboration and consultation, leadership and system management, documenting patient care and supporting patient and family decision-making. This review identified competencies unique to Advanced Practice Nurses in emergency and critical care settings. Further research is required to facilitate understanding of the crucial roles of advanced care nurses among healthcare providers.

Demystifying Limited Code: Standardizing Resuscitation Options in a Large Health Care System.

Upon admission to an acute care hospital, patients and families are faced with determining their cardiopulmonary resuscitation status during conversation with providers. Medical providers are tasked with providing education and options in the context of the patient's acute and chronic conditions. Misconceptions are common in the general public, and providers may struggle with providing guidance in high-stress situations. Literature review revealed a lack of national consensus on code status definitions. Electronic health records may include multiple options for code status orders, which may lead to confusion for patients and medical staff, resulting in provision of potentially ineffective or undesired medical care. The following discussion will examine multiple cases in a large health care system and a novel way of standardizing resuscitation options using Havelock's change theory. This quality improvement project was approved by the institutional review board.

Impact of COVID-19 pandemic at a level 1 trauma center.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic commonly called COVID-19 brought new changes to healthcare delivery in the US. The purpose of this study is to identify the impact of COVID-19 on the delivery of acute surgical care for patients at a Level 1 trauma center during the lockdown period of the pandemic from March 13-May 1 2020. All trauma admission to the University Medical Center Level 1 Trauma Center from March 13 to May 13, 2020, were retrospectively abstracted and compared to the same period during 2019. Analysis focused on the lockdown period of March 13-May 1, 2020, and compared to the same dates in 2019. Abstracted data included demographics, care timeframes, length of stay, and mortality. The data were analyzed using Chi-Square, Fisher Exact, and the Mann-Whitney U test. A total of 305 (2019) vs. 220 (2020) procedures were analyzed. No significant differences were seen in mean BMI, Injury Severity Score, American Society of Anesthesia Score, and Charlson Comorbidity Index between the two groups. Diagnosis time, interval to surgery, anesthesia time, surgical preparation time, operation time, transit time, mean hospital stay, and mortality were similar. The results of this study demonstrate that the lockdown period of the COVID-19 pandemic did not significantly affect the trauma surgery service line, aside from case volume, at a Level 1 trauma center in West Texas during the lockdown period. Despite changes to healthcare delivery during the pandemic, care of surgical patients was conserved as timely and of high quality.