Acute Medical Hospital Research Articles

A "Whole Child Approach": Parent Experiences with Acute Care Hospitalizations for Children with Autism Spectrum Disorder and Behavioral Health Needs.

Children with Autism Spectrum Disorder (ASD) experience increased hospitalizations as compared to the general population, particularly in the context of mental health crises. Given the unique needs of children with ASD and behavioral health needs that can either lead to or emerge during hospitalization, an understanding of hospital experiences is critical. To date, research on caregiver experiences in acute care medical hospital settings is limited. Therefore, the purpose of this qualitative study was to investigate caregiver experiences with inpatient care for children with ASD and behavioral health needs, including factors and practices that impacted or were desirable for care. Two focus groups were conducted with a total of 12 parents of children with ASD admitted to a large pediatric hospital. Data were analyzed using interpretive description. Emerging themes pointed to the child, family, and staff factors and practices that intersect to influence hospitalization experiences. Child factors included the child's communication, sensory, behavioral, medical, and safety needs. Family factors included the family's relationship with the healthcare team, own needs, and advocacy experiences. Staff factors included staff communication practices, comfort, and knowledge when providing care. Overall, this research demonstrates the complexity of factors and practices that impact the behavioral health hospitalization experience for children with ASD and their caregivers. Experiences varied widely and were guided by the unique needs of each child. Findings point to care practices that can be adopted to best meet the needs of all stakeholders during hospitalization and offer implications for future educational initiatives.

Medical Considerations and Consequences of Eating Disorders.

Eating disorders may result in medical complications that affect every body system with both acute and chronic consequences. Although some medical complications may require acute medical hospitalization to manage, other complications, such as low bone mineral density, may not present until malnutrition has become chronic. It is critical for team members to be aware of the early clinical signs of malnutrition and disordered eating behaviors, as well as longer-term complications that may affect their patients. When identifying eating disorder concerns, appropriate colleagues from the medical, nutrition, and psychiatric fields can be engaged in order to collaborate on stabilizing and improving the health of patients.

Multimorbidity-associated emergency hospital admissions: a “screen and link” strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol

Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub–Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng’ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.

Identifying potential cases of eating disorders in an acute medical hospital.

To identify patients presenting to an acute medical hospital with common signs and symptoms that occur in people with eating disorders (EDs), and determine by retrospective file audit if these are diagnosed cases of an ED. The investigators screened electronic medical records of people 16 years and older for common signs and symptoms of an ED such as hypokalemia, in patients presenting to an acute hospital in Sydney, Australia from 2018 to 2020. Cases where the clinical finding was unexplained had their file audited. Cases with a known ED diagnosis or coded with an ED were also retrieved to audit. Investigators identified 192 definite ED cases with a total of 598 episodes of care from 2018 to 2020 presenting to the hospital. Eighty-three cases were identified as possible EDs due to unexplained clinical signs consistent with an ED, but were not confirmed cases due to lack of clinical history in the file. Only 19.1% of presentations were diagnostically coded with an ED in the electronic medical record. Our study revealed a large number of definite ED cases presenting to an acute medical hospital via the emergency department, who were not recognized as having an ED. Greater awareness of clinical signs and symptoms of an ED, such as unexplained low body mass index and hypokalemia, is necessary among acute care clinicians. Correctly identifying EDs in those seeking somatic care should be a public health priority, to facilitate timely and equitable access to diagnostic assessment and evidence based treatment. People with eating disorders (EDs) present to acute care settings and have a relatively high utilization of generalist health services with nonspecific problems such as abdominal pain. An enhanced understanding of healthcare utilization by people with EDs, who may not disclose their symptoms, is crucial for improving access to treatment.

Multimorbidity-associated emergency hospital admissions: a "screen and link" strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol.

The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub-Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng'ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.

1813. A Retrospective Review of the Safety and Efficacy of Dalbavancin at Ireland's Largest Acute Medical Hospital

Abstract Background Dalbavancin is second-generation lipoglycopeptide antibiotic. It is licensed in Ireland and the United States for the management of acute skin and soft tissue infections. International colleagues report treatment success in its use for patients who are unable to stay in the hospital for prolonged periods and not suitable for OPAT [1]. We reviewed the use of Dalbavancin at St James's Hospital Dublin, which is the largest hospital in Ireland with over 700 acute beds. We are located in Dublin’s inner city which experiences significant socio-economic deprivation. Methods We used the electronic patient records at St James's Hospital to capture all uses of Dalbavancin from August 2018 to September 2022. We established baseline demographics, indication, microbiological characteristics if there was oversight by ID/micro, safety, and treatment outcomes. Results < We identified 23 patients who met the inclusion criteria Base demographic: The most common indication was endovascular infection (35%) and skin and soft tissue infection (35%). (Figure 1) Most patients were not bacteremic. Staph aureus was the most common organism identified on blood culture (figure 2) 322 hospital bed were saved which equates to 257,600 euro 0 patients had an adverse drug reaction 100% of cases were discussed with micro or ID Conclusion Dalbavancin is a safe and effective drug. It is another tool that can be used when caring for patients who are experiencing unstable housing and challenging social circumstances. Our experience has found 0 adverse events, 69% of patients experienced treatment success (this increases to 88.8% if we exclude those lost to follow up). This is an important finding considering on 17% of indications were considered ‘on label’. Dalbavancin can save money on hospital beds and also reduces non-recyclable plastic associated with repeated doses of IV antibiotics. Disclosures All Authors: No reported disclosures

Developing Partial Cognitive Impairment During Hospital Treatment: Capacity Assessment, Safeguarding or Recovery?

ABSTRACT This paper examines the ethical conundrum between a hospital's ethos of relieving distress, investigation and treatment, and its concurrent duties under English law to administer tests of decision-making capacity and safeguarding protection where it believes the patient may lack this capacity. Delirium, characterised by a precipitous decline in mental functioning exhibiting the shared symptomology of recoverable depressive disorders and terminal dementia, is not uncommon after emergency admission of elderly patients into acute medical hospital wards. The use of functional capacity testing as a benchmark for decision-making capacity for post-discharge residence has been criticised as outdated, conceptually floored, subjective, lacking central guidance, transparent process, and accountability. A study of patient experience demonstrates the potential for hospital misuse of capacity testing, the failure of functional testing to differentiate decision making capacity from the disability of partial cognitive impairment, and how hospital capacity processes can interact and amplify patient pathology thereby decreasing recovery prospects. Prioritisation of mental capacity obligations above thorough investigation of emergent mental pathology and relief of patient anguish, results in extended detention in medical wards lacking bespoke facilities. Further understanding of patient experience is needed to inform policy with interventions tailored to avoid harm and increase wellbeing.

Characteristics, disposition, and outcomes of children hospitalized for mental health boarding at a children's hospital.

Increasingly, youth experiencing mental health crises present to acute care medical hospitals and "board" on medical units due to inpatient psychiatric bed shortages. We conducted a retrospective cohort study of children experiencing mental health boarding at a US children's hospital from October 2020 to September 2022. We examined associations between patients'characteristics and their disposition and outcomes. Our cohort included 1891 boarding hospitalizations: 53.9% transferred to an inpatient psychiatric hospital and 46.1% discharged home. Characteristics associated with not being transferred to an inpatient psychiatric hospital includedage <13 years (adjusted odds ratio [aOR] 0.6; 95% confidence interval [CI]: 0.4-0.7), disruptive or aggressive behavior (aOR 0.6; 95% CI: 0.4-0.8), psychosis (aOR 0.5; 95% CI: 0.3-0.8), COVID-19 infection (aOR 0.3; 95% CI: 0.2-0.6), or a complex chronic medical condition (aOR 0.8; 95% CI: 0.6-1.0). Our findings suggest that certain populations of children experiencing mental health boarding face disparate access to inpatient psychiatric care.

Perspectives of patients and clinicians on older patient mobility on acute medical wards: a qualitative study

BackgroundLow mobility during an acute care medical hospitalization is frequent and associated with adverse outcomes, particularly among older patients. Better understanding barriers and facilitators to improve mobility during hospitalization could help develop effective interventions. The goal of this study was to assess barriers and facilitators to older medical patients’ hospital mobility, from the point of view of patients and clinicians, to develop a framework applicable in clinical practice.MethodsWe conducted a qualitative study in one university and two non-university hospitals of two different language and cultural regions of Switzerland, including 13 focus groups (FGs; five with patients, eight with clinicians). We included 24 adults aged 60 years or older hospitalized on an acute general internal medicine ward of one of the three participating hospitals during the previous years, and 34 clinicians (15 physicians, nine nurses/nursing assistants, 10 physiotherapists) working on those wards. The FG guides included open-ended questions exploring mobility experiences, expectations, barriers and facilitators to mobility, consequences of low mobility and knowledge on mobility. We applied an inductive thematic analysis.ResultsWe identified four themes of barriers and facilitators to mobility: 1) patient-related factors; 2) clinician-related factors; 3) social interactions; and 4) non-human factors. Clinician-related factors were only mentioned in clinician FGs. Otherwise, subthemes identified from patient and clinician FGs were similar and codes broadly overlapped. Subthemes included motivation, knowledge, expectations, mental and physical state (theme 1); process, knowledge – skills, mental state – motivation (theme 2); interpersonal relationships, support (theme 3); hospital setting – organization (theme 4).ConclusionsFrom patients’ and clinicians’ perspectives, a broad spectrum of human and structural factors influences mobility of older patients hospitalized on an acute general internal medicine ward. New factors included privacy issues and role perception. Many of those factors are potentially actionable without additional staff resources. This study is a first step in participatory research to improve mobility of older medical inpatients.

Six domains of health: a practical approach to identifying priorities in dementia care.

High-quality healthcare for people living with dementia encompasses both patients and care partners (CPs). A framework populated with simple assessment tools is needed to deconstruct this complexity into actionable domains that inform assessment and care planning for individuals and dyads, help differentiate care team roles, and can more fully estimate true population burden in health and social care systems. Researchers used a cross-sectional mixed-methods descriptive study to illustrate the use of an inductive Six Domain framework and simple assessment tools in a sample of dyads selected for complexity. Data was collected from three university-affiliated hospitals with a shared electronic medical record (EMR). Eighty-eight CPs for people living with dementia (care recipients) newly discharged home after an acute medical hospitalization participated. Care recipients' outpatient and inpatient diagnoses, medications, and care were extracted from the EMR. CPs completed an in-home semi-structured interview and study measures. Data were sorted into six domains: three care recipient-focused domains (cognition, emotion/behavior, general and functional health); a single CP-focused domain (mood, cognition, stress, and self-rated health); a health-related social needs domain (enrollment of persons with dementia in low-income insurance, CP-reported financial strain); and a care delivery domain (CP-reported engagement with clinicians in care recipients' care planning, and match between CP-reported knowledge of care recipients' medical care needs and medical records). As expected, all people living with dementia had significant cognitive, neurobehavioral, and medical complexity requiring extensive oversight and management at home. Over a third of CPs reported high stress, depression, or anxiety. A fifth screened positive for one or more indicators of poor health, cognitive impairment, and/or health-related social needs. CP reports and care recipients' medical records were discordant for chronic conditions in 68% of cases and for prescribed medications in 44%. In 85% of cases, there were gaps in indicators of CP-clinician collaboration in care management. The Six Domains of Health framework captures a broad array of challenges that are relevant to providing comprehensive dyadic care and setting individualized health and social care priorities. With further study, it could provide conceptual scaffolding for comparative population research and more equitable, fully integrated pathways for care.

P37 A retrospective audit of molnupiravir prescribing in the virtual hospital via the CMDU pathway

Abstract Background In December 2021, COVID-19 medicine delivery units (CMDU) were launched across NHS hospitals in England. They offered treatment to non-hospitalized patients who tested positive for COVID-19 and were at high risk of progression to severe disease. At the time of auditing (November 2022), NHS England had commissioned four different treatment options. Even though each of them was not directly compared in clinical trials at the time, NHSE clearly specified the order in which treatment option should be considered. Nirmatrelvir boosted with ritonavir or sotrovimab was first line. Then, remdesivir and finally molnupiravir are the last options.1,2,3 Even though molnupiravir has less drug–drug interactions and can be used with patients in all stages of renal impairment, NHSE recommended it last because at the time, it appeared to be the least effective of all four therapies.3 Objectives To review current prescribing practice of COVID-19 medicines in the virtual hospital and to improve stewardship within the Acute Medical Unit virtual hospital. Standards (i) 100% of patients prescribed molnupiravir had a confirmed SARS-CoV-2 infection, (ii) 100% of patients prescribed molnupiravir were ineligible for treatment with nirmatrelvir/ritonavir due to severe liver impairment or kidney disease, (iii) 100% of patients prescribed molnupiravir were ineligible for treatment with nirmatrelvir/ritonavir due to significant drug–drug interactions and (iv) 100% of patients prescribed molnupiravir should have a documented reason in EPR as to why they were ineligible for treatment with sotrovimab. The criteria and standards above were set using the Interim Clinical Commissioning Policy: Antivirals or neutralizing monoclonal antibodies for non-hospitalized patients with COVID-19. Methods All patients admitted to the virtual hospital via the CMDU pathway during the 9-month period from 1 January to 30 September 2022 were included in audit. A total of 602 patients were prescribed molnupiravir during this period, and 34 patients were selected randomly. The data collection involved a retrospective case note review of 34 electronic patient records (EPR) over one working week between 24 October and 28 October 2022. Data from 3 patients were excluded from the audit as liver and/or function tests were unavailable in EPR; thus, N = 31. The data collection was recorded on a Microsoft Excel data toolkit, which included the confirmation of SARS-CoV-2 infection, date of treatment commenced, nirmatrelvir/ritonavir drug interactions1, liver and renal function tests2–3 (ALT, ALP, bilirubin, eGFR/CrCl and CKD) and consideration of sotrovimab as alternative first-line treatment with documented reason. The data was then analysed and graphs were generated to draw results. All standards were set at 100%. This study did not require ethical approval. Results The results after data collation revealed that 100% patients prescribed molnupiravir had a confirmed SARs-CoV-2 infection; 29% patients were ineligible for treatment with nirmatrelvir/ritonavir due to stage 3–5 CKD; 29% patients were ineligible for treatment with nirmatrelvir/ ritonavir due to significant drug–drug interactions; 22.6% patients had a documented reason in their electronic record as to why they were ineligible for treatment with sotrovimab. Discussion and action plan Majority (71%) of patients prescribed molnupiravir did not have severe CKD or severe liver impairment. They were eligible for treatment with nirmatrelvir/ritonavir, provided that these patients did not have significant drug interactions with concomitant medications. Although most cases had documented the interactions with concomitant medications, 64.5% patients had potential interactions that could have been worked around. Documentation was poor as to why sotrovimab was not considered as first-line alternative treatment and this was fed back to the virtual hospital team to document rationale for treatment going forward. Nirmatrelvir/ritonavir could have been co-administered with concomitant medications in most cases. The team now have access to a dedicated antimicrobial pharmacist when they need advice. Limitations Both liver function tests and renal function tests were unavailable at the time when molnupiravir treatment was commenced. Hence, lab results within 1 year were used as part of this audit. Due to time constraints, only a small part of patients prescribed molnupiravir was studied. Conclusions Majority of patients were inappropriately prescribed molnupiravir, as their renal function/liver function was not poor enough to exclude them from treatment with nirmatrelvir/ritonavir. The poor documentation means we do not know why the other first-line and second-line options were not considered. Whilst a lot of patients were on medicines that interacted with nirmatrelvir/ritonavir, the majority were not significant and could have been worked around.

P03 A retrospective review of the safety and efficacy of dalbavancin at Ireland’s largest acute medical hospital

Abstract Background Dalbavancin is a second-generation lipoglycopeptide antibiotic. It is licensed in Ireland and the United Kingdom for the management of acute skin and soft tissue infections. International colleagues report treatment success in its use for patients who are unable to stay in hospital for prolonged periods and not suitable for OPAT.1 We reviewed the use of dalbavancin at St. James’s Hospital, Dublin, which is the largest hospital in Ireland with over 700 acute beds. We are located in Dublin’s inner city which experiences significant socio-economic deprivation. Methods We used the electronic patient records at St. James’s Hospital to capture all uses of dalbavancin from August 2018 to September 2022. We established baseline demographics, indication, microbiological characteristics, if there was oversight by ID/micro, safety and treatment outcomes. We considered how many hospital days were saved if a patient was changed to dalbavancin and discharged home compared with how long they would have required to stay in hospital to pursue conventional treatment. One hospital day in an acute bed is estimated to cost 800€. Results We identified 23 patients who met the inclusion criteria. Baseline demographics are shown in Table 1. The most common indication was endovascular infection (35%) and skin and soft tissue infection (35%) (Figure 1). Most patients were not bacteraemic. Staphylococcus aureus was the most common organism identified on blood culture (Figure 2). In total, 322 hospital beds were saved, which equates to 257 600 EUR. No patients had an adverse drug reaction. 100% of cases were discussed with micro or ID. Conclusions Dalbavancin is a safe and effective drug. It is another tool that can be used when caring for patients who are experiencing unstable housing and challenging social circumstances. Our experience has found 0 adverse events, 69% of patients experienced treatment success (this increases to 88.8% if we exclude those lost to follow up). This is an important finding considering 17% of indications were considered ‘on label’. Dalbavancin can save money on hospital beds and also reduces non-recyclable plastic associated with repeated doses of IV antibiotics.

Opioid-related deaths during hospital admissions or shortly after discharge in the United Kingdom: A thematic framework analysis of coroner reports.

People who use heroin and other illicit opioids are at high risk of fatal overdose in the days after hospital discharge, but the reasons for this risk have not been studied. We used the National Programme on Substance Abuse Deaths, a database of coroner reports for deaths following psychoactive drug use in England, Wales, and Northern Ireland. We selected reports where the death occurred between 2010 and 2021, an opioid was detected in toxicology testing, the death was related to nonmedical opioid use, and death was either during an acute medical or psychiatric hospital admission or within 14 days after discharge. We used thematic framework analysis of factors that may contribute to the risk of death during hospital admission or after discharge. We identified 121 coroners' reports; 42 where a patient died after using drugs during hospital admission, and 79 where death occurred shortly after discharge. The median age at death was 40 (IQR 34-46); 88 (73%) were male; and sedatives additional to opioids were detected at postmortem in 88 cases (73%), most commonly benzodiazepines. In thematic framework analysis, we categorised potential causes of fatal opioid overdose into three areas: (a) hospital policies and actions. Zero-tolerance policies mean that patients conceal drug use and use drugs in unsafe places such as locked bathrooms. Patients may be discharged to locations such as temporary hostels or the street while recovering. Some patients bring their own medicines or illicit opioids due to expectations of low-quality care, including undertreated withdrawal or pain; (b) high-risk use of sedatives. People may increase sedative use to manage symptoms of acute illness or a mental health crisis, and some may lose tolerance to opioids during a hospital admission; (c) declining health. Physical health and mobility problems posed barriers to post-discharge treatment for substance use, and some patients had sudden deteriorations in health that may have contributed to respiratory depression. Hospital admissions are associated with acute health crises that increase the risk of fatal overdose for patients who use illicit opioids. Hospitals need guidance to help them care for this patient group, particularly in relation to withdrawal management, harm reduction interventions such as take-home naloxone, discharge planning including continuation of opioid agonist therapy during recovery, management of poly-sedative use, and access to palliative care.

Development and Validation of the Medical Emergency Team-Risk Prediction Model for Clinical Deterioration in Acute Hospital Patients, at Time of an Emergency Admission.

To develop and validate a prediction model to estimate the risk of Medical Emergency Team (MET) review, within 48 hours of an emergency admission, using information routinely available at the time of hospital admission. Development and validation of a multivariable risk model using prospectively collected data. Transparent Reporting of a multivariable model for Individual Prognosis Or Diagnosis recommendations were followed to develop and report the prediction model. A 560-bed teaching hospital, with a 22-bed ICU and 24-hour Emergency Department in Melbourne, Australia. A total of 45,170 emergency admissions of 30,064 adult patients (≥18 yr), with an inpatient length of stay greater than 24 hours, admitted under acute medical or surgical hospital services between 2015 and 2017. The outcome was MET review within 48 hours of emergency admission. Thirty candidate variables were selected from a routinely collected hospital dataset based on their availability to clinicians at the time of admission. The final model included nine variables: age; comorbid alcohol-related behavioral diagnosis; history of heart failure, chronic obstructive pulmonary disease (COPD), or renal disease; admitted from residential care; Charlson Comorbidity Index score 1 or 2, or 3+; at least one planned and one emergency admission in the last year; and admission diagnosis and one interaction (past history of COPD × admission diagnosis). The discrimination of the model was comparable in the training (C-statistics 0.82; 95% CI, 0.81-0.83) and the validation set (0.81; 0.80-0.83). Calibration was reasonable for training and validation sets. Using only nine predictor variables available to clinicians at the time of admission, the MET-risk model can predict the risk of MET review during the first 48 hours of an emergency admission. Model utility in improving patient outcomes requires further investigation.

Workplace health promotion interventions for nurses in Germany: a systematic review based on the RE-AIM framework

BackgroundThe German health care system is faced with a serious shortage of nurses. This is associated, amongst other things, with difficult working conditions and work-related health burdens. Workplace health promotion (WHP) is considered a promising approach to promote the health of nurses. The present review aims to give an overview on existing interventions in different nursing settings (acute care hospitals, long-term care (LTC) facilities and home-based long-term care) in Germany.MethodsA systematic literature search was conducted in PubMed and PubPsych. Studies were included if published after 2010 and provided data of intervention studies on workplace health promotion among nurses in Germany (RCTs, non-RCTs, non-controlled intervention studies and pilot studies). The setting in which the study was conducted (acute medical care hospital, inpatient LTC facilities, home-based LTC, cross-setting) as well as the health issue assessed (physical health, mental health and/or violence experience) were extracted. The intervention was reported against the background of the quality criteria for prevention measures of the statutory health insurers in Germany. The results of the studies were presented according to the RE-AIM framework.ResultsEleven studies on WHP for nurses were included, whereof seven studies were conducted in acute medical care hospitals and four in LTC facilities. No study reported results on WHP for nurses working in the setting of home-based LTC. Most studies aimed at improving mental health. The intervention contents and forms of implementation were heterogeneous. According to the RE-AIM criteria, the reporting of most studies showed several limitations, especially a lack of reporting on Implementation and Adoption. Most studies showed no statistically significant effect on the respective outcomes (Effectiveness). Four studies reported results on Maintenance indicating a sustained effectiveness.ConclusionDespite the high relevance for health promotion for nurses, our review showed a striking lack of intervention studies in this field. From this we derive a high need of tailored interventions, taking into account the setting-specific development, implementation of WHP interventions for nurses. With regard to the evaluation, the RE-AIM criteria should be taken more into account in order to meet the requirements of evaluating complex interventions and thus contribute to evidence development of WHP in nursing. In terms of content, the topic of violence prevention and dealing with experiences of violence should also be taken into account. Regarding the settings, the working conditions and health burdens in LTC facilities, home-based LTC and acute medical hospitals must be considered.Trial registrationPROSPERO registration number: CRD42021231891

Health Care Expenditures Among Individuals With Chronic Psychotic Disorders in Ontario: An Analysis Over Time.

Chronic psychotic disorders are severe and disabling mental disorders associated with poor psychiatric and medical outcomes, and among the most costly mental disorders to treat. Understanding trends in aggregate health care expenditures over time, and respective drivers, can provide relevant insights for decision makers, namely around appropriate allocation of scarce resources within the health care sector. Using administrative health care times series data from Ontario, this analysis examined trends in aggregate public health care expenditures and activity from 2012 to 2019 among all individuals with a diagnosis of a chronic psychotic disorder. Total aggregate health care expenditures for individuals with a chronic psychotic disorder in Ontario increased at a moderate rate over this time period, in line with the growth of the number of people diagnosed, and thus not likely driven by unit costs or resource use. Psychiatric hospitalizations made up the largest share of health care expenditures (~30%). Nonetheless, among all health services, expenditures of acute medical hospitalizations, outpatient prescription drugs and home care saw the largest growth over time. Mean/per capita health care expenditures were greater for females, and increased with age as well as with the presence of comorbidities/chronic conditions. In particular, mean/per capita health care expenditures increased steadily with the number of comorbidities and were highest for individuals with 5 or more comorbidities and those with congestive heart failure, highlighting the ever-increasing importance of addressing physical health conditions among this patient population. These findings will have important implications for decision makers, namely around the appropriate allocation of health care resources for patients with chronic psychotic disorders. Future research should continue to monitor health care expenditures for individuals with chronic psychotic disorders as well as extend this analysis beyond 2019 to understand how the COVID-19 pandemic, and resulting lockdowns, has impacted aggregate health care expenditures and outcomes for patients living with chronic psychotic disorders.

Impact of Change in Allocation Score Methodology on Post Kidney Transplant Average Length of Stay.

BackgroundIn December 2014, a new Kidney Allocation System (KAS) was implemented nationwide to improve access and quality of care to historically disadvantaged patients. However, no study to date has examined the relationship between the KAS and potential changes in hospital length of stay (LOS). This study aimed to examine the relationship between the KAS implemented in December 2014 and potential changes in hospital LOS.MethodsWe used data from the Florida Agency for Health Care Administration on kidney transplant surgeries completed between 2011 and 2018. A cross-sectional cohort study design included seven hospitals that performed kidney transplants for the duration of the study. A propensity score matching approach was used to examine the relationship between KAS and LOS. All acute general medical and surgical hospitals in Florida that performed kidney transplant surgery were included in the analysis.ResultsWe included 7,795 patients, 6,119 discharged to home, and 1,676 discharged to home with home health services after transplant. The average LOS prior to KAS was 6.52 days and 6.08 days post KAS. Propensity matched results show that patients transferred to home experienced a decrease in the LOS (coefficient (β) = -0.68; 95% confidence interval (CI): -0.95, -0.42) after the new allocation score was implemented. Similarly, patients transferred to home with home health experienced a decrease in the LOS (β = -1.90; 95% CI: -2.69, -1.11) after the new allocation was implemented.ConclusionIn conclusion, results indicate that KAS implementation did not add a burden on the health system by increasing LOS when considering patients with similar characteristics before and after KAS implementation. KAS is an important policy change that appears to not negatively affect the LOS when sicker patients could receive a kidney transplant. Our findings improve our understanding of the KAS policy and its influence on the health system.

Differences in the delivery of medications for opioid use disorder during hospitalization by racial categories: A retrospective cohort analysis

Background: As the drug-related overdose crisis and COVID-19 pandemic continue, communities need increased access to medications for opioid use disorder (MOUD) (i.e., buprenorphine and methadone). Disparities in the type of MOUD prescribed or administered by racial and ethnic categories are well described in the outpatient clinical environment. It is unknown, however, if these disparities persist when MOUD is provided in acute care hospitals. Methods: This study assessed differences in the delivery of buprenorphine versus methadone during acute medical or surgical hospitalizations for veterans with opioid use disorder (OUD) by racial categories (Black Non-Hispanic or Latino vs. White Non-Hispanic or Latino). Data were obtained retrospectively from the Veterans Health Administration (VHA) for federal fiscal year 2017. We built logistic regression models, adjusted for individual and hospital-related covariates, and calculated the predicted probabilities of MOUD delivery by racial categories. Results: The study cohort (n = 1,313 unique patients; N = 107 VHA hospitals) had a mean age of 57 (range 23 to 87 years), was predominantly male (96%), and composed entirely of Black (29%) or White (71%) patients. White patients were 11% more likely than Black patients to receive buprenorphine than methadone during hospitalization (p = 0.010; 95% CI: 2.7%, 20.0%). Among patients on MOUD prior to hospitalization, White patients were 21% more likely than Black patients to receive buprenorphine (p = 0.000; 95% CI: 9.8%, 31.5%). Among patients newly initiated on MOUD during hospitalization, there were no differences by racial categories. Conclusion: We observed disparities in the delivery of buprenorphine versus methadone during hospitalization by racial categories. The observed differences in hospital-based MOUD delivery may be influenced by MOUD received prior to hospitalization within the racialized outpatient addiction treatment system. The VHA and health systems more broadly must address all aspects of racism that contribute to inequitable MOUD access throughout all clinical contexts.

Improving facilitation of ECT treatment for patients in an acute medical hospital

AimsA Quality Improvement Project aiming to streamline facilitation of electroconvulsive therapy (ECT) treatment for psychiatric patients at a general acute hospital and reduce cancellation rates via the use of a checklist.ECT treatment is an essential aspect of psychiatric care for patients with severe depression or treatment-resistant psychosis. Facilitation of ECT treatment is an uncommon task for liaison psychiatry and the medical and nursing teams responsible for patients’ medical care. Between August-October 2019, this liaison psychiatry team had 3 patients undergoing ECT treatment a total of 13 times, with treatment being cancelled on 4 occasions. After engagement with stakeholders from the acute medical teams, the liaison team and the ECT suite team, key areas requiring intervention were identified to help reduce the rates of cancellation. Areas identified included a lack of ownership on the logistic and operational aspects of ECT amongst staff, a lack of knowledge of what the process involved and a lack of confidence in managing said patients. Difficulties in communication between teams and accurate documentation may contribute to errors and cancellation of ECT sessions, which in turn would delay treatment and impact on patient safety and clinical outcomes.MethodThe first author, a Foundation Year 1 doctor, developed a 10-point checklist to be referred to when arranging ECT for patients, to ensure errors were not made which could lead to missed treatment and delayed recovery. The tasks and responsibilities of each key member of the team were clearly identified. This checklist was included in all ECT patients’ files and teaching was provided to staff involved. Feedback was obtained from staff involved regarding the clarity of information and their confidence in managing such cases.ResultIn the month following initial intervention the liaison psychiatry team organised 12 ECT sessions. The checklist was pasted into notes the day before each ECT session and 0 sessions were missed for avoidable reasons. Feedback from staff showed all teams felt more confident co-ordinating ECT treatment as a result of the checklist.ConclusionCreating a 10-point checklist for the facilitation of ECT treatment in patients at a medical hospital was beneficial in reducing avoidable errors from 16% to 0%. The liaison psychiatrists, medical doctors, and nurses involved reported greater confidence in managing patients undergoing ECT and described the checklist as enhancing the feeling of teamwork and communication within the multi-disciplinary team, and felt it had improved patient safety and clinical outcomes.

Utilisation of mental health transfer checklist proforma from acute physical health hospitals (Liverpool University Hospitals NHS Foundation Trust) to mental health hospitals (Mersey Care NHS Foundation Trust)

AimsTesting the compliance and completion rate of a transfer checklist (proforma) created in accordance with local hospital policies.BackgroundThe proforma was developed following serious incidents where medically unstable patients were inappropriately discharged to mental health hospitals, requiring readmission to acute medical hospitals. Frequently these events reported an inadequate handover from medical to mental health teams and patients were often prematurely deemed medically fit with evidence to the contrary.Although parity of esteem between mental and physical health has been a high profile political issue in the UK since 2011, evidence indicates that parity is far from being achieved. This first ever checklist was designed to improve safety of patient transfer from acute physical health hospitals to mental health hospitals by ensuring patients are medically fit and better communication between the two trusts.MethodData were collected retrospectively over a six-month period between August 2018 and January 2019 and retrieved from patient notes available at relevant trusts. Electronic notes were obtained from medical wards, accident and emergency and Mersey Care electronic systems. Notes were specifically scrutinised for presence of the proforma, quality of completion and, number and reasons for readmission from mental health hospitals to acute physical health hospitals following their medical optimization. Readmissions were considered as admissions to physical health hospitals up to one month following discharge with evidence of ongoing concerns.Result6597 referrals were made to liaison services from Liverpool University Hospitals, of which 5–6 % were admitted to inpatient mental health units. 31% of admissions from Liverpool University Hospitals were readmitted to a physical health hospital within one month of discharge indicating inappropriate and unsafe discharges. Of all those readmitted, 10% had ongoing acute medical concerns prior to admission to a mental health hospital. The proforma was filled in 13% of admissions from Liverpool University Hospitals. None of the forms were fully complete.Conclusion10% of patient admissions to mental health hospitals were identified as inappropriate due to ongoing acute medical concerns. The proforma served as structured guidance and evidence of medical fitness at time of transfer. However poor compliance was observed, which could be secondary to lack of awareness of the proforma and inadequate dissemination of the policy. Findings were shared and discussed with the appropriate teams both in acute physical health and mental health hospitals and steps will be taken to raise awareness of the proforma before completing a second audit.