Acute Services Research Articles

Community Palliative Care: What are the Best Models?

Palliative care seeks to address the physical, psychosocial and spiritual concerns of patients with a life limiting illness and their caregivers. Early referral to palliative care improves symptoms and is the standard of care. This paper evaluates the evidence for different models of community palliative care and looks at the effects of homecare, hospice programs and residential aged care facility (RACF) interventions on symptom management, home death rate and acute health service utilization. It also examines the impact of COVID-19, telehealth, integration and staffing models on the efficacy of community palliative care. Evidence suggests that community palliative care increases the rate of death at home and may improve satisfaction with care, but effect on symptoms and acute health care utilization are less certain. Enrolment in a hospice program may decrease hospitalizations and improve satisfaction. RACF staff training interventions to improve the quality of palliative care provided to residents show mixed results across all indicators. COVID-19 saw a relative increase in the demand for community palliative care, as people opted out of the hospital system. Models of community palliative care that facilitate integration, support primary health providers, and promote technological innovation are worthy of further research.

EGS SO15 - The “Not” Cholecystectomy: Barriers to Early Cholecystectomy in a District General Hospital

Abstract Background The benefit of early or “hot” cholecystectomy in acute cholecystitis and pancreatitis is now widely recognised and recommended by NICE guidelines. However, in reality, surgery within the index admission is not always universally practised. We aim to report our experience of barriers to performing emergency cholecystectomy in the context of a district general London hospital. Method Data from patients admitted within a 1 month period with acute calculous cholecystitis, gallstone pancreatitis or recurrent biliary colic were retrospectively collected. Data points included patient demographics, reasons for not having emergency surgery and time to subsequent elective surgery. Any patients who underwent early emergency cholecystectomy were excluded from analysis. Results Twenty six (76.5%) out of 34 admissions did not receive emergency cholecystectomy. Eight (30.8%) were male and mean age was 69. Most common presentation was acute calculous cholecystitis (13, 50%). Reasons for not having surgery included frailty (7, 26.9%), waitlisted for endoscopic investigation (5, 19.2%), lack of emergency theatre capacity (4, 15.4%), unknown (3, 11.5%), severe disease (2, 7.7%), patient refusal (3, 11.5%) and acute medical contraindication (2, 7.7%). Four (15.4%) patients had repeat acute admission. To date, 4 patients subsequently underwent elective cholecystectomy with one procedure within 3 months. Conclusion Early cholecystectomy rates in district general hospitals can be affected by availability of local resources. By identifying the key factors for not proceeding to surgery, we can increase efforts to improve access to emergency theatre space, high-risk anaesthetic input and acute endoscopy services.

Value in acute care surgery, part 4: The economic value of an acute care surgery service to a hospital system

ABSTRACT The Healthcare Economics Committee of the American Association for the Surgery of Trauma has published a series of three articles on the topic of value in acute care surgery (ACS). In this series, the key elements of value, cost and outcomes, and the impact of stakeholder perspective on what constitutes high-value care are discussed. The fourth article in this series continues the discussion by focusing on the unique economic value that an ACS service brings to a hospital system and its patients. Characterized by the immediate 24-hour availability of surgeons trained in trauma management, emergency general surgery, and surgical critical care, acute care surgeons extend the benefits of surgical rescue and critical care to all hospitalized patients. As such, an ACS service acts as a vital part of a hospital's infrastructure to successfully care for complex and seriously ill patients, in addition to enabling the establishment of other, high revenue-generating services such as vascular, transplant, and complex oncologic surgery programs. The trauma service acts as intake for patients that lead to downstream revenue creation by other disciplines such as orthopedic and neurological surgery, while trauma center designation itself results in dedicated state funding to ensure trauma readiness in many states in the United States. The traditional “value equation” in health care of outcomes achieved per dollar spent is ill-suited to capture many of these unique aspects and benefits of ACS. This article provides the background to understand the economic value of an ACS service and future directions toward improving overall value of care. LEVEL OF EVIDENCE Economic & Value-based Evaluations: Level IV.

Qualitative study exploring perceptions and experiences of Pharmacy technicians’ professional identity in NHS Scotland

Abstract Introduction Pharmacy technicians worldwide share workplace challenges including: job role; scope of practice; level of pharmacist’ supervision; and education1. In the USA, Canada and many European countries, pharmacy technicians require national or state registration2. In the UK, Pharmacy technicians became registered professionals in 2011, as a means of improving patient safety through compliance with General Pharmaceutical Council (GPhC) standards. There are approximately 2,500 pharmacy technicians and 5,500 pharmacists registered with the GPhC in Scotland3. Given the importance of professional identity, and the lack of research exploring pharmacy technicians’ professional affiliation, we explored the perspectives and experiences of pharmacy technicians’ professionalism across Scotland. Aim To explore pharmacy technicians’ perceptions and experiences of their professional status and professional identity. Methods Following West of Scotland Research and Ethics Service Scientific Officer’s approval, Pharmacy technicians from all fourteen Scottish territorial health boards were invited by email using snowball sampling technique to provide a national representation. A draft semi-structured interview was piloted on four pharmacy technicians. Between May and August 2023, 36 pharmacy technicians were recruited: 23 from acute services; mental health (n=1); rehabilitation hospitals (n=1); primary care (n=8); and community pharmacy (n=3). Twenty two participants were interviewed in person and 14 on line. Interviews lasted between 17-91 minutes, were audio recorded, transcribed verbatim and accuracy checked, then analysed thematically using a framework approach and NVivo software. Three researchers analysed data including initial coding, categorisation, and theme generation. Any disagreements were discussed and addressed within the research team. Results Seven themes emerged from the data describing pharmacy technicians: feeling stuck in the shadow of pharmacists; underrepresented in policy and practice; and marginalised, undervalued and underpaid. There was frustration at the lack of awareness of pharmacy technician roles amongst the wider healthcare team. Primary care pharmacy technicians were thought to have more opportunities than secondary care colleagues. There was a pervasive feeling that pharmacy technicians were increasingly squeezed between pharmacists and support workers and a lack of confidence and feeling unsupported in the delivery of clinical roles. Pharmacy technicians acknowledged that they may not have used their initiative to take new opportunities, but did not feel they had sufficient clinical and educational opportunities. Catalysts to professional development were recognised including pharmacy technician led management and leadership, readiness to undertake traditional pharmacist roles and the potential positive impact of strengthened professional identity. Interviewees described the absence of a structured, funded career framework, and lack of post-registration higher-level professional qualification as inhibiting increased responsibility and scope of practice. Discussion/Conclusion Professional registration does not appear to have strengthened pharmacy technicians’ professional identity. There is a pervasive lack of development opportunities impacting negatively on pharmacy technicians and therefore, service delivery across Scotland. A review of defined roles is required. A lack of previous qualitative evaluation limits comparisons with the perceptions and experiences of pharmacy technicians worldwide. Findings offer a starting point to inform practice and policy. Further research could explore pharmacy technicians’ perceptions of the potential impact of the emerging career framework on developing roles and responsibilities. Keywords: Pharmacy technician, Professional identity

A review of UK primary care pathways for acute ophthalmic conditions.

Care pathways for the management of acute ophthalmic conditions have developed and transformed significantly over recent years, owing to a combination of legislative changes, policy implementation and the pressing requirement to redistribute increased demand away from traditional secondary care providers through collaboration with primary care. Following UK healthcare devolution in 1999, each nation has developed and implemented their own strategies for managing the growing demands on acute ophthalmology services. Local commissioning across England has seen Enhanced Service Pathways develop to provide acute eye care by primary care optometrists, with provision and access dependent upon locality. Northern Ireland has seen the implementation of a nationwide Primary Eyecare Acute Referral Service, whilst in Scotland and Wales, the respective Governments have redesigned primary care optometry General Ophthalmic Service contracts to incorporate provision of extended investigations and management of acute conditions by optometrists across the nation, recognising the added benefit of optometrists with higher qualifications. This narrative review summarises both peer reviewed and appropriate grey literature articles reporting on acute eye care pathways in primary care. Despite significant progress, particularly during the global COVID-19 pandemic, there is arguably still a great deal of further research and evaluation required relating to pathway innovation, the role of professionals with higher qualifications, including independent prescribing, the role of telemedicine, reassurance around clinical safety, and how digital interconnectivity could potentially add value to collaborative schemes to meet the growing demand on acute eyecare.

Hospital costs of COVID-19, post-COVID-19 condition and other viral pneumonias: a cost comparison analysis.

To compare hospital admission costs for coronavirus disease 2019 (COVID-19) cases to hospital admission costs for other viral pneumonia cases in Australia, and to describe hospital admission costs for post-COVID-19 condition. A cost comparison analysis of hospital admissions due to COVID-19 or other viral pneumonias between 1 January 2020 and 30 June 2021 at Victorian public health acute and subacute services. Demographic characteristics, clinical outcomes (including diagnoses, impairment, subacute admission, intensive care unit admissions, ventilation, and length of stay) and cost data (including diagnostic-related groups, and total, direct and indirect costs). During the study period, 3197 patients were admitted to hospital due to COVID-19 and 15 761 were admitted for other viral pneumonias. Admissions for COVID-19 cost 29% more than admissions for other viral pneumonias. Admissions for COVID-19 requiring intensive care unit admission incurred significantly higher mean costs (A$120 504 or US$90 595) compared with those not requiring intensive care unit admission (A$19 634 or US$14 761). The adjusted cost of admissions related to post-COVID-19 condition was A$11 090 or US$8 337, and these admissions were significantly more likely to be elective. Direct costs accounted for most of the costs for all groups, and admissions for post-COVID-19 condition used less allied health services than other groups. Given its recent emergence, cases of acute COVID-19 and post-COVID-19 condition have had a significant additional financial impact on Australian hospitals. Further studies are required to understand long term costs and identify trends over time in the context of increased vaccination rates and subsequent variants of severe acute respiratory syndrome coronavirus 2.

Patient Satisfaction With Meal Service With Leftovers At Grandmed Hospital Lubuk Pakam

Food service is an important issue in the hospital environment, and patient satisfaction levels are often indicated by food consumption and waste. The current study compared patient satisfaction in hospital areas and other factors and determined the relationship between patient satisfaction and food waste. This quantitative study was conducted in RS. GrendMed Lubuk Pakam. Patients in these hospitals were asked to fill out a questionnaire consisting of three parts: general information, patient satisfaction questionnaire (Patient Satisfaction Questionnaire for Acute Care Hospital Food Service). A total of 74 patients participated. The results showed that overall, 18.9% (finished and satisfied), 39.2% (not finished and satisfied), and 41.9% (Not satisfied and not finished). Satisfaction with hospital food varies according to the service of each patient with health conditions. However, the results also showed that satisfaction with hospital food service was significantly associated with food waste (p value = 0.000). Various factors in hospital food service, especially food quality, should be improved to motivate patients to consume hospital food..

Implementing a pathway for patients diagnosed with cancer in the emergency department.

Patients diagnosed with cancer or suspected cancer during an emergency department (ED) presentation are often signposted back to their GP for urgent referral to cancer services. However, this can result in delays in patients receiving specialist support, confirmation of diagnosis and, vitally, starting treatment. A quality improvement initiative that aimed to address these issues through the introduction of an ED suspected cancer diagnosis pathway was implemented by the acute oncology service in two EDs in Oxford University Hospitals NHS Foundation Trust in April 2023. Data collected during the first year of implementation of the pathway show there has been a significant increase in the numbers of patients meeting the NHS England 62-day referral to treatment standard and in the numbers of patients receiving support from an acute oncology named cancer clinical nurse specialist from the point of discharge from the ED. This article details the initiative, which is ongoing, and shares some of the results from the first year of data collection.

Cardiac rehabilitation ambassadors - a new model to enhance patient participation

Abstract Introduction Participation in outpatient Cardiac Rehabilitation (CR) is considered an integral part of secondary treatment of heart disease. Despite being considered standard care, participation remains low internationally. Encouraging patients to enrol in CR during their hospital stay is linked to higher participation. [1] This study was conducted at a hospital that provides acute cardiac and rehabilitation services in Australia. Purpose As a provider of cardiac care, we identified that increasing nurses’ knowledge of the of CR would improve their capacity to promote CR during patient’s hospital stay. Methods Utilising a quality improvement methodology, the Cardiac Ambassador Initiative was developed with key stakeholders working on cardiac units in 2022. The program consisted of an immersion experience for cardiac nurses to shadow CR nurses working in a specialist rehabilitation centre providing best practice CR for patients with a variety of cardiac conditions. To evaluate the impact of the program, cross-sectional surveys and individual interviews were conducted with participants and Nurse-Unit-Managers (NUMs). Key outcomes included: ambassadors’ knowledge and confidence to promote CR participation to their patients on the wards and NUM's perceptions of the impact of the program. Results The program was run over two years. The NUMs and CR-coordinator selected a total of 13 nurses to participate. In 2022 4 participants attended a total of 5 days each. Following evaluation, the program was modified to 3 days for participants in 2023, which enabled 9 participants to attend. All participants described not fully understanding the nature of CR and its impact on patients until they attended a program. Prior to attendance, 100% of participants considered it was important or somewhat important for patients to attend CR. Following attendance 100% of participants consider it essential or important for patients to attend. They also reported feeling more confident to discuss CR with patients and colleagues and encourage patient participation following the immersion experience. Pre-attendance 100% of participants felt either not at all confident or somewhat confident to discuss CR with their patients and this improved post program with 100% feeling very confident. 100% of participants also indicated that their confidence and skill in discussing CR with patients greatly improved and recommended that others should participate in the CR Ambassador program. Nurse Unit Managers reported that the CR Ambassadors were a valuable resource for both staff and patients on the cardiac unit and that they had identified a need to review the accessibility of CR information and referral documentation available on their wards. Conclusion The immersion experience represents a feasible and sustainable approach to establishing CR ambassadors on acute cardiac wards with the skills needed to promote CR participation to colleagues and patients.

Sociodemographic Patterns of Patients Engaging with an Acute Hospital Alcohol Care Team: An Underused Resource

ABSTRACT Alcohol care teams represent a unique resource to deliver holistic care for those presenting to acute hospital services with alcohol-related ill-health. However, most existing data regarding the characteristics of individuals engaging with alcohol support services concern those involved with community services. We reviewed the sociodemographic and alcohol-use characteristics of patients presenting to the Sandwell and West-Birmingham NHS Trust Alcohol Care team between 2018 and 2023. Patients engaging with Alcohol Care Teams in hospitals represent a population of significant vulnerability, driven by multiple sociodemographic and alcohol-use characteristics. These patients are distinct from those in community service treatment.

From ‘strong recommendation’ to practice: A pre-test post-test study examining adherence to stroke guidelines for fever, hyperglycaemia, and swallowing (FeSS) management post-stroke

BackgroundThe Quality in Acute Stroke Care (QASC) Trial demonstrated that assistance to implement protocols to manage Fever, hyperglycaemia (Sugar) and Swallowing (FeSS) post-stroke reduced death and disability. In 2017, a ‘Strong Recommendation’ for use of FeSS Protocols was included in the Australian Clinical Guidelines for Stroke Management. We aimed to: i) compare adherence to FeSS Protocols pre- and post-guideline inclusion; ii) determine if adherence varied with prior participation in a treatment arm of a FeSS Intervention study, or receiving treatment in a stroke unit; and compare findings with our previous studies. MethodsPre-test post-test study using Australian acute stroke service audit data comparing 2015/2017 (pre-guideline) versus 2019/2021 (post-guideline) adherence. Primary outcome was adherence to all six FeSS indicators (composite), with mixed-effects logistic regression adjusting for age, sex, stroke type and severity (ability to walk on admission), stroke unit care, hospital prior participation in a FeSS Intervention study, and correlation of outcomes within hospital. Additional analysis examined interaction effects. ResultsOverall, 112 hospitals contributed data to ≥1 one Audit cycle for both periods (pre=7011, post=7195 cases); 42 hospitals had participated in any treatment arm of a FeSS Intervention study. Adherence to FeSS Protocols post-guideline increased (pre: composite measure 35% vs post: composite measure 40 %, aOR:1.2 95 %CI: 1.2, 1.3). Prior participation in a FeSS Intervention study (aOR:1.6, 95 %CI: 1.2, 2.0) and stroke unit care (aOR 2.3, 95 %CI: 2.0, 2.5) were independently associated with greater adherence to FeSS Protocols. There was no change in adherence over time based on prior participation in a FeSS Intervention study (p = 0.93 interaction), or stroke unit care (p = 0.07 interaction). ConclusionsThere is evidence of improved adherence to FeSS Protocols following a ‘strong recommendation’ for their use in the Australian stroke guidelines. Change in adherence was similar independent of hospital prior participation in a FeSS Intervention study, or stroke unit care. However, maintenance of higher pre-guideline adherence for hospitals prior participation in a FeSS Intervention study suggests that research participation can facilitate greater guideline adherence; and confirms superior care received in stroke units. Nevertheless, less than half of Australian patients are being cared for according to the FeSS Protocols, providing impetus for additional strategies to increase uptake.

Physiotherapy management of acute perineal trauma: a patient satisfaction survey

Pelvic floor muscle (PFM) training is recommended in the immediate postpartum period because it can restore PFM function and prevent pelvic floor dysfunction. There are no national physiotherapy guidelines on how to deliver this intervention in the acute period. There is also no consensus on the need for outpatient follow-up to treat pelvic floor dysfunction that arises from perineal trauma, or as a preventative strategy in the long term. The aim of this study was to evaluate a current service provided for women with acute perineal trauma. The authors assessed patient satisfaction and compliance with physiotherapy advice, and identified preferences for future service development. One hundred and thirty patients completed satisfaction questionnaires after receiving inpatient physiotherapy treatment. Thirty consented to completing a retrospective telephone consultation about their care at 6–8 weeks postpartum. The questionnaire found high levels of satisfaction, and recorded a National Health Service Friends and Family Test score of 93. In the telephone consultation, 87% of the women reported that they were complying with ongoing PFM training. Eighty-five per cent of women who completed the questionnaire suggested that outpatient physiotherapy follow-up would be useful. Fifty per cent stated that options inclusive of outpatient follow-up would be useful for onward service development. Because of the high levels of satisfaction recorded and high compliance with the information provided in the acute postpartum period, it was concluded that the service should continue as it is. It is hoped that this service evaluation can be utilized as a benchmark for other acute and outpatient pelvic health physiotherapy services.

The patient-reported outcome measure for older people living with frailty receiving acute care (PROM-OPAC): field-testing and validation

BackgroundCurrent acute healthcare service metrics are not meaningful for older people living with frailty. Healthcare knowledge, situational security, and physical and psychosocial function are important outcomes typically not collected. The use of patient-reported outcome measures (PROMs) could support these assessments. Existing instruments are not comprehensive as they typically consider function, while older people with frailty also value enablement (self-determination and security in health and healthcare). This study field-tested and validated a PROM for older people with frailty receiving acute care (PROM-OPAC) to measure enablement.MethodsPeople aged 65+ with Clinical Frailty Scale 5–8 were recruited within seventy-two hours of an emergency attendance. Iterations of the novel instrument were administered over three stages: (1) preliminary field-testing for reliability (response distribution and internal consistency) and structure (exploratory factor analysis, EFA); (2) intermediate field-testing of an improved instrument for reliability and structure; (3) final draft validation assessing reliability, structure (confirmatory factor analysis, CFA), and construct validity based on a priori hypotheses. Feasibility was appraised throughout using data completeness and response rates and times.Results241 people participated. Three items of a preliminary seven-item measure had poor response distribution or loading and were accordingly improved. The intermediate instrument had interpretability issues and three items required further improvement. The final eight-item draft had acceptable reliability (Cronbach’s alpha: 0.71), structure (two factors for self-determination and security; RMSEA: 0.065; TLI: 0.917; CFI: 0.944), and construct validity (lower scores from respondents waiting longer and requiring admission). Feasibility was promising (response rate 39%; 98% responses complete; median completion time 11 (IQR: 12) minutes).ConclusionsAdministration of the PROM-OPAC appeared feasible and the instrument had acceptable psychometric properties. Further evaluation is required to assess generalisability.

Delayed treatment of diabetic foot ulcer in patients with type 2 diabetes and its prediction model

BACKGROUND Diabetic foot (DF) is a serious complication of type 2 diabetes. This study aimed to investigate the factors associated with DF occurrence and the role of delayed medical care in a cohort of patients with type 2 diabetes. AIM To reveal the impact of delayed medical treatment on the development of DF in patients with type 2 diabetes and to establish a predictive model for DF. METHODS In this retrospective cohort study, 292 patients with type 2 diabetes who underwent examination at our hospital from January 2023 to December 2023 were selected and divided into the DF group (n = 82, DF) and nondiabetic foot group (n = 210, NDF). Differential and correlation analyses of demographic indicators, laboratory parameters, and delayed medical treatment were conducted for the two groups. Logistic regression was applied to determine influencing factors. Receiver operating characteristic (ROC) analysis was performed, and indicators with good predictive value were selected to establish a combined predictive model. RESULTS The DF group had significantly higher body mass index (BMI) (P < 0.001), disease duration (P = 0.012), plasma glucose levels (P < 0.001), and HbA1c (P < 0.001) than the NDF group. The NDF group had significantly higher Acute Thrombosis and Myocardial Infarction Health Service System (ATMHSS) scores (P < 0.001) and a significantly lower delayed medical treatment rate (72.38% vs 13.41%, P < 0.001). BMI, duration of diabetes, plasma glucose levels, HbA1c, diabetic peripheral neuropathy, and nephropathy were all positively correlated with DF occurrence. ATMHSS scores were negatively correlated with delayed time to seek medical treatment. The logistic regression model revealed that BMI, duration of diabetes, plasma glucose levels, HbA1c, presence of diabetic peripheral neuropathy and nephropathy, ATMHSS scores, and delayed time to seek medical treatment were influencing factors for DF. ROC analysis indicated that plasma glucose levels, HbA1c, and delayed medical treatment had good predictive value with an area under the curve of 0.933 for the combined predictive model. CONCLUSION Delayed medical treatment significantly affects the probability of DF occurrence in patients with diabetes. Plasma glucose levels, HbA1c levels, and the combined predictive model of delayed medical treatment demonstrate good predictive value.

Disparities in infectious disease-related health care utilization between Medicaid-enrolled American Indians and non-Hispanic Whites-Lessons from the first 16 months of coronavirus disease 2019 and a decade of flu seasons.

To understand why American Indian and Alaskan Native (AIAN) populations have had exceptionally high COVID-19 mortality, we compare patterns of healthcare utilization and outcomes for two serious infectious respiratory diseases-Influenza-like-illness (ILI) and coronavirus disease 2019 (COVID-19)-between American Indian and Alaskan Native (AIAN) populations (as identified in Medicaid data) and non-Hispanic Whites over the 2009-2021 period. We select all people under the age of 65 years identified as non-Hispanic White or AIAN in the New York State Medicaid claims data between 2009 and 2021. We analyze data across 10 ILI cohorts (between September 2009 and August 2020) and 4 COVID-19 cohorts (March-June 2020, July-September 2020, October-December 2020, and January-June 2021). We examine mortality and utilization rates using logistic regressions, adjusting for demographic characteristics, prior chronic conditions, and geographic location (including residence near a reservation). We stratify the analysis by rural vs. nonrural counties. We use the New York State Medicaid claims data for the analysis. We find that even among Medicaid beneficiaries, who are similar in socioeconomic status and identical in health insurance coverage, AIAN populations have much lower rates of use of outpatient services and much higher rates of acute (inpatient and emergency room) service utilization for both ILI and COVID-19 than non-Hispanic Whites. Prior to COVID-19, demographic and health status-adjusted all-cause mortality rates, including from ILI, were lower among American Indians than among non-Hispanic Whites on New York State Medicaid, but this pattern reversed during the COVID-19 pandemic. Both findings are driven by nonrural counties. We did not observe significant differences in all-cause mortality and acute service utilization comparing AIAN to non-Hispanic Whites in rural areas. The utilization and mortality disparities we identify within the Medicaid population highlight the need to move beyond insurance in addressing poor health outcomes in the American Indian population.

Healthcare for People With Intellectual Disabilities: An Exploration of Intellectual Disability Service Providers' Experiences of Joint Working With Acute Service Providers When People With Intellectual Disabilities Access Healthcare in Acute Services

Healthcare for People With Intellectual Disabilities: An Exploration of Intellectual Disability Service Providers' Experiences of Joint Working With Acute Service Providers When People With Intellectual Disabilities Access Healthcare in Acute Services

Involvement in serious incident investigations: a qualitative documentary analysis of NHS trust policies in England

BackgroundThe considered shift from individual blame and sanctions towards a commitment to system-wide learning from incidents in healthcare has led to increased understanding of both the moral and epistemic importance of involving those affected. It is important to understand whether and how local policy describes and prompts involvement with a view to understanding the policy landscape for serious incident investigations in healthcare.This study aimed to explore the way in which involvement of those affected by serious incidents is represented in incident investigation policy documents across acute and mental health services in the English NHS, and to identify guidance for more effective construction of policy for meaningful involvement.MethodsWe conducted a documentary analysis of 43 local serious incident investigation policies to explore the way in which involvement in serious incident investigations is represented in policy documents across acute and mental health services in the NHS in England.ResultsThree headline findings were generated. First, we identified involvement as a concept was conspicuous by its absence in policy documents. Direct reference to support or involvement of those affected by serious incidents was lacking. Even where involvement and support were recognised as important, this was described as a passive process rather than there being moral or epistemic justification for more active contribution to learning. Second, learning from serious incidents was typically described as a high priority but the language used was unclear and ‘learning’ was more often positioned as construction of an arbitrary set of recommendations rather than a participatory process of deconstruction and reconstruction of specific systems and processes. Third, there was an emphasis placed on a just and open culture but paradoxically this was reinforced by expected compliance, positioning investigations as a tool through which action is governed rather than an opportunity to learn from and with the experiences and expertise of those affected.ConclusionsMore effective representation in policy of the moral and epistemic reasons for stakeholder involvement in serious incident investigations may lead to better understanding of its importance, thus increasing potential for organisational learning and reducing the potential for compounded harm. Moreover, understanding how structural elements of policy documents were central to the way in which the document is framed and received is significant for both local and national policy makers to enable more effective construction of healthcare policy documents to prompt meaningful action.

Hospitalization trends among immigrants and natives in an acute psychiatric service: a descriptive study from Italy

Acute psychiatric services are crucial for immigrants who face barriers in accessing outpatient mental healthcare due to socio-economic, cultural, and linguistic challenges. This study compared psychiatric hospitalization characteristics between immigrants and native Italians at the University of Foggia from 2004 to 2019. A total of 536 inpatients, equally divided between immigrants and natives, were analysed for sociodemographic and clinical variables. Findings revealed that immigrants were hospitalized through emergency departments for severe psychiatric disorders such as psychosis, while natives were more often admitted for mood disorders. Immigrants showed a higher incidence of substance abuse and suicidal attempts and a lower number of prior hospitalizations compared to natives, with higher incidence of first episodes of mental illness. Despite presenting with severe psychopathology, natives exhibited better clinical outcomes, longer hospitalizations and higher functioning improvements. We also found that natives received more psychotropic medications but experienced fewer adverse effects compared to immigrants. Differences in pharmacological treatments and hospital outcomes suggested that culturally tailored interventions could improve the effectiveness of psychiatric care for migrants. These findings emphasized the necessity for systemic changes in mental health services to address disparities and improve care for migrant populations.

Predictive model for the risk of paediatric intensive care utilization in children with medical complexity: A longitudinal retrospective cohort study.

Children with medical complexity (CMC) are at increased risk of admission in intensive care. Despite improvements in mortality rates, there remains a burden of morbidity, long-term health care needs and hospital readmissions. Beyond clinical factors, socio-demographic determinants could impact utilization of acute services. To identify risk factors that can differentiate CMC who are admitted to the paediatric intensive care unit (PICU). A 6-year longitudinal retrospective cohort study evaluated clinical, socio-demographic and health care utilization. A total of 248 CMC were included, with a median age of 13 years (9.75-17.00). Intensive care admission rate was 47.2%. The risk of PICU admission was higher for children undergoing surgical interventions (HR = 1.58, 95% CI 1.34-1.86, p < .001) and those using medical devices (HR = 1.81, 95% CI 1.54-2.13, p < .001). Mother's higher educational level was a protective factor (HR = 0.66, 95% CI 0.55-0.79, p < .001). Multivariable analysis revealed significant associations between risk of admission and the presence of malignancy, comorbidities, home medical devices, surgical procedures and higher health care utilization. Children's age and higher maternal educational level acted as protective factors. Socio-demographic factors should be considered in the provision of care to CMC. Individualized assessments to guide supportive interventions adapted to socio-economic factors may prevent PICU admissions. This study highlights the importance of integrating individualized assessments of socio-demographic risk factors, such as maternal educational level, into the clinical practice of paediatric nurses. Moreover, targeted interventions, including educational resources and community support programmes, may optimize care.

Impact of Loneliness and Social Support on Acute Health Service Use and Symptom Exacerbation Among Adults with Asthma and COPD.

Loneliness and low social support are associated with negative health outcomes among adults with asthma or COPD. Although social support is correlated with loneliness, low social support is neither necessary nor sufficient for the experience of loneliness. This study compares the relative association of loneliness and social support on symptom exacerbation (i.e., acute deteriorations in respiratory health) and acute health service utilization (i.e., hospitalizations, emergency department visits) among 206 adults with asthma and 308 adults with COPD. Separate logistic regression models were used to simultaneously examine the association of loneliness and social support with each outcome. Among adults with asthma, loneliness was associated with greater odds of hospitalization (AOR = 2.81, 95%CI [1.13, 7.02]), while low social support was not (AOR = 1.44, 95%CI [0.78, 2.65]). However, neither loneliness nor social support were associated with any other acute health service use or symptom exacerbation among adults with asthma. Among adults with COPD, loneliness, and greater social support were associated with increased odds of symptom exacerbation (AOR = 1.67, 95%CI [1.03, 2.69]; AOR = 1.36, 95%CI 1.02, 1.83]) and hospitalization (AOR = 3.46, 95%CI [1.65, 7.24]; AOR = 1.92, 95%CI [1.15, 3.22]), but only social support was significantly associated with ED visits (AOR = 1.72, 95%CI 1.12, 2.66]). These findings support prior research demonstrating that loneliness and social support are related but separate determinants of patients' physical symptoms and service utilization.