Acute Care Providers Research Articles

Disparities in casemix, acute interventions, discharge destinations and mortality of patients with traumatic brain injury between Europe and India.

Traumatic brain injury (TBI) is a major global health problem that disproportionally affects low- and middle-income countries. The needs for patients with TBI therefore may differ between levels of national development. We aimed to describe differences in epidemiology and acute care provision of TBI between India and Europe. We used data from two prospective observational registry studies - the Collaborative Indian NeuroTrauma Effectiveness Research in TBI (CINTER-TBI) and the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI), which included TBI patients with an indication for brain CT-scan presenting to 65 centres across Europe and Israel and two trauma centres in India. We performed descriptive analyses of demographic, injury, and treatment characteristics and used random-effects logistic regression with covariate adjustment to examine the likelihood of acute neurosurgical interventions and in-hospital mortality. We included 22 849 patients from CENTER-TBI and 3904 from CINTER-TBI. The median age in Europe was 55 years (IQR = 32-76) compared to 27 years (IQR = 18-40) in India. The most common cause of TBI in Europe were falls (n = 12150 (53%), while traffic incidents predominated in India (n = 2130 (55%)). The proportion of patients with severe TBI was higher in India (n = 867 (22%)) than in Europe (n = 1661 (7%). Professional pre-hospital care involving ambulance service was utilised by three-fourths (n = 17203 (75%)) of European and less than a one-tenth (n = 224 (6%)) of Indian patients in our sample. Patients with severe TBI were more likely to undergo surgical contusion/haematoma evacuation in India compared to Europe (OR = 2.0; 95% CI = 1.7-2.5) and Indian patients had higher odds of undergoing intracranial pressure monitor placement (OR = 2.3; 95% CI = 2.0-2.7). A primary decompressive craniectomy was likewise more often performed in the Indian cohort (OR = 5.1; 95% CI = 3.5-7.5). Discharge destinations in Europe included rehabilitation centres (n = 1261 (6%)) or nursing homes (n = 1208 (5%)), which was rarely the case in India (n = 13 (0%) and n = 9 (0%), respectively). Substantial disparities between India and Europe exist along the neurotrauma care chain, with both systems being likely to face unique features and challenges in the future.

The Problem of Sequential Entry of Nurses as a Disincentive to Medical Safety and a Factor Increasing Overtime.

The purpose of this study was to visualize the nurses' approach to recording and to identify the causes that lead to overtime. The data used were those related to the performance and entry of nursing tasks (observation and care acts). Data from Hospital A, a provider of acute care with approximately 400 beds, was used. One month of work data were obtained from 12 nurses who were judged by the chief nurse to be excellent and efficient in their work. 12 nurses were divided into three groups: a high-level sequential entry rate group (>0.6), a medium-level sequential entry rate group (0.4 to <0.6), and a low-level sequential entry rate group (<0.4). The high-level sequential input rate group had data input every time they performed their work, so that the work implementation and input implementation were completed at 5:00 p.m. The medium-level sequential entry rate group tended to enter data about an hour late when they started work, which tended to result in overtime. The low-level sequential input rate group tended to input work in the afternoon, resulting in significant overtime. The data of approximately 400 nurses in a 900-bed University Hospital B, where Team Compass is implemented, were used to analyze the actual sequential input rate. 884 nurses in University Hospital B, of whom 397 had input data for 19 consecutive months. The sequential input rate in November 2020, one and a half years after the start of operation, was divided into five groups by 20%: 0-20%: 27 (7%), 20-40%: 30 (7%), 40-60%: 37 (9%), 60-80%: 69 (17%), and over 80%: 234 (59%). The number of employees who have been working overtime hours is also high. Although the importance of sequential entry to achieve results in reducing overtime hours continued to be strongly presented, there were 23% of nurses who indicated a sequential entry rate of less than 60%.

Early surgical treatment using regional clinical pathways to reduce the length of postoperative hospital stay in hip fracture patients: A retrospective analysis using the Japanese Diagnosis Procedure Combination database.

Hip fracture is a common injury in older adults; however, the optimal timing of surgical treatment remains undetermined in Japan. Therefore, this retrospective study aimed to ascertain the rate of early surgery among hip fracture patients and investigate its effectiveness, along with "regional clinical pathways" (patient plan of care devised by Japanese clinicians), in reducing the length of hospital stay (LOS) postoperatively. We hypothesized that performing early surgery along with a regional clinical pathway is effective to reduce the postoperative LOS and complications among hip fracture patients. We examined the data of patients diagnosed with femoral neck and peritrochanteric fractures retrieved from the Japanese Diagnosis Procedure Combination database between April 2016 and March 2018. Patients were divided into the early (43,928, 34%; surgery within 2 days of admission) and delayed (84,237, 66%; surgery after 2 days of admission) surgery groups. The difference in postoperative LOS between the two groups was 3 days (early vs. delayed: 29 days vs. 32 days). The early surgery group had more cases of intertrochanteric fractures (57% vs. 43%) and internal fixation (74% vs. 55%) than did the delayed surgery group. In contrast, the delayed surgery group had more cases of femoral neck fractures (43% vs. 57%) and bipolar hip arthroplasty (25% vs. 42%) or total hip arthroplasty (1.2% vs. 3.0%). Moreover, the early surgery group showed a lower incidence of complications, except anemia (12% vs. 8.8%). Logistic regression analysis using the adjusted model revealed that early surgery and implementation of regional clinical pathways reduced LOS by 2.58 and 8.06 days, respectively (p<0.001). Early surgery and implementation of regional clinical pathways for hip fracture patients are effective in reducing postoperative LOS, allowing regional clinical pathways to have a greater impact. These findings will help acute care providers when treating hip fracture patients.

A Case study of polypharmacy-induced serotonin syndrome in a cancer patient.

Polypharmacy in cancer care can be complex and detrimental, particularly among younger patients, who can be easily overlooked. This report showcases a 54-year-old woman with cancer, treated for dapsone-induced methemoglobinemia with methylene blue (MB), subsequently developing serotonin syndrome (SS) due to concurrent serotonin-active medications. This case highlights the critical impact of polypharmacy, emphasizing the necessity for acute care providers to diligently assess medication interactions, especially in emergencies. It underscores the importance of considering alternative treatments and the vigilant monitoring of symptoms indicative of adverse drug interactions to ensure patient safety and optimize outcomes in complex therapeutic scenarios.

Adolescent Substance Use, and Related Emergency Room Visits, and Continuum of Care

Abstract: Adolescence is a unique developmental period marked by biophysiological changes and psychosocial exploration. Risk-taking behaviors, including experimentation with psychoactive substances, are common during this period. Emergency room (ER) visits for adverse events related to adolescent substance use have increased over the last two decades. Without a continuum of care from the ER, significant opportunities to intervene are missed. The narrative review article aims to provide an overview of substance use during Adolescence in the United States, highlight related ER visits, and discuss extending care beyond the ER. A literature review was conducted to reveal historical and recent studies related to adolescent substance use trends, morbidity, and mortality patterns, as well as the much-needed continuum of care after the ER. Our approach prioritized capturing diverse perspectives and significant studies relevant to these themes, aiming for a thorough discussion without strict adherence to systematic review methodologies. The selection of studies involved a comprehensive search across multiple databases, including PubMed, Google Scholar, and relevant academic journals. Search terms were tailored to capture studies addressing adolescent substance abuse, ER visitation, and aftercare. Studies were screened based on title, abstract, and full-text review, with a focus on relevance and significance to the review's objectives. The strategy for this narrative review facilitated a detailed exploration of the selected themes while also allowing for flexibility in study selection and interpretation. National studies indicate an overall decline in the proportions of adolescents using substances compared to pre-COVID-19 levels. However, morbidity and mortality patterns have not mirrored this decline. Various factors, including gender, location, and specific mental health disorders, are associated with adolescent substance use presentations. Acute care providers in emergency settings, employing protocols like SBIRT, can significantly impact outcomes by facilitating appropriate screening and referral to aftercare treatment programs. Identification of barriers to care, such as stigma and social determinants of health, is important in formulating tailored interventions. While acute care provides an opportunity to intervene and initiate treatment, a continuum of care is essential to reduce morbidity and mortality patterns among adolescents with substance use.

Ten Influential Point-of-Care Ultrasound Papers: 2023 in Review.

In an effort to help keep busy clinicians up to date with the latest ultrasound research, our group of experts has selected 10 influential papers from the past 12 months and provided a short summary of each. We hope to provide emergency physicians, intensivists, and other acute care providers with a succinct update concerning some key areas of ultrasound interest.

Pain management in trauma: the need for trauma-informed opioid prescribing guidelines

Background/objectivesSurgical populations and particularly injury survivors often present with complex trauma that elevates their risk for prolonged opioid use and misuse. Changes in opioid prescribing guidelines during the past several...

Evaluation of a Pediatric High-Flow Nasal Cannula Training Program for Providers at Moi Teaching and Referral Hospital in Eldoret, Kenya

Background: High-flow nasal cannula (HFNC) is a relatively safe, effective, and well-tolerated form of non-invasive ventilation for children with respiratory distress and is regularly used in resource-rich settings. Pediatric HFNC has been successfully implemented in resource-limited settings; however, little is known about the training process required to integrate HFNC into care. The present study evaluates a pediatric HFNC training program conducted at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya prior to HFNC implementation at Shoe4Africa Children’s Hospital.&#x0D; Methods: This study took place within the Academic Model Providing Access to Healthcare (AMPATH) program, a partnership among MTRH, Moi University, and a consortium of North American universities led by Indiana University. The training program curriculum included information about HFNC; clinical signs of respiratory distress; a demonstration and hands-on practice with HFNC machines; a locally adapted protocol for pediatric HFNC implementation; and a sample patient case. Fifty-nine acute care providers (nurses, clinical officers, medical officers, and registrars) participated in training. Participants completed pre-tests and post-tests (immediate and 3-month follow-up) containing open-ended questions to assess HFNC knowledge and five-point Likert scale questions to assess HFNC comfort and attitudes. Data were analyzed using descriptive statistics and two-proportion Z-tests (α=0.05).&#x0D; Results: Average knowledge assessment scores significantly increased from pre-test (2.19/6) to post-test (5.59/6; p&lt;0.001). While scores decreased slightly at the 3-month follow-up, they remained increased from pre-test levels (4.53/6; p&lt;0.001). The percentage of respondents who answered each knowledge assessment question correctly on the post-test and 3-month followup were significantly increased from the pre-test. Participant comfort using HFNC was increased on both the post-test (p&lt;0.001) and 3-month follow-up (p=0.038).&#x0D; Conclusions: This program successfully trained providers in pediatric HFNC use at MTRH and could inform future HFNC training in resource-limited settings. Future studies should evaluate pediatric outcomes at Shoe4Africa after HFNC implementation.

Healthcare apprenticeships: assessing the potential benefits to an acute care provider NHS organization.

The introduction of healthcare-based apprenticeships to become both a physician associate and a doctor has been approved for delivery in England. This will revolutionize medical training and it is hoped that medical training would be more accessible. This has generated a mixture of reactions, some enthusiastic and others concerned. This paper gauges interest among staff at Barking, Havering, and Redbridge University Hospitals NHS Trust in pursuing training as a doctor and/or physician associate through the apprenticeship route. Applicants were interviewed to discover their motivations for interest, and the potential benefit to the Trust of these new opportunities was also assessed. This revealed that applicants were primarily driven through intrinsic motivations, such as a lifelong dream to be a doctor and a desire to fulfil a patient-facing role. Many expressed financial and social situations were a barrier to prior application, making the apprenticeship role more attractive. Healthcare professionals should accurately represent the population that they serve, which is currently not the case. The prospective applicants, with diverse backgrounds and existing healthcare experience, can help to improve patient care through their diverse perspective and understanding of multidisciplinary team working. This article highlights the potential of medical-based apprenticeships to help address longstanding challenges in medical education and workforce diversity. Furthermore, there could be significant financial and practical benefits to the trust of upskilling enthusiastic staff. However, there is currently a lack of clarity regarding selection processes and entry criteria, which must be addressed.

Virtual cardiac hospital in the home following cardiac surgery delivers superior patient outcomes, reduces costs, and increases bed availability

Abstract Introduction Increasing patient complexity and unprecedented bed access constraints are important challenges in contemporary delivery of post-operative cardiac surgical care. Bed constraints lead to inefficient ICU discharge, excessive hospital Length Of Stay (LOS), and ineffective transitional care which results in suboptimal patient experience and hospital readmissions. The Cardiac Hospital in the Home (cHITH) model was designed to provide an early supported discharge in a virtual ward environment by an expert team of advanced practice cardiac nurses, pharmacists and cardiologists. The model utilizes wearable technology to monitor cardiac rhythm, oxygen saturation and vital signs in conjunction with daily virtual ward rounds using a standard tele health platform. Care is focused on coaching around mobilization and medical therapy, detection and management of complications and liaison with community pharmacies and providers of sub acute care. Escalation pathways for clinical deterioration were designed to support patient safety. Results Between March and October 2022, 123 of 197 patients were referred to cHITH of whom 103 (84%) were recruited. Where appropriate, results were compared with those from the same calendar period in 2021 and dichotomized to detect early trends in care. The cHITH group had a mean age of 62 ± 4 years with 82% males, 62% underwent isolated CABG surgery and there were no mortalities. Compared with historical results, inpatient LOS was reduced 1.6 days with 35% of care delivered in the virtual cardiac hospital. Readmission at 30 days was reduced by 42% (p&amp;lt;0.05)* and patient satisfaction was &amp;gt;90% (net promoter score). Important trends included an increase in cHITH LOS and a reduction in Total LOS. Projections Modelling of total hospital costs and bed-day savings was performed using real data from the medical centre. Assuming that 75% of patients would be managed in the cHITH for 3.5 days, the projected cost of cHITH care was $24.2M comparing favorably with $27.8M for usual care. When readmitted days are subtracted from total virtual care days the cHITH model of care is projected to save 975 inpatient bed days. Conclusions This virtual model of care has demonstrated safety, efficiency and high levels of patient satisfaction. Ongoing analysis is required to understand the broader applications of this model and to further evaluate quality, safety and efficiency metrics.Table 1.Results

“Building the plane while flying it” Reflections on pandemic preparedness and response; an organisational case study

BackgroundThe COVID-19 pandemic provided a unique opportunity to learn about acute health organisations experiences implementing a pandemic response plan in real-time. This study was conducted to explore organisational leader’s perspectives and experience activating a COVID-19 pandemic response plan in their health service and the impact of this on service provision, clinicians, and consumers.MethodsThis study was conducted at a large metropolitan health service in Australia that provides acute, subacute, and residential aged care services. Semi-structured interviews were conducted with 12 key participants from the COVID-19 leadership team between November-January 2021/2022. A semi-structured interview guide was developed to explore how the health service developed a clinical governance structure, policy and procedures and experience when operationalising each element within the Hierarchy of Controls Framework. Thematic analysis was used to code data and identify themes. A cross-sectional survey of frontline healthcare workers on the impacts and perceptions of infection control practices during the COVID-19 pandemic, was also completed in 2021 with 559 responses.ResultsTwelve organisational leaders completed the semi-structured interviews. Key themes that emerged were: (1) Building the plane while flying it, (2) A unified communications strategy, (3) Clinicians fear ‘my job is going to kill me’, (4) Personal Protective Equipment (PPE) supply and demand, and (5) Maintaining a workforce. When surveyed, front-line healthcare workers responded positively overall about the health services pandemic response, in terms of communication, access to PPE, education, training, and availability of resources to provide a safe environment.ConclusionHealth service organisations were required to respond rapidly to meet service needs, including implementing a pandemic plan, developing a command structure and strategies to communicate and address the workforce needs. This study provides important insights for consideration when health service leaders are responding to future pandemics. Future pandemic plans should include detailed guidance for acute and long-term care providers in relation to organisational responsibilities, supply chain logistics and workforce preparation.

Impact of primary to secondary care data sharing on care quality in NHS England hospitals

Health information exchange (HIE) is seen as a key component of effective care but remains poorly evidenced at a health system level. In the UK National Health Service (NHS), the ability to share primary care data with secondary care clinicians is a focus of continued digital investment. In this study, we report the evolution of interoperable technology across a period of rapid digital transformation in NHS England from 2015 to 2019, and test association of primary to secondary care data-sharing capabilities with clinical care quality indicators across all acute secondary care providers (n = 135 NHS Trusts). In multivariable analyses, data-sharing capabilities are associated with reduction in patients breaching an Accident & Emergency (A&E) 4-h decision time threshold, and better patient-reported experience of acute hospital care quality. Using synthetic control analyses, we estimate mean 2.271% (STD+/−3.371) absolute reduction in A&E 4-h decision time breach, 12 months following introduction of data-sharing capabilities. Our findings support current digital transformation programmes for developing regional HIE networks but highlight the need to focus on implementation factors in addition to technological procurement.

A comparison of symptom management and utilization of specialist palliative care in the early COVID-19 pandemic: A multi-site retrospective chart review

Background: COVID-19 is associated with high rates of morbidity and mortality. Previous work has described symptom management provided by specialists in palliative care for COVID-19 patients. However, there is a paucity of literature describing primary level palliative care provided by general internal medicine teams or reasons for referral to specialists. Objective: Our aim was to describe and compare the following outcomes for patients dying of COVID-19: (1) symptom management by acute care providers and palliative care specialists, and (2) utilization of palliative care consultation across two acute care hospitals in Toronto, Ontario during the onset of the COVID-19 pandemic. Methods: We undertook a retrospective chart review of 45 adult inpatients diagnosed with COVID-19 between 23 January 2020 to 19 May 2020 who died, and/or those who had a palliative care consultation. Findings: Forty-one of the 45 patients died. Common symptoms were shortness of breath and agitation. For these symptoms, pharmacologic management was not significantly different for patients seen by palliative care compared to those without consultation. Most consultations were for end-of-life care. There were significantly more palliative care consults for COVID-19 patients at one hospital (P=.001). Conclusion: The findings highlight the significant discrepancy in involvement of specialist palliative care between settings. More research is needed to validate the initial findings from this small sample size, understand the needs of palliative care providers in this setting, and appreciate the factors influencing consultation.

Patient satisfaction in inpatient psychiatric treatment compared with inpatient equivalent home treatment in Germany: an in-depth qualitative study.

Inpatient treatment (IT) is the predominant form of psychiatric care in Germany and worldwide, whereby forms of psychiatric treatment have mainly evolved in the direction of home services. Inpatient equivalent home treatment (IEHT) is a new and additional pillar of psychiatric acute care provision legally embedded since 2018 in Germany. The aim of this study was to conduct an in-depth exploration as little qualitative research has been performed so far in Germany to examine possible differences in patient satisfaction with IT compared with IEHT. In the current qualitative study, N = 9 patients of a German hospital providing IT and IEHT were interviewed with the problem-centered interview. Inclusion criteria were IT or IT with subsequent IEHT. The theoretical sampling method was applied to select test persons in the research process. The experiences of the participants during their psychiatric treatment were analyzed using a qualitative content analysis. The results of both types of psychiatric treatment refer to different satisfaction factors during the treatment period. The function of fellow patients, the setting of the treatment, the conditions in place, and the relationship to relatives turn out to be pivotal for patient satisfaction. In addition, the quality of the therapy and relationship to caregivers itself can have an impact on patient satisfaction, particularly by shared decision making. During the IEHT, patient satisfaction can be strengthened by the possibility to handle daily tasks, to be close to relatives, while not so close to fellow patients, whereas IT patients are mostly satisfied because of the distance to their everyday life and the closeness to fellow patients. The choice of the form of psychiatric treatment according to the individual needs of the patients seems to be one key driver that can in turn increase patient satisfaction. In addition, a clean and hygienic environment seems to be critical for our respondents as a lack of it is one of the reasons to drop out of treatment. Despite its limitations, this hypothesis-generating study is one of the first investigating German IEHT in comparison with IT in an in-depth qualitative approach contributing to a patient-oriented and cost-effective psychiatric treatment. Although hospitals are highly complex organizations and therefore not directly comparable, other German and international providers of IEHT may derive several generic success factors from this study for the development and improvement of patient satisfaction.

The correct way to deal with the definitivesurgical airway

Dealing with adifficult airway is familiar to emergency care providers in both the prehospital and clinical settings. In anesthesiology and emergency medical care different algorithms almost equal in their wording have been introduced, indicating that an emergency front of neck airway access (eFONA) has to be established in the case of acannot ventilate-cannot oxygenate situation. In asurvey (Surveymonkey®) data concerning the level of experience with eFONA, devices required, previous training and complications were allocated among acute and emergency care providers of different backgrounds (doctors and paramedics). Furthermore, we asked about individual attitudes to and frequency of previous situations, in which an eFONA was not established despite strong indications. Of the respondents 15% (n = 63) answered that they had experienced this type of situation. eFONA had been performed by 28% of the interviewed (n = 117), reflecting the high number of military and EMT (emergency medical team) physicians participating in the survey. The number of experiences are rarely representative for the civilian setting. Different adjuncts may be helpful to detect the cricothyroid ligament. To use ultrasound seems obvious but it doubles the time for the detection of the cricothyroid ligament. Laryngeal masks can be employed as asupraglottic airway device (SAD) during "planB". Stabilizing the airway with aSAD almost doubles the success of identifying laryngeal landmarks in females. The crew resource management (CRM) guidelines are more than essential in threatening situations demanding measures like eFONA. Providers should anticipate emerging problems and whenever feasible call for help and finally speak up. Naming afailed airway should be avoided as it implies afailure of the provider or of the entire airway team. In fact, the term non-accessible airway should be introduced. This might help to avoid the implication of amajor failure. So far, an ideal simulator to train eFONA has not been introduced but it is mandatory to train procedures and algorithms on different types of simulators and manikins to achieve mastery.

The potential role of improvisation training to optimize communication in emergency care

One of the most common challenges in acute care is the time- and space-limited communication with patients, relatives and colleagues. There is ample evidence, however, that the quality of care, patient and staff satisfaction can be improved, measured and researched using simple communication tools (e.g., training). This improvement was what we focused on when carrying out voluntary participation surveys with the staff of the Department of Emergency Medicine of the Clinical Centre of the University of Pécs. With the help of a trained psychologist-actor and a senior specialist in medical communication, we investigated the potential impact of applied improvisation on medical communication by testing the participants in various situations simulating communication challenges after having completed an improv-based communication training full of exercises, games and tasks. After warm-up games taken from improv, the participants completed pre-defined tasks and finished every session with discussion and self-reflective feedback. Questionnaire (Interpersonal Confidence Questionnaire - ICQ) was used to check the potentially positive impact of improvisation on emergency communication. Our studies confirmed that the applied elements of medical improvisation, developing communication skills through play not only make participants more assertive and empathic, but also - after preparation - lead to a smoother and more effective exchange of information. Positive feedback from participants in the training sessions also confirms this. Our aim is to develop an improvisation-based communication training focused specifically on acute care providers, which, based on our initial experience, could optimize communication with patients, relatives and also between professionals. Application of improvisational techniques in this segment of acute care studied by us might open new perspectives to improve communication. Orv Hetil. 2023; 164(19): 739-746.

Acute hospital-community hospital care bundle for elderly orthopedic surgery patients: A propensity score-matched economic analysis.

While Singapore attains good health outcomes, Singapore's healthcare system is confronted with bed shortages and prolonged stays for elderly people recovering from surgery in acute hospitals. An Acute Hospital-Community Hospital (AH-CH) care bundle has been developed to assist patients in postoperative rehabilitation. The core concept is to transfer patients out of AHs when clinically recommended and into CHs, where they can receive more beneficial dedicated care to aid in their recovery, while freeing up bed capacities in AHs. To analyze the AH length of stay (LOS), costs, and savings associated with the AH-CH care bundle intervention initiated and implemented in elderly patients aged 75 years and above undergoing elective orthopedic surgery. A total of 862 1:1 propensity score-matched patients aged 75 years and above who underwent elective orthopedic surgery in Singapore General Hospital (SGH) before (2017-2018) and after (2019-2021) the care bundle intervention period was analyzed. Outcome measures were AH LOS, CH LOS, hospitalization metrics, postoperative 30-d mortality, and modified Barthel Index (MBI) scores. The costs of AH inpatient hospital stay in the matched cohorts were compared using cost data in Singapore dollars. Of the 862 matched elderly patients undergoing elective orthopedic surgery before and after the care bundle intervention, the age distribution, sex, American Society of Anesthesiologists classification, Charlson Comorbidity Index, and surgical approach were comparable between both groups. Patients transferred to CHs after the surgery had a shorter median AH LOS (7 d vs 9 d, P < 0.001). The mean total AH inpatient cost per patient was 14.9% less for the elderly group transferred to CHs (S$24497.3 vs S$28772.8, P < 0.001). The overall AH U-turn rates for elderly patients within the care bundle were low, with a 0% mortality rate following orthopedic surgery. When elderly patients were discharged from CHs, their MBI scores increased significantly (50.9 vs 71.9, P < 0.001). The AH-CH care bundle initiated and implemented in the Department of Orthopedic Surgery appears to be effective and cost-saving for SGH. Our results indicate that transitioning care between acute and community hospitals using this care bundle effectively reduces AH LOS in elderly patients receiving orthopedic surgery. Collaboration between acute and community care providers can assist in closing the care delivery gap and enhancing service quality.

Ten Influential Point-of-Care Ultrasound Papers: 2022 in Review.

Keeping up with the latest developments in the point-of-care ultrasound (POCUS) literature is challenging, as with any area of medicine. Our group of POCUS experts has selected 10 influential papers from the past 12 months and provided a short summary of each. We hope to provide emergency physicians, intensivists, and other acute care providers with a succinct update concerning some key areas of ultrasound interest.

Contemporary Use of Ultrasonography in Acute Care Pediatrics.

Use of ultrasonography by clinicians at the point of care has expanded widely and rapidly. Pediatric acute care providers now leverage this valuable tool to guide procedures, diagnose pathophysiologic processes, and inform time-sensitive decisions in sick and unstable children. However, the deployment of any new technology must be packaged with training, protocols, and safeguards to optimize safety for patients, providers, and institutions. As ultrasonography is increasingly incorporated into residency, fellowship, and even medical student curricula, it is important that educators and trainees are aware of the diversity of its clinical applications. This article aims to review the current state of point-of-care ultrasonography in acute care pediatrics, with an emphasis on the literature supporting the use of this important clinical tool.

ERCP for bile duct stones across a national service, demonstrating a high requirement for repeat procedures.

Background and study aims Bile duct stones (BDS) represent approximately 50 % of the requirement for endoscopic retrograde cholangiopancreatography (ERCP) within most services. Significant variation in outcome rates for BDS clearance at ERCP has been reported, and endoscopy societies have set standards for expected clearance rates. The aim of this study was to analyze procedure outcomes across a national service. Patients and methods Using verified hospital episode statistics (HES) data for the National Health Service (NHS) in England, we analyzed all patients having first ERCPs for BDS from 2015 to 2017, and followed these patients for at least 2 years. Results In total 37,468 patients underwent a first ERCP for BDS, with 69.8 % undergoing only one procedure. This figure of less than 70 % of BDS cleared at first ERCP is below the Key Performance Indicators as set by the British Society of Gastroenterology (> 75 %) and the European Society of Gastrointestinal Endoscopy (> 90 %). Of 55,556 ERCPs done for BDS, 52.9 % were repeat procedures, with 11,322 patients needing multiple procedures. For hospitals performing significant numbers of ERCPs (more than 600 for BDS during the study period) patients undergoing repeat ERCPs for BDS ranged from 9 % to 50 %. Conclusions In this nationwide study, the performance at clearing BDS at first ERCP was suboptimal, with high numbers of repeat procedures required. This may have a negative impact on both patient outcomes and experience, and increase pressure on endoscopy services. Apparent variation of outcome between acute hospital care providers requires further analysis.