Acute Health Care System Research Articles

How can we reduce healthcare costs by using Enhanced Recovery After Surgery more effectively in different groups of gynaecological patients? A single-centre experience.

The objective of this study was to assess the impact of the Enhanced Recovery After Surgery (ERAS) programme implementation on treatment costs at a university-type centre, using the DRG scheme. Retrospective analysis of patients' data in a group of 604 individuals enroled in the study. We evaluated three groups of patients according to the ERAS clinical protocol (CP): (1) CP oncogynaecology, (2) CP simple hysterectomy, (3) CP laparoscopy. The study aimed to evaluate the impact on the length of stay (LOS), savings in bed-days, and the reduction in direct treatment costs. Three parameters-antibiotic consumption, blood derivative consumption and laboratory test costs-were chosen to compare direct treatment costs. The statistical significance of the difference in the observed parameters was tested by a two-sample unpaired t test with unequal variances at the 0.05 significance level. We analysed data from 604 patients. In all three groups, the length of stay (LOS) was significantly reduced. The most significant reduction was observed in the CP oncogynaecology group, where the LOS was reduced from 11.1 days to 6.8 days (2022) and 7.6 days (2023) compared to 2019 (p < 0.05). Furthermore, there was a notable reduction in inpatient bed-days, which resulted in the capacity being made available to admit additional patients. A statistically significant reduction in direct costs was observed in the group of CP hysterectomy (antibiotic use) and in the CP laparoscopy (laboratory test costs). The implementation of the ERAS principles resulted in a number of significant positive economic impacts-reduction in the LOS and a corresponding increase in bed capacity for new patients. Additionally, direct treatment costs, including those related to antibiotic use or laboratory testing were reduced. The Czech Republic's acute healthcare system, like the majority of European healthcare systems, is financed by the DRG system. This flat-rate payment per patient encourages hospital management to seek cost-reduction strategies. The results of our study indicate that fast-track protocols represent a potential viable approach to reducing the cost of treatment while simultaneously meeting the recommendations of evidence-based medicine.

Right Care, Right Now: Bringing More Critical Care to Boarding Patients in the Emergency Department.

Right Care, Right Now: Bringing More Critical Care to Boarding Patients in the Emergency Department.

The Equitability of Universal Vaccine Mandates – A Bioethical Analysis of COVID-19 Vaccine

In public health emergencies that warrant mass vaccination, vaccine mandates are sometimes imposed. There is historical evidence of the effectiveness of vaccination mandates, but varying strategies in policy implementation. The COVID-19 vaccine mandate presents an ethical imbroglio that poses these bioethical questions, “Is there ethical justification for a vaccine mandate?”, and “Whose responsibility is it to ensure the equitability of a vaccine mandate in a pandemic?” Using ethical principles and theories, this paper focuses on the health equity of vaccine mandates, considering both the global and local implications. Vaccination mandate, in a pandemic, is driven by the need to accelerate the achievement of public health goals of herd immunity, protecting the most vulnerable in terms of case fatality and hospitalization rates, protecting the capacity of the acute health care system, as well as circumventing the economic impact. These mandates must still be guided by appropriate stakeholder involvement and bioethical considerations, to assess their validity and equitability, as vaccine mandates may impose restrictions on the freedoms and rights of an individual. Using COVID-19 as a case study, we argued the equitability of vaccine mandates based on the WHO framework of ethical considerations and caveats for mandatory vaccination. Necessity and proportionality of the vaccine, sufficient evidence of safety, efficacy, and effectiveness, sufficient supply, and public trust are key during ethical processes of decision-making. We conclude that vaccine mandates are more equitable as population-specific mandates, as opposed to global or universal mandates, even in pandemics. This is due to varying geographic, socio-cultural, and economic characteristics. Bioethicists should be actively engaged in discussions on the vaccine mandate, as its equitability is a function of critically analyzing the proposed mandate based on ethical recommendations prior to being issued. Retrospective bioethical analysis is warranted to identify shortfalls and make recommendations for future decision-making.

Analysis of the dynamics of the nomenclature of medicines in the government program «Available medicines»

The availability of medicines the public is a problem with the most acute health care systems. Not only the issue of physical availability of medicines, their availability in pharmacies, but also the economic assistance of the population to purchase drugs is relevant. To overcome these problems, the Government has recognized the introduction of a reimbursement process in the pharmaceutical sector. The content of improving the quality and life expectancy of the population, with increasing physical and economic accessibility of drugs for the treatment of the most socially significant diseases, April 1, 2017 the Government introduced a reimbursement program «Available medicines». In the beginning there were spreads with cardiovascular disease, type II diabetes and bronchial asthma. From October 1, 2021, the program includes drugs for the treatment of diabetes mellitus, mental and behavioral disorders, epilepsy.&#x0D; The aim of the work is to study the dynamics of the range of drugs included in the government programs «Available medicines» for 2017–2022.&#x0D; The content analysis of 13 issues of Registers of medicines subject to reimbursement shows the updating and growth of the number of international non-proprietary names and in accordance with the trade names of drugs for the treatment of nosologies, which countries have recognized as the best. The nomenclature of medicines has been updated twice with international non-proprietary names and in almost 3 varieties – by trade names compared to the first issue, which is associated with both the expansion of names for the treatment of the disease, which were in programs since 2017 and the emergence of new nosology from 2021. On average, the share of drugs of domestic pharmaceutical companies is only 60%, which opens a significant prospect of import substitution, reduces drug prices under the government program «Available medicines» and, for example, increase the physical and economic availability of drugs.&#x0D; The conducted studies allow us to conclude that there is a need to improve the assortment policy of the government program «Available medicines» using the population of Ukraine available drugs in accordance with the needs of the population and the standards for the treatment socially significant diseases.

An interprofessional approach to reducing hospital-onset Clostridioides difficile infections

BackgroundClostridioides difficile is the most prevalent hospital-onset (HO) infection. There are significant financial and safety impacts associated with HO-C. difficile infections (HO-CDIs) for both patients and health care organizations. The incidence of HO-CDIs at our community hospital within an academic acute health care system was continuously above the national benchmark. MethodsIn response to the high HO-CDI rates at our facility, an interprofessional team selected evidence-based interventions with the goal of reducing HO-CDI incidence rates. Interventions included: diagnostic stewardship, enhanced environmental cleaning, antimicrobial stewardship and education and accountability. ResultsAfter one year, we achieved a 63% reduction in HO-CDI and have sustained a 77% reduction. The infection rate remained below national benchmark for HO-CDI for over 4 years at a rate of 2.80 per 10,000 patient days and a SIR of 0.43 in 2020. DiscussionMultiple evidence-based interventions were successfully implemented over several service lines over a 4-year period through the collaboration of an interprofessional team. The addition of an accountability processes further improved compliance with standards of practice. ConclusionsCollaboration of an interprofessional team led to substantial and sustained reductions in HO-CDI.

Do nurses know their patients?

Background: Good quality of health care requires patient participation, however emergency medicine is centered around flow and production and to a lesser degree the patients’ contextual perception of acute illness. Degree-of-worry is a simple subjective measure used to enable patients to rate their worry about the condition that initiated their contact to the acute health care system on a scale from 1 (minimally worried) to 10 (maximum worried). This study examines the agreement between patients’ self-rated DOW and their nurses’ estimation of the patients’ DOW.&#x0D; Methods: A total of 194 patient/nurse-pair from the emergency department at Amager Hvidovre Hospital were asked to rate their DOW (patients) and estimate their patients’ DOW (nurses). Patients’ age, gender, triage level, and co-morbidity was registered alongside the corresponding nurses’ age, gender and work experience (years). DOW was categorized as DOW1 (DOW=1-3), DOW2 (DOW=4-6) and DOW3 (DOW=7-10). The agreement between patients’ 3-level DOW and nurses’ estimation of patients’ 3-level DOW was assessed with equal weighted Cohen’s Kappa. Additional kappa values stratified on patient’s gender, age, co-morbidity and nurses’ gender, age and seniority are also estimated.Results: The difference between patients’ 3-level DOW and nurses’ estimation was in total agreement in n=58 pairs (29.9%) of the ratings. For n=136 patient/nurse-pairs there was not agreement between scores, which corresponds to a weighted Cohen’s Kappa of 0.19 (0.30;0.08, p&lt;0.001). Similar kappa values were found in analyses stratified for age, gender, nurse seniority.&#x0D; Conclusion: The agreement between patients’ 3-level DOW and nurses’ estimation of patients’ 3-level DOW is low and suggests that nurses do not know their patients’ worries. This should be addressed in further research, as well as, clinical work.

Protocols for an Aboriginal-led, Multi-methods Study of the Role of Aboriginal and Torres Strait Islander Health Workers, Practitioners and Liaison Officers in Quality Acute Health Care

Objectives Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers play an important, often critical role providing advocacy and cultural and emotional support for Aboriginal and Torres Strait Islander patients. The main goals of this research are to explore i) how Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers are integrated in the routine delivery of care for Aboriginal and Torres Strait Islander peoples in hospital, and ii) how the role of Aboriginal and Torres Strait Islander Health Workers/Practitioners and Liaison Officers facilitates quality health outcomes. Methods This study is being conducted in three different hospitals using a multi-method approach including: yarning and Dadirri, patient journey mapping, survey and semi-structured interviews. Ethics approval has been provided from four ethics committees covering the three project sites in Australia (Adelaide, South Australia; Sydney, New South Wales and Alice Springs, Northern Territory). Significance This study uses innovative methodology founded on the privileging of Aboriginal and Torres Strait Islander knowledges to collect Aboriginal and Torres Strait Islander perspectives and understand patient journeys within acute health care systems. This project is led by Aboriginal and Torres Strait Islander researchers and guided by the Project Steering Committee comprised of stakeholders. Implications There is limited research that explores quality acute care processes and the integration of Aboriginal and Torres Strait Islander Health Workers/Practitioners work within health care teams. This research will make a valuable contribution to understanding how hospital services can achieve quality acute health care experiences for Aboriginal and Torres Strait Islander People.

The co-occurrence of smoking and alcohol use disorder in a hospital-based population: Applying a multimorbidity framework using geographic information system methods

Tobacco and alcohol use are leading causes of premature mortality in the US and concurrent use is associated with even greater health risks. A cross-sectional study of 20,310 patients admitted to a Mid-Atlantic acute health care system between July 1, 2018 and June 30, 2019 were categorized according to smoking and alcohol use disorder (AUD) status. Of the total admissions, 1464 (7.2%) were current smokers with an AUD. These patients were younger (52.4 vs. 63.9), more likely to be male (64.1% vs. 38.0%) and covered by Medicaid (46.9% vs. 11.6%), and resided in proximity to higher counts of tobacco (10.3 vs. 4.72) and alcohol (2.24 vs. 1.14) retailers than never smokers without an AUD. Clinically, these patients had higher rates of other substance use disorders (60.4% vs. 6.1%), depression (64.6% vs. 34.8%), HIV/AIDS (3.3% vs. 0.6%), and liver disease (40.7% vs. 13.2%) than never smokers without an AUD. Patients who concurrently smoke and have an AUD face unique and serious health risks. A multimorbidity framework can guide clinical and community-based interventions for individuals with concurrent psychiatric and chronic medical conditions, complex social needs, and adverse environmental exposures.

Nebulous Intentioning - Acute hospital nurses' struggle to deliver core nursing care.

To explore the influences on nursing practice in acute hospital care. A Classic Grounded Theory study. Data collection (2013-2015) was through interviews and non-participant observations. Analysis was undertaken using constant comparative data analysis and theoretical sampling. Memo writing was used as an aid to understanding and conceptualizing data during analysis. Theoretical coding served to integrate emerging concepts. This theory explains core nursing as a nebulous intention, an idea which acute care nurses retain throughout each shift, that they will nurse their patients fully when they have the opportunity. It reveals this as the resolution of their main problem which is the constant deferral of core nursing care. This study explains its two sub-core categories, accommodating and integrity eroding. The theory highlights nurses' attitudes towards their role, demonstrated by deferring it to accommodate the work of others, but offers a new perspective on the significant contribution nurses make to the safe and cohesive transition of patients through the acute healthcare system. The theory adds a new understanding of the unique contribution nurses make to patient health and safety in acute care environments. It also provides insight into nurses' attitudes towards their own professional work. It explains the consequences of attitudes which undermine core nursing when it competes for priority with accommodating. Accommodating indicates a greater workload for nurses than has been previously understood in explaining the activities, additional to core nursing care, which nurses undertake to contribute safety and cohesion to the patient's acute care journey. These new insights suggest a role for managers in recognizing accommodating in decisions about staffing and resources and for educators in improving the profession's regard for its theoretical underpinnings and for its self-image.

Development and validation of a machine learning-based prediction model for near-term in-hospital mortality among patients with COVID-19

ObjectivesTo develop and validate a model for prediction of near-term in-hospital mortality among patients with COVID-19 by application of a machine learning (ML) algorithm on time-series inpatient data from electronic...

Value-based healthcare in mental health services

SUMMARYIn value-based healthcare (VBHC) value is defined as outcomes that matter to patients divided by the cost of achieving these outcomes. Value is measured for discrete medical conditions across the whole cycle of care. Data on the value achieved by different providers is openly shared. Providers increase value using quality improvement (QI) techniques to improve outcomes, reduce costs or both. Patients or commissioners choose the provider achieving the greatest value. Units should compete regionally or nationally. There are challenges to implementing such ideas in the mental health services in the UK. However, measuring outcomes, understanding costs and using QI to drive up value may be possible without adopting the complete model that has developed in the context of a North American and acute hospital healthcare system.

Stigmatisation of those with mental health conditions in the acute general hospital setting. A qualitative framework synthesis.

Patients with long-term mental health conditions often have complex physical, mental, and social needs. They are frequent users of the acute general healthcare system, but can experience stigmatising attitudes and behaviours, and structural discrimination. We wished to improve understanding of stigmatisation in the acute healthcare setting, to target areas for future intervention. A synthesis of qualitative literature was undertaken in order to understand how patients with long-term mental health conditions are stigmatised, or otherwise treated, within the acute healthcare system. A theory-driven framework approach was implemented. Existing stigma theory was used to outline a framework for categorizing stigmatising and non-stigmatising phenomena within the acute healthcare system. A systematic literature search of qualitative studies identified a sample of 51 studies that would inform the framework. Using data in these studies, a final theoretical 'best fit' framework was developed. In this framework there is an overarching pattern of labelling and stereotyping, plus five ways in which patients with mental health conditions are stigmatised in the acute healthcare system: devaluation, social control, avoidance, rejection, and failure to act. In addition, the framework outlines positive attitudes and behaviours - valuing, adjustment, responding, legitimising, and positive action - which contrast with the stigmatisation patterns. The study offers a framework for identifying stigmatisation and positive treatment of those with mental health conditions in an acute health setting. This framework is of potential value in targeting areas for improved quality of care and may have utility beyond this setting and stigmatised group.

Health Care Usage among Children and Adults with Cerebral Palsy

Objective − This paper aims to quantify and compare health care usage among children and adults with and without cerebral palsy (CP). Materials and Methods − A population-based study using public registries with follow-up of children and adults. Persons with CP born from 1950 to 2003 were identified in the Danish Cerebral Palsy Registry (4235 persons). Persons without CP were selected randomly from the Danish Civil Registration System and matched by birth year and gender (22,351 persons). Hospitalizations, visits to specialists, general practitioners and emergency health services were analysed. Children were born 1995-2003 and monitored until 2012 (1996-2012). Adults were born 1950-1985 and monitored for ten years (2003-2012). Results − Significantly fewer adults with CP visited specialists compared with children with CP. At the same time, the differences in use of general practitioners and between persons with and without CP were smaller in adulthood compared to childhood. Persons with CP and the most severe impairments had an unexpected low frequency of acute admissions compared with children with CP. We did not find a high use of acute contact with the health care system among adults with CP. Conclusion − If acute contacts with the health care system could be assumed to be a direct measurement of serious illness, this study does not identify a larger risk of serious illness in adults with CP, but other factors, such as reduced access to the acute health care system may, however, also be a reason for the lower use in adulthood.

New Awareness of Blood Sugar Management, Self-Care Creates a Win-Win Situation

The diabetes population continues to grow worldwide both in terms of overall numbers and rate of increase. It is estimated that 642 million people will suffer from diabetes by 2040 (International Diabetes Federation, 2017). Diabetes was ranked the fifth main cause of death in Taiwan in 2017. (Department of Statistics, Ministry of Health and Welfare, Taiwan, ROC, 2019). Because of differences in the population in terms of disease cognition and disease control behaviors, despite recent advances in medicine and treatment efficacy, many diabetes patients continue to suffer from complications caused by improper blood sugar control, leading to a considerable number of subsequent health problems. Healthcare professionals, especially nurses, have critical roles to play in the health management of diabetes and metabolic-syndrome patients. In both the acute healthcare system and community homecare units, glycemic-related management of diabetes is important. We invite diabetes experts from academic and clinical practice units to share their professional knowledge and practical experiences, emphasizing patient-centered self-management principles. Related articles are expected to draw readers' attention to diabetes-related issues in order to gain new knowledge and skills related to blood sugar management.

EVALUATING GERIATRIC WORKFORCE DEVELOPMENT NEEDS AMONG HOSPITALS USING NICHE BENCHMARKING DATA

The Nurses Improving Care for Health System Elders (NICHE) program aims to improve geriatric care competencies for improved care quality. A quantitative descriptive design utilizing secondary data analysis was done to evaluate geriatric workforce enhancement efforts in one acute healthcare system. Data were collected using the Geriatric Institutional Assessment Profile (GIAP) from 2008 and 2013. The GIAP measures perceived professional issues (disagreements among staff and families, limited access to geriatric services, vulnerability to legal action, intensity and burden of behavioral problems) on a Likert scale from best=0 to poor=10. Staff perception of the Geriatric Care Environment was scored by the GIAP as: age sensitive care delivery (0-40), institutional values (0-28), resource availability (0-32) and capacity for collaboration (0-12). Higher scores on the Geriatric Care Environment reflected improvements. Independent sample t-tests examined changes in baseline scores. Post-NICHE implementation, compared to peer hospitals by teaching status and bed size in 3 hospitals there were significantly (p<0.05) improved scores for: access to geriatric services (2.79-3.21), burden of behavioral problems (2.40-3.15), aging sensitivity care delivery (26.05-29.53), institutional values (18.85-19.59) and resource availability (19.51-19.97). Peer hospitals had significantly (p<0.05) better scores for: disagreements among staff about treatment of older adults (1.63-1.94) and capacity for collaboration (7.72-7.99). Findings indicate improvement in perceived professional issues and need for improvement in the geriatric care environment and care redesign to progress to becoming an Age-Friendly health system. This was an initial step in a health system to improve care quality through health workforce development.

General practitioners (GPs) and end-of-life care: a qualitative study of Australian GPs and specialist palliative care clinicians

ObjectivesGeneral practitioners (GPs) are well placed to be involved in end-of-life care for patients with life-limiting illnesses. However, differing views exist regarding their role. This study aims to explore the...

Understanding the Impacts of Maritime Disruption Transportation to Hospital-Based Acute Health Care Supplies and Personnel in Coastal and Geographically Isolated Communities.

This study aimed to identify maritime transportation disruption impacts on available health care supplies and workers necessary to deliver hospital-based acute health care in geographically isolated communities post-disaster. Semi-structured interviews were conducted with 25 key informants knowledgeable about the hospital-based acute health care supply chain and workforce emergency management plans and procedures in 2 coastal communities in British Columbia. These locations were accessed primarily through maritime transportation, including one urban center and one smaller, more remote community. Interview transcriptions were thematically analyzed. Critical vulnerabilities to hospital-based acute health care delivery due to a maritime transportation disruption identified include lack of information about the existing supply chain, lack of formal plans and agreements, and limited local supply storage and workforce capacity. Measures to decrease vulnerability and enhance system capacity can be fostered to enhance acute health care system resilience for these and other geographically isolated communities. A maritime transportation disruption has the potential to impact the availability of hospital-based health care supplies and health care personnel necessary to deliver acute health care in coastal communities post-disaster. Multisector engagement is required to address complex interdependencies and competing priorities in emergency response. Additional research and public-private collaboration is necessary to quantify potential impacts of maritime transportation disruption on the acute health care system. (Disaster Med Public Health Preparedness. 2019;13:440-448).

Person-centred acute hospital care for older people transitioning to residential aged care- whose needs are being met?

ABSTRACTThe acute health care system in Australia, as in the global north, has been increasingly dominated by neoliberal market principles prioritising efficiency and cost reduction. This has occurred in conjunction with a shift towards ‘personalised care’ models in health and social services. Personalised care models are intended to support the provision of holistic health care and consumer choice. Yet, the bureaucratic context of acute health care produces constrained applications of person-centred care that can undermine patient participation. Personalised care models have been criticised for diminishing the choices available to socioeconomically disadvantaged groups. There has been scant attention to these equity issues and ethical implications of the model for older people transferring from acute hospital settings to residential aged care. This is significant, as this major life event is associated with social- and identity-related losses; can produce poor health outcomes; and is affecting an increasing population of older people. The aim of this paper is to address this gap in the debate through a critical literature review applying Tronto’s critical ethics of care. We highlight the current Australian context for this patient group and the transferability of palliative care models as an example for change in practice and resource allocation.

Promoting patient-centred fundamental care in acute healthcare systems

Meeting patients’ fundamental care needs is essential for optimal safety and recovery and positive experiences within any healthcare setting. There is growing international evidence, however, that these fundamentals are often poorly executed in acute care settings, resulting in patient safety threats, poorer and costly care outcomes, and dehumanising experiences for patients and families. Whilst care standards and policy initiatives are attempting to address these issues, their impact has been limited. This discussion paper explores, through a series of propositions, why fundamental care can be overlooked in sophisticated, high technology acute care settings. We argue that the central problem lies in the invisibility and subsequent devaluing of fundamental care. Such care is perceived to involve simple tasks that require little skill to execute and have minimal impact on patient outcomes. The propositions explore the potential origins of this prevailing perception, focusing upon the impact of the biomedical model, the consequences of managerial approaches that drive healthcare cultures, and the devaluing of fundamental care by nurses themselves. These multiple sources of invisibility and devaluing surrounding fundamental care have rendered the concept underdeveloped and misunderstood both conceptually and theoretically. Likewise, there remains minimal role clarification around who should be responsible for and deliver such care, and a dearth of empirical evidence and evidence-based metrics. In explicating these propositions, we argue that key to transforming the delivery of acute healthcare is a substantial shift in the conceptualisation of fundamental care. The propositions present a cogent argument that counters the prevailing perception that fundamental care is basic and does not require systematic investigation. We conclude by calling for the explicit valuing and embedding of fundamental care in healthcare education, research, practice and policy. Without this re-conceptualisation and subsequent action, poor quality, depersonalised fundamental care will prevail.

Factors associated with aggressive end of life cancer care.

BackgroundMany patients with cancer experience aggressive care towards the end of life (EOL) despite evidence of an association with poor outcomes such as prolonged pain and overall dissatisfaction with care.PurposeTo investigate socio-demographic, clinical and community health care service factors associated with aggressive EOL cancer care.MethodsAn analysis of pooled data from two mortality follow-back surveys was performed. Aggressive EOL care was defined as greater than or equal to one of the following indicators occurring during the last 3 months of life: greater than or equal to two emergency department visits, ≥30 days in hospital and death in hospital.ResultsOf the 681 included patients, 50.1 % were men and mean age at death was 75 years. The majority of patients (59.3 %, 95 % confidence interval (CI) 55.6–63.0 %) experienced at least one indicator of aggressive EOL care: 29.7 % experienced greater than or equal to two ED visits, 17.1 % spent ≥30 days in hospital and 37.9 % died in hospital. Patients with prostate or haematological cancer were more likely to experience aggressive EOL care (adjusted odds ratio (AOR) 4.36, 95 % CI 1.39–13.70, and 4.16, 95 % CI 1.38–12.47, respectively, reference group lung cancer). Patients who received greater than five general practitioner (GP) home visits (AOR 0.37, 95 % CI 0.17–0.82, reference group no GP visits) or had contact with district nursing (AOR 0.48, 95 % CI 0.28–0.83, reference group no contact) or contact with community palliative care services (AOR 0.27, 95 % CI 0.15–0.49, reference group no contact) were less likely to experience aggressive EOL care. No association was found between aggressive EOL care and patients’ age, gender, marital, financial or health status.ConclusionsCommunity health care services, in particular contact with community palliative care, are associated with a significant reduction in the odds of cancer patients receiving aggressive EOL care. Expansion of such services may help address the current capacity crises faced by many acute health care systems.