Patients In Acute Care Hospitals Research Articles

Pilot Testing the Clinically Aligned Pain Assessment (CAPA) Measure

BackgroundPain is one of the most common symptoms experienced by patients in acute care hospitals and acutely ill patients experience both acute and chronic pain. Unrelieved pain can have a profound negative impact on individuals’ functional status, well-being, quality of life, and satisfaction with care. For providers, managing pain can be challenging. While the numeric rating scale is widely accepted and used, it measures only pain intensity. CAPA® pain assessment offers an alternative approach in which providers have a conversation with patients about pain and how it impacts five key areas. AimsThe purpose of this pilot project was to evaluate provider and patient satisfaction with the CAPA® measure as compared to a numeric rating scale when evaluating patients’ experience with pain. DesignA mixed methods qualitative design was employed. SettingThis study was conducted at a 247-bed community teaching hospital in Providence, RI. ParticipantsThe target sample included patients admitted to the study units and providers who delivered care to patients on the study units and used the numeric rating scale and the CAPA® method of assessment. MethodsIn focus groups, nurses and physicians were asked about satisfaction with evaluating patients’ pain with the numeric rating scale as compared to CAPA®. During a one-to-one interview, patients were asked to describe their impressions of the two assessment measures. ResultsNurses, physicians, and patients were satisfied that CAPA® effectively evaluated pain and provided more information about pain than the numeric rating scale. ConclusionsCAPA® is recommended as a supporting assessment to evaluate patients’ pain experience in acute care.

Validation of Early Warning Scores at Two Long-Term Acute Care Hospitals

Early warning scores were developed to identify high-risk patients on the hospital wards. Research on early warning scores has focused on patients in short-term acute care hospitals, but there are other settings, such as long-term acute care hospitals, where these tools could be useful. However, the accuracy of early warning scores in long-term acute care hospitals is unknown. Observational cohort study. Two long-term acute care hospitals in Illinois from January 2002 to September 2017. Admitted adult long-term acute care hospital patients. None. Demographic characteristics, vital signs, laboratory values, nursing flowsheet data, and outcomes data were collected from the electronic health record. The accuracy of individual variables, the Modified Early Warning Score, the National Early Warning Score version 2, and our previously developed electronic Cardiac Arrest Risk Triage score were compared for predicting the need for acute hospital transfer or death using the area under the receiver operating characteristic curve. A total of 12,497 patient admissions were included, with 3,550 experiencing the composite outcome. The median age was 65 (interquartile range, 54-74), 46% were female, and the median length of stay in the long-term acute care hospital was 27 days (interquartile range, 17-40 d), with an 8% in-hospital mortality. Laboratory values were the best predictors, with blood urea nitrogen being the most accurate (area under the receiver operating characteristic curve, 0.63) followed by albumin, bilirubin, and WBC count (area under the receiver operating characteristic curve, 0.61). Systolic blood pressure was the most accurate vital sign (area under the receiver operating characteristic curve, 0.60). Electronic Cardiac Arrest Risk Triage (area under the receiver operating characteristic curve, 0.72) was significantly more accurate than National Early Warning Score version 2 (area under the receiver operating characteristic curve, 0.66) and Modified Early Warning Score (area under the receiver operating characteristic curve, 0.65; p < 0.01 for all pairwise comparisons). In this retrospective cohort study, we found that the electronic Cardiac Arrest Risk Triage score was significantly more accurate than Modified Early Warning Score and National Early Warning Score version 2 for predicting acute hospital transfer and mortality. Because laboratory values were more predictive than vital signs and the average length of stay in an long-term acute care hospital is much longer than short-term acute hospitals, developing a score specific to the long-term acute care hospital population would likely further improve accuracy, thus allowing earlier identification of high-risk patients for potentially life-saving interventions.

Surgical patients' experiences of readiness for hospital discharge and perceived quality of discharge teaching in acute care hospitals.

To examine the level of perception of the quality of discharge teaching and its associations with the readiness for hospital discharge among surgical patients in acute care hospitals. Discharge teaching is a primary strategy to facilitate patients' readiness for hospital discharge. The extent to which the surgical ward was perceived as providing patient-focused education when discharged has never been explored. Its impact on a patient's readiness is also unknown in the Indonesian context. A correlational descriptive study was used to collect data from four hospitals in Indonesia. Ninety-six surgical patients who were in the discharge process enrolled in this study. The demographic form, the quality of discharge teaching scale (QDTS) and the readiness for hospital discharge scale (RHDS) were utilised for data collection. Data were collected from January-February 2018. Descriptive statistics and Spearman rank-order correlation were applied for data analysis. The discharge teaching quality was perceived as being at a low level. The readiness for hospital discharge was reported to be at a moderate level. Overall, the discharge teaching quality was not statistically associated with the patients' readiness. However, positive correlations were found in QDTS and RHDS subscales such as content received and delivery, knowledge, coping ability and expected support. Patient's readiness for hospital discharge was also greater for those who had a caregiver, a short hospital stay, a health insurance and occupation. Surgical patients perceived a low quality of discharge teaching, which may decrease their readiness for hospital discharge. This study provides baseline information reflecting the patient learning needs in discharge preparation to guide surgical nurses for improving the discharge teaching quality and enhancing the patients' readiness for hospital discharge.

Burden of healthcare-associated infections in European acute care hospitals.

Point prevalence surveys of healthcare-associated infections (HAI) and antimicrobial use in the European Union and European Economic Area (EU/EEA) from 2016 to 2017 included 310,755 patients from 1,209 acute care hospitals in 28 countries. After national validation, we estimated that 6.5% (cumulative 95% confidence interval (cCI): 5.4-7.8%) patients in acute care hospitals had at least one HAI (country-weighted prevalence). On any given day, 98,166 patients (95% cCI: 81,022-117,484) in acute care hospitals had an HAI; 3.8 million (95% cCI: 3.1-4.5 million) patients acquired an HAI each year. Our study confirmed a high annual number of HAI in healthcare facilities in the EU/EEA.

Acute intestinal failure: International multicenter point-of-prevalence study

Intestinal failure (IF) is defined from a requirement or intravenous supplementation due to failing capacity to absorb nutrients and fluids. Acute IF is an acute, potentially reversible form of IF. We aimed to identify the prevalence, underlying causes and outcomes of acute IF. This point-of-prevalence study included all adult patients hospitalized in acute care hospitals and receiving parenteral nutrition (PN) on a study day. The reason for PN and the mechanism of IF (if present) were documented by local investigators and reviewed by an expert panel. Twenty-three hospitals (19 university, 4 regional) with a total capacity of 16,356 acute care beds and 1237 intensive care unit (ICU) beds participated in this study. On the study day, 338 patients received PN (21 patients/1000 acute care beds) and 206 (13/1000) were categorized as acute IF. The categorization of reason for PN was revised in 64 cases (18.9% of total) in consensus between the expert panel and investigators. Hospital mortality of all study patients was 21.5%; the median hospital stay was 36 days. Patients with acute IF had a hospital mortality of 20.5% and median hospital stay of 38 days (P>0.05 for both outcomes). Disordered gut motility (e.g. ileus) was the most common mechanism of acute IF, and 71.5% of patients with acute IF had undergone abdominal surgery. Duration of PN of ≥42 days was identified as being the best cut-off predicting hospital mortality within 90 days. PN≥42 days, age, sepsis and ICU admission were independently associated with 90-day hospital mortality. Around 2% of adult patients in acute care hospitals received PN, 60% of them due to acute IF. High 90-day hospital mortality and long hospital stay were observed in patients receiving PN, whereas presence of acute IF did not additionally influence these outcomes. Duration of PN was associated with increased 90-day hospital mortality.

Conceptual modelling of the flow of frail elderly through acute-care hospitals

PurposeThe ageing of the world’s population is causing an increase in the number of frail patients admitted to hospitals. In the absence of appropriate management and organisation, these patients risk an excessive length of stay and poor outcomes. To deal with this problem, the purpose of this paper is to propose a conceptual model to facilitate the pathway of frail elderly patients across acute care hospitals, focussed on avoiding improper wait times and treatment during the process.Design/methodology/approachThe conceptual model is developed to enrich the standard flowchart of a clinical pathway in the hospital. The modified flowchart encompasses new organisational units and activities carried out by new dedicated professional roles. The proposed variant aims to provide a correct assessment of frailty at the entrance, a better management of the patient’s stay during different clinical stages and an early discharge, sending the patient home or to other facilities, avoiding a delayed discharge. The model is completed by a set of indicators aimed at measuring performance improvements and creating a strong database of evidence on the managing of frail elderly’s pathways, providing proper information that can validate the model when applied in current practice.FindingsThe paper proposes a design of the clinical path of frail patients in acute care hospitals, combining elements that, according to an evidence-based management approach, have proved to be effective in terms of outcomes, costs and organisational issues. The authors can, therefore, expect an improvement in the treatment of frail patients in hospital, avoiding their functional decline and worsening frailty conditions, as often happens in current practice following the standard path of other patients.Research limitations/implicationsThe framework proposed is a conceptual model to manage frail elderly patients in acute care wards. The research approach lacks application to real data and proof of effectiveness. Further work will be devoted to implementing a simulation model for a specific case study and verifying the impact of the conceptual model in real care settings.Practical implicationsThe paper includes suggestions for re-engineering the management of frail elderly patients in hospitals, when a reduction of lengths of stay and the improvement of clinical outcomes is required.Originality/valueThis paper fulfils an identified need to study and provide solutions for the management of frail elderly patients in acute care hospitals, and generally to produce value in a patient-centred model.

End-of-life care for cancer patients in Japanese acute care hospitals: A nationwide retrospective administrative database survey.

End-of-life (EOL) cancer care in Japanese acute care hospitals has not been well described. We aimed to assess the aggressiveness of EOL care and examine common treatments administered to cancer patients using a health administrative database. Subjects are adult cancer patients who died at acute care hospitals between April 2011 and March 2014. Data from the Japanese Diagnosis Procedure Combination database were analysed to measure the aggressiveness of care (chemotherapy, intensive care unit [ICU] admission and cardiopulmonary resuscitation [CPR]) and describe procedures and prescriptions administered in the last 14 and 30 days of life, disaggregated by hospital case volume: high, intermediate and low volumes. Of 248,978 cancer decedents, 170,024 died in high-, 70,231 in intermediate- and 8,723 in low-volume hospitals. Aggressive treatment in the last 14 days of life included chemotherapy (9.4%, 7.3%, and 5.4%, respectively), ICU admission (3.0%, 2.0%, and 2.4%) and CPR (5.8%, 6.4%, and 8.3%). Opioids were administered to 66.0%, 59.0% and 49.4% patients, while Palliative Care Team intervention was performed for 8.5%, 2.2% and 2.0% of patients, respectively in the last 30 days. In high-volume hospitals, radiotherapy and certified outpatient chemotherapy fees were more frequent. Catecholamines and hyperalimentation were more frequently administered in low-volume hospitals. This is the first study to assess EOL care among Japanese acute care hospitals. More frequent use of chemotherapy at high-volume hospitals may reflect a well-established cancer treatment system. The approach for low-volume hospitals might improve the EOL care for all cancer patients in Japan.

Gut Microbiota and Clinical Features Distinguish Colonization With Klebsiella pneumoniae Carbapenemase-Producing Klebsiella pneumoniae at the Time of Admission to a Long-term Acute Care Hospital.

BackgroundIdentification of gut microbiota features associated with antibiotic-resistant bacterial colonization may reveal new infection prevention targets.MethodsWe conducted a matched, case–control study of long-term acute care hospital (LTACH) patients to identify gut microbiota and clinical features associated with colonization by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp), an urgent antibiotic resistance threat. Fecal or rectal swab specimens were collected and tested for KPC-Kp; 16S rRNA gene-based sequencing was performed. Comparisons were made between cases and controls in calibration and validation subsamples using microbiota similarity indices, logistic regression, and unit-weighted predictive models.ResultsCase (n = 32) and control (n = 99) patients had distinct fecal microbiota communities, but neither microbiota diversity nor inherent clustering into community types distinguished case and control specimens. Comparison of differentially abundant operational taxonomic units (OTUs) revealed 1 OTU associated with case status in both calibration (n = 51) and validation (n = 80) subsamples that matched the canonical KPC-Kp strain ST258. Permutation analysis using the presence or absence of OTUs and hierarchical logistic regression identified 2 OTUs (belonging to genus Desulfovibrio and family Ruminococcaceae) associated with KPC-Kp colonization. Among clinical variables, the presence of a decubitus ulcer alone was independently and consistently associated with case status. Combining the presence of the OTUs Desulfovibrio and Ruminococcaceae with decubitus ulcer increased the likelihood of KPC-Kp colonization to >38% in a unit-weighted predictive model.ConclusionsWe identified microbiota and clinical features that distinguished KPC-Kp gut colonization in LTACH patients, a population particularly susceptible to KPC-Kp infection. These features may warrant further investigation as markers of risk for KPC-Kp colonization.

Implementing a Nurse-Driven Protocol to Reduce Catheter-Associated Urinary Tract Infections in a Long-Term Acute Care Hospital.

Catheter-associated urinary tract infections (CAUTIs) are the second most common health care-associated infection. CAUTIs represent a serious threat to chronic critically ill patients in long-term acute care hospitals (LTACHs). Evidence-based guidelines have been shown to reduce the risk of infection in acute care settings but are not well documented in LTACHs. An evidence-based urinary catheter protocol was developed and implemented across three units in a large LTACH. RNs were oriented to the new protocol through online educational modules. During the evaluation period, 120 patients were admitted with a urinary catheter who qualified for chart review for CAUTI incidence. Overall catheter-days and CAUTI rates were compared, and changes in practice were noted. After the education intervention, overall urinary catheter-days decreased by 10.1%, and CAUTI incidence decreased by 74% (4.82 CAUTI per 1,000 patient-days to 1.24). The absolute risk reduction was 3.58 infections per 1,000 catheter-days. The findings were statistically significant (z = 1.00, p < .03). Significant reductions were noted in total catheter-days, and CAUTI rates improved after implementation of an education program and an evidence-based urinary catheter protocol in an LTACH. J Contin Educ Nurs. 2018;49(8):372-377.

Implementing the I-DECIDED clinical decision-making tool for peripheral intravenous catheter assessment and safe removal: protocol for an interrupted time-series study

IntroductionMillions of acute care hospital patients need a peripheral intravenous catheter (PIVC) each year. However, up to half of PIVCs remain in situ when not being used, and 30%–50% of...

Lessons Learned from a Healthcare Associated Infection Tabletop Exercise, June 2017

ObjectiveTo assess healthcare facilities’ level of readiness to respond to an HAI outbreak, the Florida Department of Health in Pinellas County (DOH-Pinellas) conducted an HAI outbreak tabletop exercise (TTX) on June 6, 2017. Other benefits of this TTX were to provide opportunities for collaborative learning, building community partnerships and evaluation of HAI preparedness activities in Pinellas County healthcare facilities.IntroductionOne in twenty-five patients in acute care hospitals develop at least one health care associated infection (HAI); this resulted in approximately 75,000 preventable deaths in 2011. Risk factors associated with developing HAIs include older patients, serviced at a large hospital, central catheter placement, receiving medical ventilation, and placement in a critical care unit. In Pinellas County, individuals 65 years of age and older comprise approximately 24% of the total population.MethodsA line list of contact information for all long-term care facilities in Pinellas County was obtained from the DOH–Pinellas Environmental Health Program. An invitation to the TTX was sent to 234 health care and assisted living facilities. Of those invited, 35 individuals attended the TTX on June 6, 2017. The methods used to facilitate discussion included the four scenarios that addressed different stages of an outbreak investigation and a “force decision-making” framework. Following the course, a twelve-question evaluation was distributed. The first seven questions were based on a five-point Likert scale assessing the course’s impact on knowledge and tabletop learning environment. The other five were open-ended and asked participants to elaborate on what they learned and provide feedback regarding the strengths and areas for improvement of the TTX.ResultsExercise participants included infection control practitioners, safety officers, nursing supervisors, facility managers and epidemiologists from hospitals, assisted living and skilled nursing facilities, hospice, rehabilitation centers and health departments. Of the 35 participants, 30 completed the course evaluation for a completion rate of 86%. For questions addressing HAI knowledge, participants strongly agreed that the tabletop exercise enhanced their understanding of infection control guidelines for HAIs. The question that received the lowest score of 4.3 was the perception that “I was able to develop tools for my agency’s infection control guidelines.” In the open-ended questions, themes regarding HAI knowledge, resources, response and policies were frequently mentioned, in addition to confusion over the health department’s role and available resources during an HAI outbreak.ConclusionsParticipation and feedback during the TTX substantiated the importance of increased collaboration across organizations and opportunities for training on HAI outbreak response. Participants identified a need for an open forum to discuss best practices for HAI control and surveillance methods to help guide preparedness and response efforts. To address this need, DOH-Pinellas will create a HAI coalition which would aim to improve understanding of each facility’s role in responding to an HAI outbreak.

Pediatric Nurses' Knowledge, Values, and Implementation of Evidence-based Practice and Use of Two Patient Safety Goals

PurposeTo describe knowledge, values, and implementation of evidence-based practice (EBP) and use of two National Patient Safety Goals–Central Line Associated Blood Stream Infections (CLABSI) and Surgical Site Infections (SSI)–between nurses working in Magnet® versus non-Magnet® designated hospitals. BackgroundThere is a gap in the literature concerning nurses' understanding of EBP and how EBP guidelines are used in practice and if guidelines are being used as intended. The Conceptual Model of Nursing and Health Policy was used to guide the study. MethodsA descriptive survey methodology using three instruments was delivered electronically to members of the Society of Pediatric Nurses–the Quick-EBP-VIK, the Use of Evidence-based Practice Questionnaire, and a Background Data Sheet. ResultsResults revealed statistically significant differences between the Magnet and non-Magnet participants only for the Quick-EBP-VIK value domain; nurses from Magnet hospitals had a higher value for EBP compared with nurses from non-Magnet hospitals, nurses from both groups had a moderate amount of knowledge about EBP, and very few nurses indicated they were implementing EBP. There were no differences in CLABSI and SSI prevention care for patients in acute care hospitals in the United States by nurses working in Magnet versus non Magnet designated hospitals. ConclusionThe findings of this study have implications for practice, education, policy, and research. A disconnect between the use of policy and implementation of EBP has been identified. Specifically, nurses need to understand how EBP is embedded in hospital and organizational policy.

Malnutrition, poor food intake, and adverse healthcare outcomes in non-critically ill obese acute care hospital patients

Obesity, defined as a BMI≥30kg/m2, has demonstrated protective associations with mortality in some diseases. However, recent evidence demonstrates that poor nutritional status in critically ill obese patients confounds this relationship. The purpose of this paper is to evaluate if poor nutritional status, poor food intake and adverse health-related outcomes have a demonstrated association in non-critically ill obese acute care hospital patients. This is a secondary analysis of the Australasian Nutrition Care Day Survey dataset (N=3122), a prospective cohort study conducted in hospitals from Australia and New Zealand in 2010. At baseline, hospital dietitians recorded participants' BMI, evaluated nutritional status using Subjective Global Assessment (SGA), and recorded 24-hfood intake (as 0%, 25%, 50%, 75%, and 100% of the offered food). Post-three months, participants' length of stay (LOS), readmissions, and in-hospital mortality data were collected. Bivariate and regression analyses were conducted to investigate if there were an association between BMI, nutritional status, poor food intake, and health-related outcomes. Of the 3122 participants, 2889 (93%) had eligible data. Obesity was prevalent in 26% of the cohort (n=750; 75% females; 61±15 years; 37±7kg/m2). Fourteen percent (n=105) of the obese patients were malnourished. Over a quarter of the malnourished obese patients (N=30/105, 28%) consumed ≤25% of the offered meals. Most malnourished obese patients (74/105, 70%) received standard diets without additional nutritional support. After controlling for confounders (age, disease type and severity), malnutrition and intake ≤25% of the offered meals independently trebled the odds of in-hospital mortality within 90 days of hospital admission in obese patients. Although malnourished obese experienced significantly adverse health-related outcomes they were least likely to receive additional nutritional support. This study demonstrates that BMI alone cannot be used as a surrogate measure for nutritional status and warrants routine nutritional screening for all hospital patients, and subsequent nutritional assessment and support for malnourished patients.

Case Analysis of Factors Contributing to Patient Falls.

Falls are a constant risk for patients in acute-care hospitals, which can lead to serious consequences. The purpose of this study was to examine hospital fall case studies and to learn the contributing factors for patient falls. This was achieved by conducting a secondary analysis of 11 fall case studies obtained from two previous studies. The fall cases used the Senior Falls Investigative Methodology (SFIM) approach, which provided detailed analysis of the circumstances surrounding the falls. A total of 549 contributing factors were identified in the 11 case studies, where major categories were classified according to the four different layers of defenses using Reason's Swiss Cheese Model of Accident Causation (organizational factors, supervision, preconditions, and unsafe acts). Hospital policies, reduced supervision, disease processes, the environment, and patients transferring without assistance dominated the reasons for increased risk. Additional strategies were recommended for all layers of defense to reduce patient falls.

The characteristics of frail elderly patients in acute care hospitals

Efforts to improve the treatment of frail elderly patients in acute care hospitals are urgently needed because a low physical activity level due to hospitalization is reported to be associated with a risk of disability. The aim of this study was to clarify the characteristics of frail elderly patients in acute care hospitals. We assessed 198 elderly patients who were admitted to acute care hospitals. The factors that were evaluated included the presence of frailty, the age, gender, and nutritional status of the patients, and complications that developed during hospitalization. In this study, frailty was evaluated using the Kihon checklist (KCL), and was defined by a total KCL score of ≥7 points. A total of 87 (43.9%) subjects met the definition of frailty and there was a female predominance (63.2%). The nutritional status of the subjects with frailty was significantly worse than that of the non-frail patients. In comparison to the non-frail subjects, the frail subjects were significantly older and the onset of complications during hospitalization was observed significantly more frequently. Moreover, a large number of frail subjects showed low scores on the KCL items related to their social activity, physical and oral functions, and psychological status. These findings suggest that efforts to improve the treatment of frail elderly patients in acute care hospitals are important because of the high incidence of frailty. Multifaceted assessments and the promotion of physical activity to prevent the onset of complications during hospitalization may be needed for frail elderly patients in acute care hospitals.

Assessment of the“Post-Acute Care Discharge Scores”(PACD) [Translated from the Original Article in German Published in Pflegewissenschaft 2015; 11: 582-95

A systematic and early biopsychosocial assessment of older patients in acute care hospitals is necessary for a proactive and effective discharge plan in order to identify patients at risk for a care deficit after hospitalization. Our study aim was to adapt the, “Post Acute Care Discharge“ (PACD) Scores developed in Geneva for use in the Cantonal Hospital of Aarau and evaluate as screening instruments in selected medical patients in a medical university clinic. Among 308 patients admitted from home with urinary tract infections, falls, syncope or heart failure day 1 PACD ≥ 8 had a sensitivity of 90% and a specificity of 62% and day 3 PACD ≥ 8 a sensitivity of 80% and a specificity of 60% to identify a nursing care deficit. The PACD is used as a screening instrument to identify patients at risk and therefore facilitate a structured, interdisciplinary and patient-centered analysis of the situation and discharge plan.

Physician-Level Variation in Outcomes of Mechanically Ventilated Patients.

Physicians are increasingly being held accountable for patient outcomes, yet their specific contribution to the outcomes remains uncertain. To determine variation in outcomes of mechanically ventilated patients among intensivists, as well as associations between intensivist experience and patient outcomes. We performed a retrospective cohort study of mechanically ventilated Medicare fee-for-service patients in acute care hospitals in Pennsylvania using administrative, clinical, and physician data from Centers for Medicare and Medicaid Services and the American Medical Association from 2008 and 2009. We identified intensivists by training background, board certification, and claims for services provided to patients admitted to an intensive care unit. We assigned patients to intensivists for outcome attribution based on submitted claims for critical care and in-patient services. We estimated the physician-specific adjusted odds ratios (ORs) for 30-day mortality using a hierarchical model with a random effect for physician, adjusted for patient and hospital characteristics. We tested for independent association of physician experience with patient outcomes using mixed-effects regression for the primary outcome of 30-day mortality. We defined physician experience in two ways: years since training completion ("duration") and annual number of mechanically ventilated patients ("volume"). We assigned 345 physicians to 11,268 patients. The 30-day mortality was 43% and median hospital length of stay was 11 days (interquartile range = 6-18). The physician adjusted OR varied from 0.72 to 1.64 (median = 0.99; interquartile range = 0.92-1.09). A total of 48% of physicians was outliers, with an adjusted OR significantly different from 1. However, among intensivists, physician experience was not associated with 30-day mortality (duration OR = 1.00 per additional year; 95% confidence interval = 1.00-1.01; volume OR = 1.00 per additional patient; 95% confidence interval = 1.00-1.00). Intensivists independently contribute to outcomes of Medicare patients who undergo mechanical ventilation, as evidenced by the variation in risk-adjusted mortality across intensivists. However, physician experience does not underlie this relationship between intensivists, suggesting the need to identify modifiable physician factors to improve outcomes.

Associations of Nurse Staffing and Education With the Length of Stay of Surgical Patients

To examine the association of nurse staffing and education with the length of stay of surgical patients in acute care hospitals in South Korea. A cross-sectional survey design was used for a nurse survey in acute hospitals collected between 2008 and 2009. The survey data (N = 1,665) were linked with patient discharge data (N = 113,438) and hospital facility data from 58 hospitals with 100 or more beds in South Korea. The dependent variable was the length of stay, that is, the number of days a patient remained in the hospital. The independent variables were nurse staffing (number of patients per nurse) and nurses' education level (percentage of nurses with a bachelor of science in nursing [BSN] degree). A multilevel analysis was used to analyze the associations of nurse staffing and education level with the length of stay by controlling for both hospital and patient characteristics. The average proportion of nurses with a BSN in all the hospitals was 30.86%, while the average number of patients per nurse was 14.31. The median length of hospital stay for patients was about 7 days. The multilevel analysis showed that nurse staffing and nurse education level were significantly associated with the length of stay of surgical patients in acute care hospitals. A 10% increase in the average number of patients per nurse increased the length of stay by 0.284 days (p = .037). When the number of nurses with a BSN was increased by 1%, the length of stay decreased by 0.42 days (p = .025). Nurse staffing and nurses' education levels were significantly associated with the length of stay of surgical patients in South Korean hospitals. The findings from this study suggest that the South Korea healthcare system should develop appropriate strategies to improve the nurse staffing and education levels to ensure high-quality patient care in hospitals. Healthcare policymakers and nurse managers need to modify adequate nurse staffing and education levels in order to reduce the length of stay of patients.

Patients with dementia in acute care hospitals : Across-sectional study of physicians' experiences and attitudes.

Patients with dementia (PwD) are avulnerable group and caring for these patients in acute care hospitals is challenging. Structural conditions and standardized treatment procedures in hospitals often do not correspond to the needs of this patient group. Physicians may not be well prepared for caring for PwD. This study aimed to ascertain physicians' experiences and attitudes in caring for PwD or cognitive disorders and their subjective workload. This describes physicians' estimation of the share of the overall workload resulting from caring for PwD on the ward. Furthermore, we identified factors that are most likely to contribute to the workload. An online survey was conducted using aself-developed standardized questionnaire with 29questions based on asystematic literature review. The questionnaire was pretested in several steps and finally sent out via e‑mail to 610 physicians in 9hospitals in northern Germany. Aspects surveyed were: physicians' confidence in caring for PwD and resulting workload, challenges in caring for PwD, collaboration with relatives and other professionals and educational needs. Important influencing factors were determined by multiple linear regression analyses. A total of 192 hospital physicians completed the questionnaire (response rate 32%). According to respondents the proportion of PwD in acute care hospitals increased significantly during the last 3 years. Only one third of respondents reported feeling confident in caring for PwD and 65% stated that they do not feel confident in caring for PwD especially in situations of nutrition in cases of food refusal and distinguishing between delirium and dementia. The strongest influencing factors were increased efforts in terms of time and support needs, complex medical situations, difficult collaboration with relatives and lack of patient compliance. Asuccessful collaboration with other professionals was associated with increased confidence in caring for PwD. Legal and ethical aspects as well as drug therapies were mentioned as desirable topics for educational programs. Arelevant number of hospital physicians feel insecure and burdened in caring for PwD. The study provides important information for the design of educational programs and for potential changes in structural and procedural aspects. The results may be used as starting points for improving hospital care for PwD.

Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States

Because nonventilator hospital-acquired pneumonia (NV-HAP) is understudied, our purpose was to determine the incidence, overall burden, and level of documented pneumonia preventive interventions of NV-HAP in 24 U.S. hospitals. This retrospective chart review extracted NV-HAP cases as per the 2014 ICD-9-CM codes for pneumonia not present on admission and the 2013 Centers for Disease Control and Prevention case definition. Patient demographic data, outcomes, and documented preventive interventions were also collected. We found 1,300 NV-HAP patients who acquired NV-HAP (rate, 0.12-2.28 per 1,000 patient days) across the 21 hospitals that completed the data collection. Most NV-HAP infections (70.8%) were acquired outside of intensive care units (ICUs); 18.8% required transfer into the ICU. In the 24 hours prior to diagnosis, most of the patients did not have fundamental hospital care associated with pneumonia prevention. This multicenter, nationwide study highlights the significant burden of NV-HAP in the U.S. acute care hospital setting. We found that NV-HAP occurred on every hospital unit, including in younger, healthy patients. This indicates that although some patients are clearly at higher risk, all patients carry some NV-HAP risk. Therapeutic interventions aimed at NV-HAP prevention are frequently not provided for patients in acute care hospitals.