In-hospital Acute Care Research Articles

Leaving the hospital on time: hospital bed utilization and reasons for discharge delay in the Netherlands.

Inappropriate bed occupancy due to delayed hospital discharge affects both physical and psychological well-being in patients and can disrupt patient flow. The Dutch healthcare system is facing ongoing pressure, especially during the current coronavirus disease pandemic, intensifying the need for optimal use of hospital beds. The aim of this study was to quantify inappropriate patient stays and describe the underlying reasons for the delays in discharge. The Day of Care Survey (DoCS) is a validated tool used to gain information about appropriate and inappropriate bed occupancy in hospitals. Between February 2019 and January 2021, the DoCS was performed five times in three different hospitals within the region of Amsterdam, the Netherlands. All inpatients were screened, using standardized criteria, for their need for in-hospital care at the time of survey and reasons for discharge delay. A total of 782 inpatients were surveyed. Of these patients, 94 (12%) were planned for definite discharge that day. Of all other patients, 145 (21%, ranging from 14% to 35%) were without the need for acute in-hospital care. In 74% (107/145) of patients, the reason for discharge delay was due to issues outside the hospital; most frequently due to a shortage of available places in care homes (26%, 37/145). The most frequent reason for discharge delay inside the hospital was patients awaiting a decision or review by the treating physician (14%, 20/145). Patients who did not meet the criteria for hospital stay were, in general, older [median 75, interquartile range (IQR) 65-84 years, and 67, IQR 55-75 years, respectively, P < .001] and had spent more days in hospital (7, IQR 5-14 days, and 3, IQR 1-8 days respectively, P < .001). Approximately one in five admitted patients occupying hospital beds did not meet the criteria for acute in-hospital stay or care at the time of the survey. Most delays were related to issues outside the immediate control of the hospital. Improvement programmes working with stakeholders focusing on the transfer from hospital to outside areas of care need to be further developed and may offer potential for the greatest gain. The DoCS can be a tool to periodically monitor changes and improvements in patient flow.

Quality Assurance Measures and Mortality After Stroke.

Quality assurance for acute in-hospital care in Germany is based on compulsory comparisons between institutions, so-called external quality assurance (EQA). The effectiveness of EQA has not yet been adequately studied. The purpose of the QUASCH project, which is supported by the Innovation Fund of the Federal Joint Committee, is to investigate the association between EQA and health care outcomes, specifically with respect to stroke. The analyses were based on data from 379 825 patients insured by the AOK health insurance fund who were acutely admitted to a hospital because of stroke over the period 2007-2017. Data on 47 659 patients were derived from EQA documentation in the state of Hesse, in which stroke EQA had already been introduced in 2003; data on the remaining 332 166 patients were from other federal states, where 117 734 of these patients had been treated under EQA conditions. The association of EQA with mortality over the period of observation was analyzed by multivariate Cox regression, with the following covariates: age, sex, comorbidities, time period of occurrence, nursing care level, type of stroke, socio-economic deprivation in the region of origin, and treatment in a stroke unit. Compared to treatment without EQA, mortality risk under EQA in the state of Hesse was significantly lower (hazard ratio [HR]: 0.93; 95% confidence interval: [0.92; 0.95]). The reduction in mortality risk with EQA was somewhat lower in the other federal states (HR: 0.96 [0.95; 0.97]). Treatment in a stroke unit was associated with a mortality risk that was lower still (HR: 0.86 [0.85; 0.87]). Mortality risk rose with age, comorbidities, and need for nursing care; it was lower in women and in persons whose stroke occurred in a later period. Quality assurance measures are associated with lower mortality risk after stroke. The concentration of care in specially qualified institutions is associated with stronger effects than EQA alone.

Design of a novel multifunction decision support/alerting system for in-patient acute care, ICU and floor (AlertWatch AC)

BackgroundMultifunction surveillance alerting systems have been found to be beneficial for the operating room and labor and delivery. This paper describes a similar system developed for in-hospital acute care environments, AlertWatch Acute Care (AWAC).ResultsA decision support surveillance system has been developed which extracts comprehensive electronic health record (EHR) data including live data from physiologic monitors and ventilators and incorporates them into an integrated organ icon-based patient display. Live data retrieved from the hospitals network are processed by presenting scrolling median values to reduce artifacts. A total of 48 possible alerts are generated covering a broad range of critical patient care concerns. Notification is achieved by paging or texting the appropriated member of the critical care team. Alerts range from simple out of range values to more complex programing of impending Ventilator Associated Events, SOFA, qSOFA, SIRS scores and process of care reminders for the management of glucose and sepsis. As with similar systems developed for the operating room and labor and delivery, there are green, yellow, and red configurable ranges for all parameters. A census view allows surveillance of an entire unit with flashing or text to voice alerting and enables detailed information by windowing into an individual patient view including live physiologic waveforms. The system runs via web interface on desktop as well as mobile devices, with iOS native app available, for ease of communication from any location. The goal is to improve safety and adherence to standard management protocols.ConclusionsAWAC is designed to provide a high level surveillance view for multi-bed hospital units with varying acuity from standard floor patients to complex ICU care. Alerts are generated by algorithms running in the background and automatically notify the selected member of the patients care team. Its value has been demonstrated for low acuity patients, further study is required to determine its effectiveness in high acuity patients.

Emergency Medical Services (EMS) Transportation of Trauma Patients by Geographic Locations and In-Hospital Outcomes: Experience from Qatar.

Background: Prehospital care provided by emergency medical services (EMS) plays an important role in improving patient outcomes. Globally, prehospital care varies across countries and even within the same country by the geographic location and access to medical services. We aimed to explore the prehospital trauma care and in-hospital outcomes within the urban and rural areas in the state of Qatar. Methods: A retrospective analysis was conducted utilizing data from the Qatar National Trauma Registry for trauma patients who were transported by EMS to a level 1 trauma center between 2017 and 2018. Data were analyzed and compared between urban and rural areas and among the different municipalities in which the incidents occurred. Results: Across the study duration, 1761 patients were transported by EMS. Of that, 59% were transported from an urban area and 41% from rural areas. There were significant differences in the on-scene time and total prehospital time as a function of urban and rural areas and municipalities; however, the response time across the study groups was comparable. There were no significant differences in blood transfusion, intubation, hospital length of stay, and mortality. Conclusion: Within different areas in Qatar, the EMS response time and in-hospital outcomes were comparable. This indicates that the provision of prehospital care across the country is similar. The prehospital and acute in-hospital care are accessible for everyone in the country at no cost. Understanding the differences in EMS utilization and prehospital times contributes to the policy development in terms of equitable distribution of healthcare resources.

AB030. SOH21AS141. Endoscopy in isolation: effect of COVID-19 on endoluminal diagnoses in a Level 3 hospital

Background: The SARS-CoV-2 2019 (COVID-19) pandemic has had a dramatic effect on the ability to deliver acute in-hospital care due to restrictions on elective and emergency services. This has been compounded by patients’ reticence to attend their general practitioner or emergency department. We sought to identify if these service disruptions affected the endoluminal diagnosis of malignancies in our Level 3 hospital.

Quality of care of acute ischemic stroke in Germany 2018

In this overview the current quality of acute in-hospital care of stroke patients in Germany in 2018 is described based on standardized and evidence-based quality indicators. For this purpose the reports of the regional quality assurance projects for stroke care, which collaborated within the German-speaking Stroke Registers Study Group (ADSR) were analyzed. Overall, more than 280,000 acute admissions of stroke patients were documented in the included quality assurance projects. The results regarding the defined 16 quality indicators comprising diagnostics, acute treatment, rehabilitation and secondary prevention showed ahigh level of acute inpatient treatment of stroke in Germany. Only a few quality indicators, such as early transfer for thrombectomy indicated a great necessity for process optimization.

Validation of REAGERA-S: a new self-administered instrument to identify elder abuse and lifetime experiences of abuse in hospitalized older adults

ABSTRACT This study aimed to develop and validate REAGERA-S, a self-administered instrument to identify elder abuse as well as lifetime experiences of abuse in older adults. REAGERA-S consists of nine questions concerning physical, emotional, sexual, financial abuse and neglect. Participants were recruited among patients (≥ 65 years) admitted to acute in-hospital care (n = 179). Exclusion criteria were insufficient physical, cognitive, or language capacity to complete the instrument. A semi-structured interview conducted by a physician was used as a gold standard against which to assess the REAGERA-S. The final version was answered by 95 older adults, of whom 71 were interviewed. Sensitivity for lifetime experiences of abuse was 71.9% and specificity 92.3%. For elder abuse, sensitivity was 87.5% and specificity was 92.3%. REAGERA-S performed well in validation and can be recommended for use in hospitals to identify elder abuse as well as life-time experience of abuse among older adults.

Freiburg Cardiac Arrest Receiving Team (CART) : Interdisciplinary solution for the acute management of non-traumatic out-of-hospital cardiac arrest

Standard procedures and guidelines provide specific instructions for basic and advanced cardiac life support. Recommendations for the admission of patients from preclinical into clinical structures after successful cardiopulmonary resuscitation (CPR) are available, but only a few are detailed. In the presence of ST-elevation myocardial infarction after return of spontaneous circulation (ROSC), coronary angiography must be performed as soon as possible. However, acute management and consecutive diagnostic procedures after hospital admission are up to the doctor on duty, who can rely on standard internal hospital procedures at best. Despite the enormous progress and new findings in intensive care and emergency medicine, intra-hospital mortality, as well as long-term survival, after CPR remains low and depends on awide variety of influencing factors. To optimize in-hospital acute care of successfully resuscitated patients, an interdisciplinary admission team, a so-called cardiac arrest receiving team (CART), has been implemented at the University Hospital of Freiburg, Germany. The aim of the CART is to provide primary care to resuscitated patients as quickly and in as standardized a manner as possible with predefined diagnostic and therapeutic pathways by ateam with special expertise in the field of CPR and post-resuscitation management. Accordingly, clear criteria for procedures and the location of primary care (e.g. emergency room vs. cardiac catheter laboratory), the composition of the CART and concrete treatment measures were defined.

In-hospital costs after severe traumatic brain injury: A systematic review and quality assessment.

BackgroundThe in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology.MethodsA systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement.ResultsTwenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported.ConclusionsHealthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.

ANMCO/SIC Consensus Document: cardiology networks for outpatient heart failure care

Changing demographics and an increasing burden of multiple chronic comorbidities in Western countries dictate refocusing of heart failure (HF) services from acute in-hospital care to better support the long inter-critical out-of- hospital phases of HF. In Italy, as well as in other countries, needs of the HF population are not adequately addressed by current HF outpatient services, as documented by differences in age, gender, comorbidities and recommended therapies between patients discharged for acute hospitalized HF and those followed-up at HF clinics.The Italian Working Group on Heart Failure has drafted a guidance document for the organisation of a national HF care network. Aims of the document are to describe tasks and requirements of the different health system points of contact for HF patients, and to define how diagnosis, management and care processes should be documented and shared among health-care professionals.The document classifies HF outpatient clinics in three groups: (i) community HF clinics, devoted to management of stable patients in strict liaison with primary care, periodic re-evaluation of emerging clinical needs and prompt treatment of impending destabilizations, (ii) hospital HF clinics, that target both new onset and chronic HF patients for diagnostic assessment, treatment planning and early post-discharge follow-up. They act as main referral for general internal medicine units and community clinics, and (iii) advanced HF clinics, directed at patients with severe disease or persistent clinical instability, candidates to advanced treatment options such as heart transplant or mechanical circulatory support. Those different types of HF clinics are integrated in a dedicated network for management of HF patients on a regional basis, according to geographic features. By sharing predefined protocols and communication systems, these HF networks integrate multi-professional providers to ensure continuity of care and patient empowerment.In conclusion, This guidance document details roles and interactions of cardiology specialists, so as to best exploit the added value of their input in the care of HF patients and is intended to promote a more efficient and effective organization of HF services.

Abstract P260: Mind the Time: A Quality Improvement Project to Increase the Percent of Ischemic Stroke Patients Receiving Intravenous Tissue Plasminogen Activator within 60 Minutes after Arrival at the Emergency Department

Background and Purpose: Stroke is the third leading cause of death and leading cause of long term disability in the USA. Intravenous administration of tissue plasminogen activator (t-PA) is the only FDA approved medical therapy for treatment of patients with acute ischemic stroke. It is recommended by the American Heart Association that earlier treatment with t-PA within 90 minutes of symptoms may result in a more favorable patient outcome. Initiating t-PA for ischemic stroke patients within 60 minutes after Emergency Department (ED) triage is an indicator tracked by the Get With The Guidelines database. The purpose of our project was to increase the number of ischemic stroke patients receiving t-PA within 60 minutes after triage. Methods: The Six Sigma® process model was applied in order to develop an understanding of variations in the times of triage to initiation of IV t-PA data. We assembled a multidisciplinary team to develop and measure aspects of our current protocols, analyze data, investigate and identify the causes of delays and form action plans to enhance our new process. We tracked the patient flow from first responder contact to thrombolysis time. As a result the team acknowledged that it was imperative to impact the early recognition of ischemic stroke patients in the field. This led to local and regional stroke educational programs. Our neuroscience team of physicians and nurses proceeded to educate over 850 emergency responders. Results: Initial analysis of the baseline data showed that 56 % (5 of 9) of the ischemic stroke patients received intravenous t-PA within 60 minutes of triage. Once the stroke code process was implemented, 79 % (15 of 19) of ischemic stroke patients received intravenous t-PA within 60 minutes after triage. These results were obtained within 9 months of process implementation. Specific process changes included the use of a standard time clock, shorter CT scan turn around times, dedicated 24/7 ED pharmacists, quicker availability of medication administration pumps and ongoing feedback by all team members on the acute stroke process. Conclusions: The stroke team was able to identify barriers, institute process changes and ensure the implementation of change from the prehospital community setting to the acute inhospital care.

Patient Dissatisfaction With Acute Stroke Care

Riks-Stroke, the Swedish Stroke Register, was used to explore patient characteristics and stroke services as determinants of patient dissatisfaction with acute in-hospital care. All 79 hospitals in Sweden admitting acute stroke patients participate in Riks-Stroke. During 2001 to 2007, 104,876 patients (87% of survivors) responded to a follow-up questionnaire 3 months after acute stroke; this included questions on satisfaction with various aspects of stroke care. The majority (>90%) were satisfied with acute in-hospital stroke care. Dissatisfaction was closely associated with outcome at 3 months. Patient who were dependent regarding activities of daily living, felt depressed, or had poor self-perceived general health were more likely to be dissatisfied. Dissatisfaction with global acute stroke care was linked to dissatisfaction with other aspects of care, including rehabilitation and support by community services. Patients treated in stroke units were less often dissatisfied than patients in general wards, as were patients who had been treated in a small hospital (vs medium or large hospitals) and patient who had participated in discharge planning. In multivariate analyses, the strongest predictor of dissatisfaction with acute care was poor outcome (dependency regarding activities of daily living, depressed mood, poor self-perceived health). Dissatisfaction with in-hospital acute stroke care is part of a more extensive complex comprising poor functional outcome, depressive mood, poor self-perceived general health, and dissatisfaction not only with acute care but also with health care and social services at large. Several aspects of stroke care organization are associated with a lower risk of dissatisfaction.

Resultados asistenciales de las unidades geriátricas de agudos. Revisión sistemática

Background The aim of this study was to perform a systematic review of the scientific information related to the results of in-hospital acute care for the elderly (ACE) units. Material and method The search strategy included consultation of different bibliographic databases (MEDLINE, EMBASE, Dialnet and the Cochrane Central Register of Controlled Trials), review of the contents pages of five geriatric journals, and a retrospective search of the references in published articles. Results Forty-one articles with information on the results of ACE units were identified. Of these, only 21 met the inclusion criteria. These 21 articles provided data on 18 experiences in 19 hospitals. All the studies except one found a reduction in the mean length of stay in ACE units compared with conventional hospitalization. This reduction ranged from 30% to 54% in studies with historical samples, was more than 10% in hospital database studies, and ranged from 17% to 46% ( P<.01) in case-control studies. Of 5 randomized controlled studies, 2 reported significant reductions in length of stay (19% and 24%, P<.01), another two studies reported trends in the same direction (3% and 12%) and 1 study found an increase in length of stay (32%) in the ACE unit. These studies reported tendencies towards reduced costs, lower institutionalization and functional improvement in patients admitted to ACE units. Conclusions The studies performed to date show reductions in length of stay in elderly patients admitted to ACE units for acute illness compared with conventional hospitalization, leading to resource savings without decreasing the quality of care. The establishment of ACE units should be considered in hospitals without these units.

Advancing Nursing Practice

Both patient and staff satisfaction with the SNP role has been high as it relates to quality of care delivery and accessibility of care and service. In particular, patients express satisfaction with the continuity of care experienced throughout the stroke care continuum, from acute in-hospital care to postdischarge follow-up. Improvements have been realized in systems and processes of care with the implementation of the SNP role. These include reductions in door-to-needle times in the administration of tPA (from 90 minutes to 60 minutes), rapid assessment and diagnostic interventions through coordination of are activities (e.g., door-to-CT scan times reduced from 60 minutes to 30 minutes), and faster consultation responses within the organization. Instituting the nurse practitioner role early in the development of the Calgary Stroke Program enhanced patient care while advancing the nursing discipline. The SNP has created a role that extends beyond that of physician helper to an autonomous nursing practice that has been beneficial to both patients with stroke and the regional healthcare delivery system. With the ability to practice autonomously, the nurse practitioner can aid in the expedient delivery of complex, comprehensive stroke care, as has been the case in the Calgary Stroke Program.

NEW APPROACHES TO EDUCATING SOCIAL WORK PROFESSIONALS FOR ADMINISTRATIVE ROLES IN A NATIONAL HEALTH SYSTEM

As national health insurance becomes a reality we can anticipate a shift in emphasis from delivery of acute in-hospital care to community-based care. Professional social work functions in the future will likely be increasingly directed toward the administration and management of supportive health care services. This paper describes an interdisciplinary graduate educational program in administration and management of social health care services, developed by the School of Social Work jointly with the Maxwell School of Citizenship and Public Affairs at Syracuse University and the Upstate Medical Center in Syracuse. The curriculum is designed to train future social work professionals in planning, evaluation, and managerial skills necessary to perform middle-management and decision-making functions. The curriculum is provided by an interdisciplinary faculty team, and implemented with a task-oriented problem-solving approach. The program is in its 3rd year and hsa graduated 20 students.