Bed Availability Research Articles

Association between the timing of ICU admission and mortality in patients with hospital-onset sepsis: a nationwide prospective cohort study

BackgroundBased on sparse evidence, the current Surviving Sepsis Campaign guideline suggests that critically ill patients with sepsis be admitted to the intensive care unit (ICU) within 6 h. However, limited ICU bed availability often makes immediate transfer difficult, and it is unclear whether all patients will benefit from early admission to the ICU. Therefore, the purpose of this study was to determine the association between the timing of ICU admission and mortality in patients with hospital-onset sepsis.MethodsThis nationwide prospective cohort study analyzed patients with hospital-onset sepsis admitted to the ICUs of 19 tertiary hospitals between September 2019 and December 2020. ICU admission was classified as either early (within 6 h) or delayed (beyond 6 h). The primary outcome of in-hospital mortality was compared using logistic regression adjusted for key prognostic factors in the unmatched and 1:1 propensity-score-matched cohorts. Subgroup and interaction analyses assessed whether in-hospital mortality varied according to baseline characteristics.ResultsA total of 470 and 286 patients were included in the early and delayed admission groups, respectively. Early admission to the ICU did not significantly result in lower in-hospital mortality in both the unmatched (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 0.99–1.85) and matched cohorts (aOR, 1.38; 95% CI, 0.94–2.02). Subgroup analyses showed that patients with increasing lactate levels (aOR, 2.10; 95% CI, 1.37–3.23; P for interaction = 0.003), septic shock (aOR, 2.06; 95% CI, 1.31–3.22; P for interaction = 0.019), and those who needed mechanical ventilation (aOR, 1.92; 95% CI, 1.24–2.96; P for interaction = 0.027) or vasopressor support (aOR, 1.69; 95% CI, 1.17–2.44; P for interaction = 0.042) on the day of ICU admission had a higher risk of mortality with delayed admission.ConclusionsAmong patients with hospital-onset sepsis, in-hospital mortality did not differ significantly between those with early and delayed ICU admission. However, as early intensive care may benefit those with increasing lactate levels, septic shock, and those who require vasopressors or ventilatory support, admission to the ICU within 6 h should be considered for these subsets of patients.

A prolonged wait: The impact of COVID-19 on elective surgeries in India, a prospective study

Background: The continuing Coronavirus Disease 2019 (COVID-19) pandemic has had a massive impact on healthcare systems all around the globe. There is no exception in the demographics of elective surgery also. Like any other medical professionals, surgeons and post-graduates are redirected to the management of patients with COVID-19. The purpose of this study is to determine how the COVID-19 pandemic affected elective surgeries, surgeon skills, and post-graduate training. Methods: This prospective study was done among 320 participants through a 15-question online cross-sectional survey sent primarily to surgeons practicing in six states of India that were most affected by the pandemic according to recent statistics and also to surgeons in other states via email or other online messaging services. Results: In our study, the following observations were made: Patient/ patient attendant dissatisfaction in a reduction in the availability of hospital beds, shortage of medical oxygen and lack of availability of surgical implants. Conclusions: All these factors showed significant p-values with statistical significance, thereby indicating the impact of the COVID-19 pandemic on the healthcare system and healthcare delivery. The pandemic also had a significant impact on post-graduate training.

Comparative analysis of the activities of emergency hospitals in the «covid» period

INTRODUCTION: The pandemic of a new coronavirus infection has become a serious test of our country’s health care system. OBJECTIVE OF THE STUDY: Analysis of the dynamics of the performance of emergency hospitals during the pandemic of a new coronavirus infection. MATERIALS AND METHODS: The material was the data of federal state statistics (sources - FSN No. 14 and 30, 2019- 2021) of 2 multidisciplinary hospitals operating in ambulance hospitals (24/7/365), which have fundamental structural and functional features related to the availability of beds for patients with COVID-19. Regulatory, statistical (analysis of averages using parametric T-test and one-way-ANOVA analysis of variance, Spearman correlation analysis) and analytical methods (analysis, synthesis, comparison) were used. RESULTS: For a hospital with deployed beds for patients with COVID-19, there was a characteristic decrease in volumetric performance indicators: the number of patients in the admission department (by 61.7 %), non-hospitalized patients (by 82.2 %) and patient refusals from hospitalization (by 83.6 %), the number of outpatients (by 77.7 %), the number of discharged patients (by 17.7 %), carried out by patients bed-days (2.9 %), patient re-hospitalizations (96.1 %). For a hospital that was not re-profiled for COVID-19, there was a slight increase in visits (+ 1.4 %) with a decrease in the number of discharged patients (-22.8 %) and spent bed days (-12.4 %), an increase in the number of non-hospitalized patients (by 34.2 %) and the volume of care on an outpatient basis (+ 22.7 %), the number of re-hospitalized patients increased (+ 55.5 %). In hospitals, there was an increase in the number of patients who died (by 154.8 % and 29.2 %, respectively), including those with respiratory diseases (by 433.3 % and 145.5 %, respectively). DISCUSSION: Two multidisciplinary emergency hospitals had significant differences in the organization of their work in the period 2019-2021, due to the re-profiling of beds for receiving infectious patients (for patients with COVID-19) and the assignment of additional volumes of specialized non-infectious medical care to the non-redesigned multidisciplinary hospital. CONCLUSION: Currently, multidisciplinary emergency hospitals require the development of new models and principles for organizing the medical and diagnostic process, providing for the deployment of inpatient emergency departments, mobile bed capacity, infectious beds, development of algorithms for admission and triage of patients, reduction of unreasonable and non-core hospitalization, increasing the availability, efficiency and quality of medical care, which will increase the readiness to work in emergency situations of such a pandemic with a new coronavirus infection (COVID-19).

From prediction to decision: Optimizing long‐term care placements among older delayed discharge patients

This study examines long‐term care (LTC) discharge planning among older delayed discharge patients. While awaiting placements in alternate care such as LTC, these patients occupy hospital beds despite not requiring an intensive level of care. This study proposes a novel discharge decision model based on the Markov decision process (MDP) framework, which incorporates predictions regarding the patients' health trajectory and the associated hospital costs. Our machine learning (ML)‐based predictive analytics allow for considering heterogeneous health transitions, hence personalized decision making, leading to valuable information for reducing hospital costs. We also develop data‐driven cost functions using patient characteristics to estimate the person‐level costs associated with the decisions in the optimization model, that is, whether or not to discharge a patient to LTC. The data analyses and cost estimations are based on large historical data collected over 13 years in Ontario, Canada. To solve the resulting high‐dimensional MDP models, we develop an index policy, where each patient's index value is calculated using their health complexity (comorbidity), sex, age, and acute length of stay in the hospital. Using extensive numerical experiments, we illustrate the superior performance of the proposed index policy against some benchmarking policies and demonstrate the significance of predictive information in optimizing discharge decisions. Our results also indicate that the value of predictive information increases with LTC bed availability and decreases with hospital capacity. We also demonstrate that with the anticipated exacerbating mismatch between supply and demand, targeted prediction‐driven discharge policies, such as the proposed index policy, become even more critical.

412 A Protocol for Reducing Intensive Care Utilization After Craniotomy: A Three-Year Assessment

INTRODUCTION: Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the “Non-Intensive CarE” (NICE) protocol to identify craniotomy patients that did not require postoperative ICU care. METHODS: Our institution’s electronic medical record (EMR) was queried to identify craniotomies prior to protocol deployment (May 2014-May 2018), and after deployment (May 2018-December 2021). Patients are considered for the protocol if they are having an elective craniotomy for select procedures (e.g. microvascular decompressions, extra-axial tumor resection), are under age of 65, have no history of coagulopathy, and have no other medical contraindications. Reason for readmission or reoperation among NICE protocol patients was collected via chart review. The primary endpoints were average POLS and ICU utilization; secondary endpoints included readmission, reoperation, and postoperative complications rates. Endpoints were compared among pre- and post-protocol cohorts. RESULTS: 4,837 craniotomies were performed from May 2014-December 2021 (2,302 pre-protocol, 2,535 post-protocol). 21% percent of post-protocol craniotomies were enrolled in the NICE protocol. After protocol deployment, overall POLS decreased from 4.0 to 3.5 days (p = 0.0031), which was driven by deceased POLS among protocol patients (average 2.4 days).ICU utilization decreased from 57% of patients to 42% (p < 0.0001), generating ∼$760,000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within thirty days; none could have been prevented through ICU stay. CONCLUSIONS: The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

Analysing Monday discharges to identify lost opportunities for weekend discharge.

Lower rates of hospital discharge occur on weekends compared with weekdays. The authors performed a retrospective chart review of Monday discharges from the Hospital Medicine service at an academic hospital over a 3-month period to identify reasons for delayed discharge despite medical stability. Of 202 eligible patients, 81 (40%) had documentation indicating stability for earlier discharge. Common causes included bed availability or insurance authorisation at a skilled nursing facility, home care services and patient/family disagreement with discharge.

Bed space, referral capacity and emergency response of the healthcare facilities in lagos state: a key to improving healthcare

Background: A health system comprises various elements such as infrastructure, human resources, data systems, and financial systems. Adequate infrastructure, including buildings, equipment, supplies, and communication, is crucial to health services. In Nigeria, some healthcare facilities do not have the needed human and infrastructure resources to manage specific conditions, causing multiple referrals and endangering patients' lives. The present study assessed the availability of in-patient beds and the referral capacity and emergency response of the healthcare facilities in Lagos State. Methods: This study leveraged Noi Polls census data on Health Facility Assessment for Lagos state conducted between November 2020 and December 2021. The survey was conducted in 1256 health facilities which are 53.8% of the entire health facilities in Lagos State, and 53.8% of the population of Lagos State was used to compute the bed/population ratio. A descriptive analysis was done to present the findings. Result: Findings revealed that Lagos State has eight (8) beds per 10,000 population which is below the global average of twenty-six (26) beds per 10,000 population and the recommended five (5) beds per 1,000 population by the World Health Organisation. The results further reveal that healthcare facilities in Lagos State need additional 2,861 beds to reach the Sub-Saharan average in-patient beds of twelve (12) per 10,000 population and an additional 31,953 beds to reach the recommended five (5) per 1,000 populations by the World Health Organization. Conclusion: Infrastructures such as beds, emergency rooms, and the emergency transportation services needed to transport patients to other facilities are lacking in most of the healthcare facilities in Lagos State. Secondary healthcare facilities in the State cannot discharge their roles, especially handling referred patients, as they lack bed space to care for in-patients and emergency rooms to carter for emergency cases.

Covid-19: did higher trust societies fare better?

Social trust—between governments and people and between individuals—and trust in science were proposed as prerequisites for tackling covid. Others suggested less democratic societies were more able to impose strict rules stopping the virus. These propositions were tested for a group of mainly advanced countries.The dependent variable is cumulated deaths from covid. Findings are broken down between (a) OECD member countries, (b) these and countries having cooperation agreements with it, and (c) all these plus China. They are also broken down by time—between (a) the period before the appearance of “new variants” in late 2020 and (b) the period from then until end September 2021.The best, most parsimonious, models explain nearly half of the changes in the level of deaths. Trust in government improves outcomes, as does interpersonal trust. Vaccine antipathy does not play a role. Also, there is little indication that authoritarian regimes performed better than higher trust societies. In the first period, increasing wealth inequality—indicating a more divided society—is related to higher death rates. Hospital bed availability is important then, but not thereafter. Furthermore, as the pandemic persisted, the importance of pre-existing levels of social trust declined.The paper warns that institutions and cultures cannot easily be transferred from one country to another. Nor would all transfers be desired. It also suggests that some other lessons of what contributed to better outcomes under covid might be relevant for the monkeypox virus—its successor public health emergency.

The physician CEO advantage and hospital performance during the COVID-19 pandemic: capacity utilization and patient satisfaction

PurposePrior studies have shown that physician-led hospitals have several advantages over non-physician-led hospitals. This study seeks to test whether these advantages also extend to periods of extreme disruptions such as the COVID-19 pandemic, which affect bed availability and hospital utilization.Design/methodology/approachThe authors utilize a bounded Tobit estimation to identify differences in patient satisfaction rates and in-hospital utilization rates of top-rated hospitals in the United States.FindingsAmong top-rated US hospitals, those that are physician-led achieve higher patient satisfaction ratings and are more likely to have higher utilization rates.Research limitations/implicationsWhile the COVID-19 pandemic generated greater demand for inpatient beds, physician-led hospitals improved their hospitals’ capacity utilization as compared with those led by non-physician leaders. A longitudinal study to show the change over the years and whether physician Chief Executive Officers (CEOs) are more likely to improve their hospitals’ ratings than non-physician CEOs is highly recommended.Practical implicationsRecruiting and retaining physicians to lead hospitals, especially during disruptions, improve hospital’s operating efficiency and enhance patient satisfaction.Originality/valueThe paper reviews prior research on physician leadership and adds further insights into the crisis leadership literature. The authors provide evidence based on quantitative data analysis that during the COVID-19 pandemic, physician-led top-rated US hospitals experienced an improvement in operating efficiency.

Abstract Number ‐ 195: Impact of COVID‐19 on Stroke Treatment in Latin America

Introduction Ischemic stroke is a neurological disease that affects people worldwide, and it occurs when there is a loss of blood to the brain due to either an artery burst or blood clot. The COVID‐19 pandemic has negatively impacted stroke treatment, specifically mechanical thrombectomy, across the world but especially in Latin and Central America. The objective of this research project is to determine the barriers that COVID‐19 has imposed on stroke treatment in the Latin America region. Methods First, data was collected from articles through NCBI and local news. The data on COVID‐19 and stroke provided input on the number of COVID‐19 cases in Latin America and the overall rate of stroke incidences in each region. Then, the countries in Latin America were divided into three different groups to determine which regions had the most Covid cases, sub‐optimal stroke treatments, and more well‐known health resources. Mexico was zeroed in on as the central region because more data and stroke resources were readily available. A survey was created which contained critical questions on the overall situation of stroke in Mexico and potential barriers, and these surveys were emailed to neurologists and other physicians who were experts in the region. Ultimately, two physicians from Mexico agreed to be interviewed, and important information was received on the status of stroke treatment in these areas. Results From the surveys and interviews, the two doctors revealed important information regarding the specific barriers to stroke treatment. The first doctor interviewed is a physician in a tertiary medical center for specialized neurological conditions. She raised concern about the lack of awareness among the general population about the early recognition of stroke and its symptoms. Additionally, she indicated that her center has the necessary endovascular equipment to offer mechanical thrombectomies, but patients are often unable to reach the hospital on time. Ambulances have been typically unavailable or delayed as they have been prioritized for transporting COVID patients. Additionally, there has been a lack of rehabilitation resources for stroke patients during the pandemic due to the shortage of beds and staff. The second doctor interviewed was additionally concerned about the lack of timely use of equipment for mechanical thrombectomies. When a patient is in need of thrombectomy treatment, the doctor has to contact the intermediary vendor, who brings the equipment for use, hence delaying treatment. He also stated that during the pandemic, a third of the beds were occupied by COVID patients, limiting the availability of hospital beds for other illnesses. Conclusions In conclusion, the COVID‐19 pandemic has negatively impacted stroke treatment in Mexico. The main barriers to stroke treatment include the limited awareness among the general population about the recognition of stroke, a lack of sufficient rehabilitation services, insufficient medical thrombectomy services and the delayed ambulance response. Based on this data, the intervention we are developing is an app that will display stroke‐specific resources and information. This platform will include information on how to recognize stroke, specific stroke‐care hospitals in the region, and helplines.

Helminth Infections in Dairy Sheep Found in an Extensive Countrywide Study in Greece and Potential Predictors for Their Presence in Faecal Samples

The aims of the present study were: (a) to describe the prevalence of helminth infections from pooled faecal samples from sheep flocks across Greece and (b) to evaluate flock-related factors potentially associated with the presence of these infections in the flocks. An extensive countrywide study was performed on 325 sheep farms throughout Greece; faecal samples were collected from ewes and processed for the identification of helminth parasites. Helminths were detected in samples from 92.9% of flocks; these included Dicrocoelium dendriticum (16.7% of flocks), Fasciola hepatica (0.6%), Paramphistomum cervi (2.2%), Moniezia spp. (18.8%), Trichostrongylidae (85.5%), Nematodirus spp. (18.8%), Strongyloides papillosus (7.1%), Trichuris spp. (20.0%) and lungworms (17.8%). Mean Trichostrongylidae counts across all flocks in the study were 215 epg. Specifically, for Trichostrongylidae, there were differences between flocks that had or had not received anthelmintics during the two months prior to sampling, as well as between flocks located in various areas of the country. In multivariable analyses, for the outcome 'high (>300) epg counts in faecal samples', the month into the lactation period at sampling and the application of reproductive control practices on the farm emerged as significant factors; for the outcome 'high proportion (>63%) of Teladorsagia spp. in faecal samples', the availability of straw bedding emerged as a significant factor; and for the outcome 'high proportion (>63%) of Haemonchus contortus in faecal samples', the age of the farmer emerged as a significant factor. For the outcome 'presence of Trichuris spp. in faecal samples', the provision of finished feed (concentrate) to animals emerged as a significant factor, whilst, finally, for the outcomes 'presence of D. dendriticum in faecal samples' and 'presence of lungworms in faecal samples,' no significant factors emerged.

The three facets of the SARS-CoV-2 pandemic during the first two waves in the northern, central, and southern Italy

BackgroundThere is a scarcity of information in literature regarding the clinical differences and comorbidities of patients affected by Coronavirus disease 2019 (COVID-19), which could clarify the different prevalence of the outcomes (composite and only death) between several Italian regions. ObjectiveThis study aimed to assess the heterogeneity of clinical features of patients with COVID-19 upon hospital admission and disease outcomes in the northern, central, and southern Italian regions. MethodsAn observational cohort multicenter retrospective study including 1210 patients who were admitted for COVID-19 in Infectious diseases, Pulmonology, Endocrinology, Geriatrics and Internal Medicine Units in Italian cities stratified between north (263 patients); center (320 patients); and south (627 patients), during the first and second pandemic waves of SARS-CoV-2 (from February 1, 2020 to January 31, 2021). The data, obtained from clinical charts and collected in a single database, comprehended demographic characteristics, comorbidities, hospital and home pharmacological therapies, oxygen therapy, laboratory values, discharge, death and Intensive care Unit (ICU) transfer. Death or ICU transfer were defined as composite outcomes. ResultsMale patients were more frequent in the northern Italian region than in the central and southern regions. Diabetes mellitus, arterial hypertension, chronic pulmonary and chronic kidney diseases were the comorbidities more frequent in the southern region; cancer, heart failure, stroke and atrial fibrillation were more frequent in the central region. The prevalence of the composite outcome was recorded more frequently in the southern region. Multivariable analysis showed a direct association between the combined event and age, ischemic cardiac disease, and chronic kidney disease, in addition to the geographical area. ConclusionsStatistically significant heterogeneity was observed in patients with COVID-19 characteristics at admission and outcomes from northern to southern Italy. The higher frequency of ICU transfer and death in the southern region may depend on the wider hospital admission of frail patients for the availability of more beds since the burden of COVID-19 on the healthcare system was less intense in southern region. In any case, predictive analysis of clinical outcomes should consider that the geographical differences that may reflect clinical differences in patient characteristics, are also related to access to health-care facilities and care modalities. Overall, the present results caution against generalizability of prognostic scores in COVID-19 patients derived from hospital cohorts in different settings.

Assessment of Excess Mortality in Italy in 2020–2021 as a Function of Selected Macro-Factors

Excess mortality (EM) can reliably capture the impact of a pandemic, this study aims at assessing the numerous factors associated with EM during the COVID-19 pandemic in Italy. Mortality records (ISTAT 2015-2021) aggregated in the 610 Italian Labour Market Areas (LMAs) were used to obtain the EM P-scores to associate EM with socioeconomic variables. A two-step analysis was implemented: (1) Functional representation of EM and clustering. (2) Distinct functional regression by cluster. The LMAs are divided into four clusters: 1 low EM; 2 moderate EM; 3 high EM; and 4 high EM-first wave. Low-Income showed a negative association with EM clusters 1 and 4. Population density and percentage of over 70 did not seem to affect EM significantly. Bed availability positively associates with EM during the first wave. The employment rate positively associates with EM during the first two waves, becoming negatively associated when the vaccination campaign began. The clustering shows diverse behaviours by geography and time, the impact of socioeconomic characteristics, and local governments and health services' responses. The LMAs allow to draw a clear picture of local characteristics associated with the spread of the virus. The employment rate trend confirmed that essential workers were at risk, especially during the first wave.

Highly varying concepts and capacities of forensic mental health services across the European Union.

There is wide variation in the processes, structures and treatment models for dealing with mentally disordered offenders across the European Union. There is a serious lack of data on population levels of need, national service capacities, or treatment outcome. This prevents us from comparing the different management and treatment approaches internationally and from identifying models of good practice and indeed what represents financial efficiency, in a sector that is universally needed. From March 2019 till January 2020 we surveyed forensic psychiatric experts from each European Union Member State on basic concepts, service capacities and indicators for the prevalence and incidence of various forensic psychiatric system components. Each expert completed a detailed questionnaire for their respective country using the best available data. Finally, 22 EU Member States and Switzerland participated in the survey. Due to the frequent lack of a clear definition of what represented a forensic psychiatric bed, exact numbers on bed availability across specialized forensic hospitals or wards, general psychiatric hospitals or prison medical wards were often unknown or could only be estimated in a number of countries. Population-based rates calculated from the survey data suggested a highly variable pattern of forensic psychiatric provision across Europe, ranging from 0.9 forensic psychiatric beds per 100,000 population in Italy to 23.3 in Belgium. Other key service characteristics were similarly heterogeneous. Our results show that systems for detaining and treating mentally disordered offenders are highly diverse across European Union Member States. Systems appear to have been designed and reformed with insufficient evidence. Service designers, managers and health care planners in this field lack the most basic of information to describe their systems and analyse their outcomes. As a basic, minimum standardized national reporting systems must be implemented to inform regular EU wide forensic psychiatry reports as a prerequisite to allow the evaluation and comparison of the various systems to identify models of best practice, effectiveness and efficiency.

COVID-19 vaccination improved outcomes in the treatment of geriatric hip fractures between December 2020 and January 2022.

Geriatric hip fracture patients are at high risk for perioperative morbidity and mortality from COVID-19. This study analyses the impact of COVID-19 vaccination on geriatric hip fracture outcomes. We hypothesise that having the COVID-19 vaccine improves outcomes for geriatric patients treated for hip fracture. Between December 2020 and January 2022, 506 patients treated for hip fracture were analysed for demographics, hospital quality measures, and outcomes. Patients were grouped according to vaccine series administration status. During the study period, there were 329 (65%) unvaccinated patients (NV), 14 (3%) partially vaccinated (PV) patients, 138 (27%) fully vaccinated (FV) patients, and 25 (5%) patients received a booster shot (BV). Variables were compared using chi square, independent sample t-tests or ANOVA as appropriate. Multivariable logistic regression was used to independently assess the impact of vaccination. The rate of minor complications decreased if any vaccination status was achieved (NV: 37.99%, PV: 21.34%, FV: 28.26%, BV: 20.00%; p = 0.054). Vaccinated patients had a decreased need for Intensive Care Unit (ICU) level care (NV: 14.89%, PV: 7.14%, FV: 5.80%, BV: 8.00%; p = 0.038). There were no differences in inpatient or 30-day mortality, major complications, length of stay, home discharge, or readmission within 30 or 90 days. Vaccination against COVID-19 was independently protective against the need for ICU level care. Additionally, female gender and vaccination against COVID-19 decreased the rate of minor complications. Older age and higher comorbidity burden increased the rate of minor complications. In the hip fracture population, vaccination against COVID-19 was protective against the need for ICU level care and decreased overall minor complications. Larger studies are needed to determine if vaccination decreases mortality in this population. These findings have resource allocation implications including ICU bed availability during pandemics and patient outreach to improve vaccination status.

A Protocol for Reducing Intensive Care Utilization After Craniotomy: A 3-Year Assessment.

Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the "Non-Intensive CarE" (NICE) protocol to identify craniotomy patients who did not require postoperative ICU care. To determine the longitudinal impact of the NICE protocol on postoperative length of stay (LOS), ICU utilization, readmissions, and complications. In this retrospective cohort study, our institution's electronic medical record was queried to identify craniotomies before protocol deployment (May 2014-May 2018) and after deployment (May 2018-December 2021). The primary end points were average postoperative LOS and ICU utilization; secondary end points included readmissions, reoperation, and postoperative complications rate. End points were compared between pre- and postintervention cohorts. Four thousand eight hundred thirty-seven craniotomies were performed from May 2014 to December 2021 (2302 preprotocol and 2535 postprotocol). Twenty-one percent of postprotocol craniotomies were enrolled in the NICE protocol. After protocol deployment, the overall postoperative LOS decreased from 4.0 to 3.5 days ( P = .0031), which was driven by deceased postoperative LOS among protocol patients (average 2.4 days). ICU utilization decreased from 57% of patients to 42% ( P < .0001), generating ∼$760 000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within 30 days; none could have been prevented through ICU stay. The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.

Coping with COVID-19: the role of hospital care structures and capacity expansion in five countries.

This contribution examines the responses of five health systems in the first wave of the COVID-19 pandemic: Denmark, Germany, Israel, Spain and Sweden. The aim is to understand to what extent this crisis response of these countries was resilient. The study focuses on hospital care structures, considering both existing capacity before the pandemic and the management and expansion of capacity during the crisis. Evaluation criteria include flexibility in the use of existing resources and response planning, as well as the ability to create surge capacity. Data were collected from country experts using a structured questionnaire. Main findings are that not only the total number but also the availability of hospital beds is critical to resilience, as is the ability to mobilise (highly) qualified personnel. Indispensable for rapid capacity adjustment is the availability of data. Countries with more centralised hospital care structures, more sophisticated concepts for providing specialised services and stronger integration of the inpatient and outpatient sectors have clear structural advantages. A solid digital infrastructure is also conducive. Finally, a centralised governance structure is crucial for flexibility and adaptability. In decentralised systems, robust mechanisms to coordinate across levels are important to strengthen health care system resilience in pandemic situations and beyond.

Experience of a demand-side subsidy scheme for residential long-term care: perspectives of elderly and their carers

BackgroundVouchers, which are demand-side subsidies to targeted groups, are a type of consumer-led near-cash social transfer for specified benefits that have been used in education, health and other sectors. To provide better access to residential care services and an additional choice for elderly people in need, a novel means-tested residential care service voucher has been introduced in Hong Kong for elderly people to purchase places in the private sector to enable consumer-directed care. The objectives of this paper are to analyze the perspectives of voucher users and their carers toward the voucher scheme and to identify key elements in the design that will contribute to meeting the scheme’s objectives.MethodsAn exploratory sequential mixed method design was adopted with initial explorative qualitative data collection of the perspectives of elderly people and their carers (Phase 1), which informed the design of the subsequent questionnaire survey (Phase 2). Thirty carers in 5 focus groups and 20 individual interviews with elderly people were conducted between April and May 2018. A total of 401 respondents (373 carers and 28 elderly people) completed the survey questionnaire. Findings from both phases were integrated both narratively and via a joint display.ResultsFive key themes summarized the features in two main elements of the design and implementation of the voucher scheme: awareness, meaning that inadequate knowledge and understanding of voucher schemes hinder participation; service needs and types, indicating that the urgent need for residential care services is the key reason for participation; shared responsibility, meaning that a high copayment level discourages participation; choice and flexibility, reflecting appreciation of the additional choices provided by voucher schemes although the availability of residential care beds limits choices; and service quality, indicating mixed perceptions of service quality and the impact of the voucher scheme. Voucher users believe that the voucher scheme is more helpful for relieving the financial burden (98.7%), reducing carers’ stress (97.0%) and reducing the waiting time for subsidized homes for elderly people (89.0%) than for increasing choice and flexibility (78.1%) and improving service quality (62.1%).ConclusionsThis study demonstrates how the design of a voucher scheme affects its take-up by targeted beneficiaries. When a voucher scheme is implemented in a long-term care system, it must consider the congruence with existing policies in long-term care provision and financing. The voucher scheme in Hong Kong has been able to generate the utilization of nonsubsidized places in homes for elderly people that were underutilized, but its effectiveness is limited by inadequate knowledge and understanding of the voucher scheme and the availability of residential care places. Giving the purchasing power and choice of providers to beneficiaries has the potential to enhance the quality of services, which will contribute to meeting the objectives. The study findings carry significant implications for long-term care policies and provide insights into the key features of the voucher scheme for residential care services and how to best design and implement a voucher scheme for elderly people in the context of policy objectives and a long-term care policy.

Experiences of Child and Adolescent Psychiatric Patients Boarding in the Emergency Department from Staff Perspectives: Patient Journey Mapping.

Over the past decade, healthcare providers nationwide have contended with a growing boarding crisis as pediatric patients await psychiatric treatment in emergency departments (EDs). COVID-19 has exacerbated this urgent youth mental health crisis, driving EDs to act as crisis units. Journey mapping is a robust methodology with which to examine strengths and challenges in patient care workflows such as boarding and emergency psychiatric care.Psychiatric, emergency medicine, and hospitalist providers serving patients boarding at a northeastern children's hospital participated in semi-structured qualitative interviews. Investigators conducted directed content analysis with an inductive approach to identify facilitators, barriers, and persistent needs of boarding patients, which were summarized in a patient journey map. Findings were presented to participants for feedback and further refinement.Quantitative data showed a three-fold increase in the number of patients who boarded over the past three years and a 60% increase in the average time spent boarding in the ED. Emergent qualitative data indicated three stages in the boarding process: Initial Evaluation, Admitted to Board, and Discharge. Data highlighted positive and negative factors affecting patient safety, availability of beds in pediatric hospital and psychiatric inpatient settings, high patient-provider ratios that limited staffing support, and roadblocks in care coordination and disposition planning.Patient journey mapping provided insight into providers' experiences serving patients boarding for psychiatric reasons. Findings described bright points and pain points at each stage of the boarding process with implications for psychiatric care and systemic changes to reduce boarding volume and length of stay.

Examining need and capacity for the development of a pediatric liver transplantation program in Kenya.

In Africa, pediatric liver transplantation (PLT) is currently only performed in Egypt and South Africa, leaving those who require treatment in Kenya to travel abroad. The aim of this study was to determine whether sufficient capacity and need exists in Kenya to establish a safe and sustainable PLT program. A descriptive analysis of the intensive care unit (ICU) beds, surgical workforce, current hepatobiliary volume, and estimated prevalence of pediatric liver disease (PLD) was conducted across 17 hospitals in Kenya between July and September 2020. Data were collected from medical superintendents, directors of surgical departments, or nominated proxies at Kenyan Level 5 and 6 hospitals via a web-based survey. A total of 165 ICU beds were reported at 17 facilities, with 15 facilities reporting five or more beds. About 39% of general surgeons at responding hospitals performed hepatobiliary procedures, and 30% performed pediatric surgeries. Only 10% of surgeons had pediatric training. Over half (57%) of hospitals performed hepatobiliary procedures; at the maximum, 1-5 cases were performed per week including cholecystectomy to Kasai portoenterostomy and hepatectomy. Across 13 hospitals, there were an estimated 192-570 cases of PLD seen per month. The most common PLDs were hepatitis B, neonatal hepatitis, cirrhosis, and acute hepatic failure. Overall, two hospitals possessed the minimum workforce and resources to attempt PLT. In Kenya, ICU bed availability, pediatric surgical training, and hepatobiliary volume are limited. However, the high prevalence of PLD demonstrated a significant need for PLT across all Kenyan hospitals.