Acute Wards Research Articles

Real-World Adherence to a Delirium Screening Test Administered by Nurses and Medical Staff during Routine Patient Care.

Delirium is often the first symptom of incipient acute illness or complications and must therefore be detected promptly. Nevertheless, routine screening for delirium in acute care hospital wards is often inadequate. We recently implemented a simple, user-friendly delirium screening test (RMA) that can be administered during ward rounds and routine nursing care. The test was found to be non-inferior to 4AT in terms of sensitivity and specificity. However, the dominant factors to take into account when assessing the performance of a test added to the routine work of busy acute care hospital wards are ease of administration, real-life amenability and the ability of the staff to adhere to testing requirements. In this study, we evaluated the prevalence of daily RMA tests that were not administered as scheduled and the impact of these omissions on the overall real-world performance of RMA. Using point-in-time assessments of 4AT by an external rater, we found that complete RMA was administered in 88.8% of the days. Physicians omitted significantly more tests than nurses, but their results were more specific for delirium. Omissions reduced the sensitivity and specificity of RMA for delirium (compared to 4AT) from 90.7% to 81.7%, and from 99.2% to 87.8%, respectively. Ideally, the number of omitted RMA tests should be minimized. However, if over 85% of the daily quota of complete tests are administered, the sensitivity and specificity of RMA for diagnosing delirium as soon as it appears remain at acceptable levels.

A Participatory Model for Cocreating Accessible Rehabilitation Technology for Stroke Survivors: User-Centered Design Approach.

Globally, 1 in 3 people live with health conditions that could be improved with rehabilitation. Ideally, this is provided by trained professionals delivering evidence-based dose, intensity, and content of rehabilitation for optimal recovery. The widely acknowledged inability of global health care providers to deliver recommended levels of rehabilitation creates an opportunity for technological innovation. Design processes that lack close consideration of users' needs and budgets, however, mean that many rehabilitation technologies are neither useful nor used. To address this problem, our multidisciplinary research group have established a cocreation center for rehabilitation technology that places the end user at the center of the innovation process. This study aims to present the participatory cocreation model that has been developed from our center and illustrate the approach with 2 cases studies. The model is built around user participation in an intensive rehabilitation program (2-hour sessions, 2-5 times per week, and 8-week duration), supervised by qualified therapists but delivered exclusively through commercial and prototype technology. This provides participants (chronic stroke survivors with movement and/or speech disability) with a rich experience of rehabilitation technology, enabling them to provide truly informed feedback, as well as creating an observatory for the research team. This process is supported by short-term focus groups for specific product development and a longer-term advisory group to consider broader issues of adoption and translation into everyday health care. Our model has been active for 3 years with 92 (92%) out of 100 participants completing the program. Five new technologies have evolved from the process with further ideas logged for future development. In addition, it has led to a set of cocreated protocols for technology-enriched rehabilitation, including recruitment, outcome measures, and intervention structure, which has allowed us to replicate this approach in an acute hospital ward. Suboptimal rehabilitation limits recovery from health conditions. Technology offers the potential support to increase access to recommended levels of rehabilitation but needs to be designed to suit end users and not just their impairment. Our cocreation model, built around participation in an intensive, technology-based program, has produced new accessible technology and demonstrated the feasibility of our overall approach to providing the rehabilitation that people need, for as long as needed.

Continuous Monitoring by a Wearable Sensor Did Not Enhance Discharge Decision-Making in an Acute Admission Ward: Results of a Randomized Controlled Trial.

Adding continuous monitoring to usual care at an acute admission ward did not have an effect on the proportion of patients safely discharged. Implementation challenges of continuous monitoring may have contributed to the lack of effect observed.

Association between neutrophil-to-lymphocyte ratio and length of hospital stay in an acute psychiatric hospital: A cross-sectional study.

The available evidence for predicting length of stay in acute psychiatric hospitals includes demographics, diagnosis, and treatment variables. This study aimed to evaluate the association between neutrophil-to-lymphocyte ratio (NLR) and length of hospital stay in an acute psychiatric hospital. A total of 116 patients who were admitted to an acute psychiatric ward at Urawa Neuropsychiatric Sanatorium (Saitama, Japan) from August 2022 to December 2022 were eligible for this study. Laboratory data of lymphocytes and neutrophils were assessed on the first day of admission and NLR was calculated based on the data. Participants were categorized into two groups, high NLR and low NLR, which were set as predictor variables, as well as using NLR as a continuous variable. Multiple linear regression was performed to determine the association between NLR and length of hospital stay, adjusting for confounding factors. A total of 90 participants were included in this study. The association of NLR as a continuous variable and length of hospital stay was not significant. When we categorized participants into high- and low-NLR groups, the association was significant even after adjusting by covariates (p < 0.05). Categorized NLR was positively associated with the length of hospital stay in patients admitted to an acute psychiatric hospital. Categorized NLR may predict the length of hospital stay for patients who are admitted to an acute psychiatric hospital.

Patient responsiveness as a safewards fidelity indicator: a qualitative interview study on an acute psychiatric in-patient ward

BackgroundThe Safewards model aims to reduce conflict and use of containment on psychiatric wards. To evaluate the implementation of Safewards and understand why it is effective in some settings but not in others, it is important to assess the level of implementation fidelity. To do this, the Safewards Fidelity Checklist (SFC) is often used, which focuses on objective visual observations of interventions but does not include patient responsiveness. The latter is a key indicator of implementation fidelity and includes engagement, relevance, acceptability and usefulness. The aim of the present study was to investigate the fidelity of Safewards implementation on an acute psychiatric ward from the perspective of patient responsiveness.MethodThe study was conducted on a ward for patients with mainly affective disorders. To assess the general level of fidelity the SFC was used together with a detailed ward walkthrough. Ten patients were interviewed with a focus on patient responsiveness to each of the seven interventions implemented on the ward. Data were analysed using qualitative descriptive analysis.ResultsThe findings indicate high implementation fidelity, which was reflected in the SFC assessment, walkthrough and patient responsiveness. Patients gave examples of improvements that had happened over time or of the ward being better than other wards. They felt respected, less alone, hopeful and safe. They also described supporting fellow patients and taking responsibility for the ward climate. However, some patients were unfamiliar with a ward where so much communication was expected. Several suggestions were made about improving Safewards.ConclusionsThis study confirms previous research that patient responsiveness is an important factor for achieving fidelity in a prevention programme. The patients’ descriptions of the acceptability, relevance and usefulness of the specific interventions reflected to a high degree the objective visual observations made by means of the SFC and ward walkthrough. Patient engagement was demonstrated by several suggestions about how to adapt the interventions. There is potential to obtain valuable input from patients when adapting Safewards in practice. This study also presents many examples of practical work with these interventions and the effects it can have on patients’ experiences of care.

2347 EXPEDITE: a sustainable initiative to improve average length of stay (ALOS) in an acute geriatric Ward in Singapore

Abstract Introduction Prolonged hospitalisation is associated with increased mortality, increased risk of hospital acquired infections, functional decline and institutionalisation in older adults. Baseline data collected for patients admitted to the Acute Geriatric ward of Alexandra Hospital, a tertiary hospital in Singapore, from 28 Feb to 31 Aug 2022 (n = 299, age &amp;gt; 65 years) revealed an average LOS of 12.3 days. Potential contributing factors identified • 98% did not have a documented medical clearance date • 3.54 days required to decide for medical social worker referral • 9 days before discharge plans are communicated to family. Aim: To reduce average length of stay (ALOS) from 12.3 days in Aug 2022 to 9.81 days by Aug 2023. This was a target set at the hospital level on our Geriatric service in the setting of a rising national pressure for inpatients beds. Method The EXPEDITE Huddle was a regular 30 minute huddle introduced, in addition to the existing weekly multidisciplinary meeting. It was developed based on the QI methodology and streamlined from 3x/week frequency to 1x/week following PDSA cycles. A chat group on the secure hospital mobile phone messaging system was also created for ease of communication among stakeholders. Results • ALOS reduced from 12.3 days to 9.1 days (3.4 days) • 91.8% of patients (n = 154) now have a documented medical clearance date • Communication on discharge plans initiated within 3 days from admission • Sustainability: -In light of positive results, a discharge care navigator (DCN) to lead the discharge planning efforts was offered by the hospital to the Geriatric service. -The EXPEDITE huddle (now led by the DCN) continues and ALOS has remained within target. Conclusion(s) Early discharge planning with a focus on system level factors that contribute to delayed discharge can help reduce ALOS in hospitalised older adults.

Adolescents Hospitalized in an Acute Psychiatric Ward: The Difference between Males and Females in the Pre- and Pandemic/Post-Pandemic Periods.

(1) Background: The pandemic lowered by 10% the psychological wellness among adolescents worldwide. (2) Methods: This observational retrospective study compared the demographic and clinical variables of male and female adolescents hospitalized in an acute psychiatric ward during the pre-pandemic, from 1 July 2017 to 28 February 2020, and the pandemic/post-pandemic, from 1 March 2020 to 30 June 2023. (3) Results: In total, 153 adolescents of 15.8 years on average (±1.14 DS) were more frequently hospitalized (n = 131, 54.4%) in the pre-pandemic than in the pandemic/post-pandemic (n = 110, 45.6%), but female hospitalizations increased in the post-pandemic more than male hospitalizations (62.9% vs. 37.1%) (Pearson Chi2 = 8.54, p = 0.003); in the pandemic/post-pandemic, we reported increased aggressive behavior and schizophrenia spectrum and emotional disorders in males, whereas in females, depressive and emotional disorders were prevalent; more adolescents previously treated in Child Mental Health Services were hospitalized in the pandemic/post-pandemic period; and males hospitalized in the study period reported higher Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) scores. (4) Conclusions: In the pandemic/post-pandemic, females more frequently required hospitalizations for depressive behavior and males for aggressive behavior and schizophrenia spectrum disorders, whereas, in both males and females, hospitalizations due to emotional disorders increased. Our results suggest the need for mental health prevention in adolescents, who represent the most vulnerable population in the case of disaster.

2269 Preventing frailty crises: improving the care of frail patients in an acute hospital Ward setting

Abstract Introduction Frailty is common in hospitalised older patients and hospitalisation can lead to negative outcomes. Our study aimed to provide insights into current decision-making processes on treatment, care and discharge by clinical teams. Methods We conducted a prospective cohort study in frail older patients ≥65 years old admitted to acute medical and surgical wards. Clinical Frailty Scale ≥5 was used to identify frail patients and process mapping was undertaken to identify common themes, trajectories and potentially modifiable factors. We followed patient journeys from admission to discharge and examined factors contributing to longer hospitalisation. We documented existing processes, environmental, system and clinical factors influencing patient care. Comprehensive geriatric assessments identified underlying geriatric syndromes and where gaps in management were identified, we recommended frailty interventions. Results Fifteen patients provided informed consent, of whom 73% were female and average age 80 years, ranging 69–95 years. 67% were frail (CFS 5–6) and 33% were severely frail (CFS 7–9). Most patients were sarcopenic with a SARC-F score of ≥4 and had functional and gait impairment. 60% were underweight (BMI &amp;lt;22). Process mapping revealed gaps in frailty-focused care and included delayed transfer to acute wards, delayed investigations, and multiple unidentified geriatric syndromes which were prevalent in this cohort. Patients fell into three broad groups, short (1–6 days), intermediate (7–14 days), or long (&amp;gt;14 days) length of stay and delays in discharge-planning were common, mean of 4.17 days, as were delays in identification of a caregiver. Recommendations for community support services were provided to &amp;gt;50% patients. Conclusion Our study shows that mapping the frail patient’s journey can identify gaps in existing processes and opportunities for improvement and collaboration. Integrating geriatric care into general wards could improve patient outcomes. We aim to use this work to guide frailty-attuned care for hospitalised older patients.

On-admission serum 25(OH)D level and mortality within one year in older patients

BackgroundMounting evidence suggests that vitamin D deficiency is associated with a higher risk of many chronic non-skeletal, age-associated diseases as well as mortality.AimTo determine, in older patients aged ≥ 80, the prevalence of vitamin D deficiency and its association with comorbidity, laboratory tests, length of stay and mortality within one year from blood withdrawal on admission to acute geriatrics ward.MethodsWe retrospectively surveyed electronic hospital health records of 830 older patients. The recorded data included patient demographics (e.g., age, sex, stay duration, readmissions number, death within one year from blood withdrawal on admission), medical diagnoses, laboratory results, including 25-hydroxyvitamin D [25(OH)D], and medications. We compared the characteristics of the patients who survived to those who died within one year.ResultsOn admission, in 53.6% patients, vitamin D levels were lower than 50 nmol/L, and in 32%, the levels were ≤ 35 nmol/L. Persons who died were likely to be older, of male sex, were likely to be admitted for pneumonia or CHF, were likely to have lower level of albumin or hemoglobin, lower level of vitamin D or higher vitamin B12 and higher level of creatinine, were also likely to have had a lengthier hospitalization stay, a greater number of hospitalizations in the last year, a higher number of comorbidities, to have consumption of ≥5 drugs or likely to being treated with insulin, diuretics, antipsychotics, anticoagulants or benzodiazepines. Higher age, male sex, on-admission CHF, higher number of drugs, lower albumin, higher vitamin B12, vitamin D < 50 nmol/L, and consumption of antipsychotics and anticoagulants – were predictors of mortality.ConclusionHypovitaminosis D is predictive of mortality in older patients within one year from hospitalization in the acute geriatric ward, but a causal relationship cannot be deduced. Nevertheless, older patients in acute care settings, because of their health vulnerability, should be considered for vitamin D testing. In the acutely ill patients, early intervention with vitamin D might improve outcomes. Accurate evaluation of mortality predictors in this age group patients may be more challenging and require variables that were not included in our study.

2226 Assessing quantitative sonographic changes in the muscle mass of geriatric patients hospitalised using point of care ultrasound

Abstract Introduction One of the most important consequences of hospitalisation in older patients is sarcopenia. This study aims to determine the impact of hospitalisation on the muscle mass, functional status, nutritional status, and short-term clinical outcomes. Methods A prospective study of patients admitted to an Acute Geriatric Ward between 1st November and 30th December 2022. Muscle ultrasound, utilising Point of Care Ultrasound (POCUS) at bedside, was employed to estimate rectus femoris muscle thickness (MT), area (Ar), pennation angle (PA), and fascicle length (FL) at the time of hospital admission, 3 days post-admission, and at hospital discharge. Results 30 patients included, with a median age of 84 years (SD 72–93), 63.3% male, and 70% Clinical Frailty Scale score ≥ 4. Barthel Index and Functional Ambulation Category revealed median values of 72.33 and 3.87 respectively. Global Deterioration Scale median was 2.47. Mini Nutritional Assessment Short-Form (MNA) and total serum protein showed median values of 7.40 and 6.35 respectively. The median length of hospital stay was 5.79 days, with inpatient mortality rate of 10% and 53.3% incidence of delirium. Ultrasound showed a decrease in PA by 36.31%, Ar by 34.30%, and MT by 24.50%, and increase in FL by 10.47%. Sarcopenia classification at admission and discharge revealed an increase in mean index from 5.04 to 7.74. Conclusions In our cohort of patients admitted to an acute geriatric unit, POCUS identified real-time decreases in MT, Ar, and PA at the muscular level before these manifested as functional changes. It demonstrated an inverse relationship between frailty and muscle morphology as living with frailty associated further decreases in muscle mass at discharge. The study also established a direct relationship between MNA, muscle thickness, PA, and fascicles length at discharge. POCUS assessment of muscle mass could indirectly predict outcomes and guide decisions to address muscle mass abnormalities.

Trends in infection incidence and antimicrobial resistance in the US Veterans Affairs Healthcare System: a nationwide retrospective cohort study (2007–22)

Antimicrobial resistance poses a major threat to public health. There are few comprehensive nationwide studies that quantify long-term trends in infection incidence and antimicrobial resistance for multiple pathogens. We aimed to analyse trends in inpatient infection incidence and antimicrobial resistance for nine pathogens over the past 15 years across the USA. In this US nationwide retrospective cohort study, we analysed clinical microbiology data from electronic health records from all patients admitted to all 138 Veterans Affairs (VA) Medical Centers with acute care wards across the USA from Feb 1, 2007, to March 31, 2022. We quantified inpatient antibiotic use as days of therapy (DOT) per 1000 patient-days and antimicrobial resistance by resistance proportion (proportion of incident isolates identified as resistant) and phenotypic incidence (incidence of infections per 1000 admissions classified as resistant, susceptible, or missing). To analyse trends before the COVID-19 pandemic and during the COVID-19 pandemic, we used generalised estimating equation models and reported average annual percentage changes (AAPC). We collected 991 527 30-day incident isolates from 507 760 patients in 138 VA Medical Centers and 50 states in the USA. Between Feb 1, 2007, and Dec 31, 2019, infection incidence and antimicrobial resistance declined for many pathogens and pathogen-drug combinations. The proportion of methicillin resistance in Staphylococcus aureus decreased from 57·7% (11 876 of 20 584 incident isolates) to 44·6% (5916 of 13 257) over these 13 years (AAPC -1·8%; 95% CI -2·4 to -1·2; p<0·0001), and vancomycin-resistant Enterococcus faecium infections decreased from 77·8% (2555 of 3285) to 65·1% (893 of 1371; AAPC -1·2%; 95% CI -2·5 to 0·0; p=0·052). Fluoroquinolone resistance declined in both proportion and incidence for most pathogens. These trends correlated with substantial reductions in fluoroquinolone use, from 125 DOT per 1000 patient-days to 20 DOT per 1000 patient-days. Third generation cephalosporin resistance increased steeply in Escherichia coli infections from 6·7% (942 of 14 042) in 2007 to 15·3% (2153 of 14 053) in 2019 (AAPC 8·5%; 95% CI 6·2 to 10·7; p<0·0001). Carbapenem resistance proportion increased in Enterobacter cloacae infections from 1·1% (30 of 2852) in 2007 to 7·3% (212 of 2919) in 2019 (AAPC 19·8%; 95% CI 13·7 to 26·2; p<0·0001), but remained low for Klebsiella pneumoniae and E coli. During the COVID-19 pandemic between Jan 1, 2020, and March 31, 2022, several pathogen-drug combinations increased in both incidence and resistance for hospital-associated infections. For some pathogen-drug combinations, trends in incidence of resistant and susceptible infections were divergent, whereas for other combinations, these trends were in the same direction. Significant reductions in methicillin resistance in S aureus, vancomycin-resistant E faecium, and fluoroquinolone resistance across multiple pathogens suggest that control efforts have had an effect on resistance. The rise in extended-spectrum β-lactamases-producing Enterobacterales and recent surge in hospital-associated infections emphasise the need for ongoing surveillance and interventions. Our study highlights how coupling the analysis of phenotypic incidence with resistance proportion can enhance interpretation of antimicrobial resistance data. US Centers for Disease Control and Prevention.

Cardio Delirium Day: national study on the prevalence of delirium in Italian cardiology wards

To date delirium prevalence in the adult acute Italian hospital cardiac population is unknown. In a multicenter study, we assessed the prevalence of delirium over a single day among a population of patients admitted to acute cardiac hospital wards in Italy. This is a point prevalence study (called "Cardio Delirium Day") which involved 55 Italian cardiologic centers (23 North, 18 Central, 12 South, 2 Sardinia) that collected data on 152 patients older than 65 years hospitalized on March 15, 2023. Delirium was assessed on the same day in all patients using the Confusion Assessment Method for the Intensive Care Unit algorithm, a validated and briefly administered tool which does not require specialized training. We also collected data about clinical variables, functional and nutritional status, dementia, comorbidity, medications, and physical restraints. The mean sample age was 79.0 ± 10 years (33% female). Delirium was diagnosed in 25 patients (16.4%); 17.1% were hospitalized in the intensive cardiac care unit and 13.8% in the cardiology ward (p=NS). Hyperactive was the commonest subtype (48%), followed by mixed (36%) and hypoactive type (8%). In a multivariate logistic regression, male sex (odds ratio [OR] 3.81, 95% confidence interval [CI] 1.18-12.26; p=0.025), chronic obstructive pulmonary disease (OR 0.24, 95% CI 0.063-0.66; p=0.008), sensorial deficit (OR 3.75, 95% CI 1.18-11.95; p=0.025), sleep deprivation (OR 5.81, 95% CI 1.47-22.9; p=0.012) and the presence of ≥3 precipitating factors (OR 7.63, 95% CI 2.32-25.2; p=0.001) were independent predictors of delirium. Delirium occurred in 16.4% of patients in a cardiology setting. The "Cardio Delirium Day" project might become a useful method to assess delirium over time and sensitize the interest and the culture of Italian cardiology in this important aspect of hospital care.

Clinical outcomes and phenotypes of respiratory failure in older subjects admitted to an acute care geriatric hospital ward.

Respiratory failure (RF) is frequent in hospitalized older patients, but was never systematically investigated in large populations of older hospitalized patients. We conducted a retrospective administrative study based on hospitalizations of a Geriatrics Unit regarding 2014, 2015, and 2016. Patients underwent daily screening for hypoxia. Hospital discharge records were coded through a standardized methodology. RF, defined as documented hypoxia on room air, was always coded, whenever present. We investigated how RF affected clinical outcomes, whether RF grouped into specific comorbidity phenotypes, and how phenotypes associated with the outcomes. RF was coded in 48.6% of the 1,810 hospitalizations. RF patients were older and more frequently had congestive heart failure (CHF: 49 vs 23%), chronic obstructive pulmonary disease (COPD: 27 vs 6%), pneumonia (14 vs 4%), sepsis (12 vs 7%), and pleural effusion (6 vs 3%), than non-RF patients. RF predicted longer length of stay (a-Beta 2.05, 95% CI 1.4-2.69; p < 0.001) and higher in-hospital death/intensive care units (ICU) need (aRR 7.12, 5-10.15; p < 0.001) after adjustment for confounders (linear and Poisson regression with robust error variance). Among RF patients, cerebrovascular disease, cancer, electrolyte disturbances, sepsis, and non-invasive ventilation predicted increased, while CHF and COPD predicted decreased in-hospital death/ICU need. The ONCO (cancer) and Mixed (cerebrovascular disease, dementia, pneumonia, sepsis, electrolyte disturbances, bedsores) phenotypes displayed higher in-hospital death/ICU need than CARDIO (CHF) and COPD phenotypes. In this study, RF predicted increased hospital death/ICU need and longer hospital stay, but also reflected diverse underlying conditions and clinical phenotypes that accounted for different clinical courses.

Transition to end-of-life care in patients with neurological diseases in an acute hospital ward

BackgroundTransitioning to end-of-life care and thereby changing the focus of treatment directives from life-sustaining treatment to comfort care is important for neurological patients in advanced stages. Late transition to end-of-life care for neurological patients has been described previously.ObjectiveTo investigate whether previous treatment directives, primary medical diagnoses, and demographic factors predict the transition to end-of-life care and time to eventual death in patients with neurological diseases in an acute hospital setting.MethodAll consecutive health records of patients diagnosed with stroke, amyotrophic lateral sclerosis (ALS), and Parkinson’s disease or other extrapyramidal diseases (PDoed), who died in an acute neurological ward between January 2011 and August 2020 were retrieved retrospectively. Descriptive statistics and multivariate Cox regression were used to examine the timing of treatment directives and death in relation to medical diagnosis, age, gender, and marital status.ResultsA total of 271 records were involved in the analysis. Patients in all diagnostic categories had a treatment directive for end-of-life care, with patients with haemorrhagic stroke having the highest (92%) and patients with PDoed the lowest (73%) proportion. Cox regression identified that the likelihood of end-of-life care decision-making was related to advancing age (HR = 1.02, 95% CI: 1.007–1.039, P = 0.005), ischaemic stroke (HR = 1.64, 95% CI: 1.034–2.618, P = 0.036) and haemorrhagic stroke (HR = 2.04, 95% CI: 1.219–3.423, P = 0.007) diagnoses. End-of-life care decision occurred from four to twenty-two days after hospital admission. The time from end-of-life care decision to death was a median of two days. Treatment directives, demographic factors, and diagnostic categories did not increase the likelihood of death following an end-of-life care decision.ConclusionsResults show not only that neurological patients transit late to end-of-life care but that the timeframe of the decision differs between patients with acute neurological diseases and those with progressive neurological diseases, highlighting the particular significance of the short timeframe of patients with the progressive neurological diseases ALS and PDoed. Different trajectories of patients with neurological diseases at end-of-life should be further explored and clinical guidelines expanded to embrace the high diversity in neurological patients.

COVID-19 Across Pandemic Variant Periods: The Severe Acute Respiratory Infection-Preparedness (SARI-PREP) Study.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has evolved through multiple phases in the United States, with significant differences in patient centered outcomes with improvements in hospital strain, medical countermeasures, and overall understanding of the disease. We describe how patient characteristics changed and care progressed over the various pandemic phases; we also emphasize the need for an ongoing clinical network to improve the understanding of known and novel respiratory viral diseases. To describe how patient characteristics and care evolved across the various COVID-19 pandemic periods in those hospitalized with viral severe acute respiratory infection (SARI). Severe Acute Respiratory Infection-Preparedness (SARI-PREP) is a Centers for Disease Control and Prevention Foundation-funded, Society of Critical Care Medicine Discovery-housed, longitudinal multicenter cohort study of viral pneumonia. We defined SARI patients as those hospitalized with laboratory-confirmed respiratory viral infection and an acute syndrome of fever, cough, and radiographic infiltrates or hypoxemia. We collected patient-level data including demographic characteristics, comorbidities, acute physiologic measures, serum and respiratory specimens, therapeutics, and outcomes. Outcomes were described across four pandemic variant periods based on a SARS-CoV-2 sequenced subsample: pre-Delta, Delta, Omicron BA.1, and Omicron post-BA.1. Multicenter cohort of adult patients admitted to an acute care ward or ICU from seven hospitals representing diverse geographic regions across the United States. Patients with SARI caused by infection with respiratory viruses. Eight hundred seventy-four adult patients with SARI were enrolled at seven study hospitals between March 2020 and April 2023. Most patients (780, 89%) had SARS-CoV-2 infection. Across the COVID-19 cohort, median age was 60 years (interquartile range, 48.0-71.0 yr) and 66% were male. Almost half (430, 49%) of the study population belonged to underserved communities. Most patients (76.5%) were admitted to the ICU, 52.5% received mechanical ventilation, and observed hospital mortality was 25.5%. As the pandemic progressed, we observed decreases in ICU utilization (94% to 58%), hospital length of stay (median, 26.0 to 8.5 d), and hospital mortality (32% to 12%), while the number of comorbid conditions increased. We describe increasing comorbidities but improved outcomes across pandemic variant periods, in the setting of multiple factors, including evolving care delivery, countermeasures, and viral variants. An understanding of patient-level factors may inform treatment options for subsequent variants and future novel pathogens.

Effects of a video-viewing intervention with positive word stimulation on the depressive symptoms of older patients with cardiac disease and subthreshold depression: a pilot randomized controlled trial protocol

BackgroundIntervention for older patients with cardiac disease and subthreshold depression (StD) may be an effective strategy to prevent the development of major depressive disorder. The subliminal priming with supraliminal reward stimulation (SPSRS) website developed by us is an advanced intervention that can improve depressive symptoms in individuals with StD by presenting positive word stimuli in videos. However, its efficacy for treating depressive symptoms in older patients with cardiac disease and StD has not been investigated. Here, we present a pilot randomized controlled trial protocol to investigate the preliminary efficacy of an intervention for older patients with cardiac disease with StD.MethodsThe study was designed as a single-center, open-label, pilot, randomized, parallel-group trial. The participants will include 30 older patients with cardiac disease and StD who are hospitalized in acute wards. The Experimental group received the SPSRS intervention (video viewing with positive word stimuli; n = 15) and the Control group will receive the YouTube intervention (video viewing without positive word stimuli; n = 15). In both groups, the intervention will be administered for 10 min per day, five times per week for 1 week. The primary outcome will be the change in the scores on the Japanese version of the Beck Depression Inventory-II at 1 week after the baseline assessment. The secondary outcomes will be the changes in the Specific Activity Scale, New York Heart Association functional classification, as well as grip strength at 1 week after the baseline assessment.DiscussionThis pilot randomized controlled trial will be the first to evaluate the SPSRS intervention for depressive symptoms in older patients with cardiac disease and StD who are admitted to acute wards. The results will provide tentative indications regarding the impact of the intervention on depressive symptoms among older patients with cardiac disease and StD who are admitted to acute wards, and will contribute to the planning of a full-scale study.Trial registrationUMIN, UMIN000052155. Registered September 8, 2023, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000059526. This study was registered with the University Hospital Medical Information Network (UMIN) (UMIN000052155) in Japan.

Patient experiences and clinical outcomes of admissions to municipal acute wards versus a hospital: a multicentre randomised controlled trial in Norway

Background In Norway, municipal acute wards (MAWs) were implemented as alternatives to hospitalisation. Evaluations of the quality of MAW services are lacking. The primary objective of this study was to compare patient experiences after admission to a MAW versus to a hospital. The secondary objective was to compare ‘readmissions’, ‘length of stay’, ‘self-assessed health-related quality of life’ as measured by the EuroQol 5 items 5 level (EQ-5D-5L) index, and ‘health status’ measured by the RAND-12, in patients admitted to a MAW versus a hospital. Methods A multicentre randomised controlled trial (RCT), randomising patients to either MAW or hospital. Results In total, 164 patients were enrolled in the study; 115 were randomised to MAW and 49 to hospital. There were no significant differences between the MAW and hospital groups regarding patient experience, which was rated positively in both groups. Patients in the MAW group reported significantly better physical health status as measured by the RAND-12 four to six weeks after admittance than those randomised to hospital (physical component summary score, 31.7 versus 27.1, p = 0.04). The change in EQ-5D index score from baseline to four to six weeks after admittance was significantly greater among patients randomised to MAWs versus hospitals (0.20 versus 0.02, p = 0.03). There were no other significant differences between the MAW and hospital groups. Conclusions In this study, patient experiences and readmissions were similar, whether patients were admitted to a MAW or a hospital. The significant differences in health status and quality of life favouring the MAWs suggest that these healthcare services may be better for elderly patients. However, unfortunately we did not reach the planned sample size due to challenges in the data collection posed by the Covid-19 pandemic.

Stress, burnout and coping among nurses working on acute medical wards and in the community: A quantitative study.

Psychological distress can cause burnout, which affects mental and physical well-being. It is important to identify factors associated with psychological distress and physical discomfort and how nurses deal with these problems. The aim was to investigate distress, burnout and coping among community nurses (CN) and hospital nurses (HN). In this cross-sectional study, 409 nurses completed three questionnaires: Perceived Stress Scale (PSS), Copenhagen Burnout Inventory (CBI) and Ways of Coping (WOC). Participants younger than 40 demonstrated significantly more distress and burnout than those older than 40 years. Participants who had moderate and high distress on the PSS were significantly more at risk for experiencing personal, work-related and patient-related burnout. A significant positive correlation was found between distress and behavioural escape-avoidance, cognitive escape-avoidance and distancing. Significant positive correlations were also seen between all the subscales of the CBI and behavioural escape-avoidance, cognitive escape-avoidance and distancing. Positive significant correlation was also obtained between staff resources and distress and personal-related and work-related burnout. Negative correlation was demonstrated between staff resources and patient-related burnout. Participants with longer work experience were less likely to report moderate or high distress, and those who scored higher on personal burnout and behavioural escape-avoidance were more likely to have moderate or high distress. The results of this study call for increased attention to the younger generation in the nursing profession. The results also validate the need to investigate further the correlation between distress, burnout and coping and how these issues might influence each other among nurses working in the community and hospitals. Findings should be taken with precaution, they do not describe in detail what underlying factors contribute to distress and discomfort found in this study, they do, however, indicate certain coping strategies nurses use to deal with distress and burnout.

A facilitator's reflection on the democratizing potential of emancipatory practice development.

Emancipatory practice development (ePD) is a practitioner-led research methodology which enables workplace transformation. Underpinned by the critical paradigm, ePD works through facilitation and workplace learning, with people in their local context on practice issues that are significant to them. Its purpose is to embed safe, person-centred learning cultures which transform individuals and workplaces. In this article, we critically reflect on a year-long ePD study in an acute care hospital ward. We explore the challenges of practice change within systems, building collective strength with frontline collaborations and leadership to sustain new learning cultures. Our work advances practice development dialogue through working closely with the underpinning theories. Our critique analyses how ePD can enact and sustain change within a complex system. We argue that ePD works to strengthen safety cultures by challenging antidemocratic practices through communicative action. By opening communicative spaces, ePD enables staff to collectively deliberate and reach consensus. Their raised awareness supports staff to resist ways of working which conspire against safe patient care. Sustainability of practice change is fostered by the co-operative democracies created within the frontline team and meso level enablement. We conclude that the democratising potential of ePDt generates staff agency at the frontline.

GDF-15 is associated with sarcopenia and frailty in acutely admitted older medical patients.

Growth differentiation factor-15 (GDF-15) has been associated with senescence, lower muscle strength, and physical performance in healthy older people. Still, it is not clear whether GDF-15 can be utilized as a biomarker of sarcopenia and frailty in the early stages of hospitalization. We investigated the association of plasma GDF-15 with sarcopenia and frailty in older, acutely admitted medical patients. The present study is based on secondary analyses of cross-sectional data from the Copenhagen PROTECT study, a prospective cohort study including 1071 patients ≥65years of age admitted to the acute medical ward at Copenhagen University Hospital, Bispebjerg, Denmark. Muscle strength was assessed using handgrip strength, and lean mass was assessed using direct segmental multifrequency bioelectrical impedance analyses and used to clarify the potential presence of sarcopenia defined according to guidelines from the European Working Group on Sarcopenia in Older People. Frailty was evaluated using the Clinical Frailty Scale. Plasma GDF-15 was measured using electrochemiluminescence assays from Meso Scale Discovery (MSD, Rockville, MD, USA). We included 1036 patients with completed blood samples (mean age 78.9±7.8years, 53% female). The median concentration of GDF-15 was 2669.3pg/mL. Systemic GDF-15 was significantly higher in patients with either sarcopenia (P<0.01) or frailty (P<0.001) compared with patients without the conditions. Optimum cut-off points of GDF-15 relating to sarcopenia and frailty were 1541 and 2166pg/mL, respectively. Systemic GDF-15 was higher in acutely admitted older medical patients with sarcopenia and frailty compared with patients without. The present study defined the optimum cut-off for GDF-15, related to the presence of sarcopenia and frailty, respectively. When elevated above the derived cutoffs, GDF-15 was strongly associated with frailty and sarcopenia in both crude and fully adjusted models.