Care In Critical Access Hospitals Research Articles

Frequency and Magnitude of Obstacles and Helpful Behavior Items in End-of-Life Care as Perceived by Nurses Working in Critical-Access Hospitals.

Twenty percent of Americans live in rural areas where most of their health care is provided in critical-access hospitals (CAHs). It is unknown how frequently obstacle and helpful behavior items occur in end-of-life (EOL) care in CAHs. The aims of this study were to determine the frequency of occurrence scores of obstacle and helpful behavior items in providing EOL care in CAHs and to also determine which obstacles and helpful behaviors have the greatest or least impact on EOL care based on the magnitude scores. A questionnaire was sent to nurses working in 39 CAHs in the United States. Nurse participants were asked to rate obstacle and helpful behavior items by size and frequency of occurrence. Data were analyzed to quantify the impact of obstacle and helpful behavior items on EOL care in CAHs by multiplying the mean size by the mean frequency of items to determine mean magnitude scores. Items with the highest and lowest frequency were determined. In addition, obstacle and helpful behavior item magnitude scores were calculated. Seven of the top 10 obstacles were related to patients' families. Seven of the top 10 helpful behaviors involved nurses ensuring families had positive experiences. Nurses in CAHs perceived issues around patient family members as significant obstacles to EOL care. Nurses work to ensure that families have positive experiences. Visiting hour issues seemed to be irrelevant. The use of technology, such as telehealth, seemed to provide little benefit in EOL care in CAHs.

Critical Access Hospital Nurses' Perceptions of Obstacles to End-of-Life Care: A Qualitative Study.

Critical care nurses working in urban settings have reported obstacles in caring for dying patients. However, the perceptions of such obstacles by nurses working in critical access hospitals (CAHs), which are located in rural areas, are unknown. To study stories and experiences related to obstacles in providing end-of-life care reported by CAH nurses. This exploratory, cross-sectional study presents the qualitative stories and experiences of nurses working in CAHs as reported on a questionnaire. Quantitative data have been previously reported. Sixty-four CAH nurses provided 95 categorizable responses. Two major categories emerged: (1) family, physician, and ancillary staff issues and (2) nursing, environment, protocol, and miscellaneous issues. Issues with family behaviors were families' insistence on futile care, intrafamily disagreement about do-not-resuscitate and do-not-intubate orders, issues with out-of-town family members, and family members' desire to hasten the patient's death. Issues with physician behaviors were providing false hope, dishonest communication, continuation of futile treatments, and not ordering pain medications. Nursing-related issues were not having enough time to provide end-of-life care, already knowing the patient or family, and compassion for the dying patient and the family. Family issues and physician behaviors are common obstacles in rural nurses' provision of end-of-life care. Education of family members on end-of-life care is challenging because it is most families' first experience with intensive care unit terminology and technology. Further research on end-of-life care in CAHs is needed.

Implementing a Hospitalist Program in a Critical Access Hospital.

The hospitalist model of inpatient care has rapidly expanded, but little is known about hospitalist care in critical access hospitals (CAHs). We aimed to determine the impact of a hospitalist model of care on staff satisfaction, patient volumes, patient satisfaction, length of stay, and care quality in a CAH. We initiated a hybrid rotating hospitalist program in September 2008 at Winneshiek Medical Center (Decorah, Iowa), a 25-bed rural CAH. We reviewed patient volumes, Centers for Medicare and Medicaid Services core quality measures, acute length of stay, and staff satisfaction for primary care-hospitalist physicians and inpatient and clinic nurses. Patient volume and length of stay were compared with CAH data reported by the Iowa Hospital Association. Patient volumes (acute, skilled, and observation) increased by 15% compared with a 17% decrease for statewide CAHs. Length of stay decreased from 2.88 to 2.75 days and remained lower than the average stay for Iowa CAHs (3.05 days). In the year after implementation, we observed no deterioration in core quality measures (range, 93%-100%) or patient satisfaction (86th percentile). Inpatient nurse satisfaction and primary care-hospitalist satisfaction improved. Early clinic nurse skepticism showed improved satisfaction at the 5-year review. Hospitalist care contributed to ongoing delivery of high-quality care and satisfactory patient experiences while supporting the mission of a CAH in rural Iowa. Implementation required careful consideration of its effects on the outpatient practice. Broader implementation of this model in CAHs may be warranted.

Critical Care in Critical Access Hospitals.

What began as a grant-funded demonstration project, as a means of bridging the gap in rural health care, has developed into a critical access hospital system comprising 1328 facilities across 45 states. A critical access hospital is not just a safety net for health care in a rural community. Such hospitals may also provide specialized services such as same-day surgery, infusion therapy, and intensive care. For hospitals located near the required minimum of 35 miles from a tertiary care center, management of critically ill patients may be a matter of stabilization and transfer. Critical access hospitals in more rural areas are often much farther from tertiary care; some of these hospitals are situated within frontier areas of the United States. This article describes the development of critical access hospitals, provision of care and services, challenges to critical care in critical access hospitals, and suggestions to address gaps in research and collaborative care.

A Comparison of Quality of Care in Critical Access Hospitals and Other Rural Hospitals

Purpose: The United States has about 2100 rural hospitals. Approximately 1300 are Critical Access Hospitals (CAHs) with 25 beds or less. CAHs receive cost-based reimbursement through the federal Flex program with the goal to improve quality and access to health care. Reports on quality of care (QOC) and factors that influence quality in CAHs are mixed. This study compared QOC and factors that influence QOC in CAHs and other rural hospitals. Sample: 385 staff nurses in 6 CAHs and 9 other rural hospitals in North Carolina and Virginia. Method: Descriptive cross-sectional design using nurse surveys aggregated to the hospital level, data from provider of services file, and the United States Department of Agriculture, Economic Research files. Variables on community, hospital, and nursing unit characteristics, the nurse work environment, nurse rated QOC and community perception of hospital quality were compared using t-test or chi-square. Findings: There were no differences in the majority of factors influencing QOC. A culture of safety, the nurse work environment, and QOC were rated high in all hospitals. Compared to other rural hospitals CAHs tend to be located in communities with better economic status and their nurses had more years of nursing experience. More nurses in CAHs felt their community recognized their hospital as a good place for minor health issues and would recommend the hospital to family and friends. Conclusions: The high ratings of QOC were accompanied with the presence of safety cultures and work environments rated as highly as in Magnet hospitals. The lower poverty levels in communities with CAHs suggest possible community financial benefits from CAHs. More studies are warranted to explore these relationships. Further reporting to public quality indicator databases by all CAHs should be encouraged and QOC measures relevant for small rural hospitals should be developed. DOi : http://dx.doi.org/10.14574/ojrnhc.v14i2.328

The medicare flex program: a partner in improving quality of care in critical access hospitals.

The medicare flex program: a partner in improving quality of care in critical access hospitals.

A pilot study of staff nurses' perceptions of factors that influence quality of care in critical access hospitals.

Knowledge is limited about quality of care (QOC) in rural hospitals, including the smallest hospitals, critical access hospitals. Staff nurses from 7 critical access hospitals identified items important for QOC across 4 levels of care: patients, microsystems, organizations, and environments. Several items were unique to critical access hospitals. Most QOC items were at the microsystem level, yet few of these items are routinely measured. These findings offer beginning evidence about how to advance QOC evaluations in rural hospitals.

What Is the Impact of Health Reforms on Uncompensated Care in Critical Access Hospitals? A 5‐Year Forecast in Washington State

The 2008 financial crisis had a far-reaching impact on nearly every sector of the economy. As unemployment increased so did the uninsured. Already operating on a slim margin and poor payer mix, many critical access hospitals are facing a tough road ahead. We seek to examine the increasing impact of uncompensated care on the revenues earned by Washington's critical access hospitals; to forecast uncompensated care to the year 2014; and to forecast the financial impact on rural hospital uncompensated care of HR 3590, the Affordable Care Act (ACA). For critical access hospitals in the state of Washington, total uncompensated care increased by almost $16 million, a 22% increase from 2008 to 2009. By 2014, total uncompensated care is forecast to more than double from 2009, totaling $174 million annually without health reforms. Using the Urban Institute's Health Insurance Policy Simulation Model, uncompensated care is forecast to fall by $106 million in 2014, thereby reducing the uncompensated care percentage from 5.31% to 2.07%. Policy makers and health care managers should note that a substantial portion of the newly insured from the ACA will most likely be Medicaid participants. Given this source of lower revenue per case, critical access hospital administrators should seek additional public and private sources of revenue. Most importantly, rural hospital managers must maintain or improve their cost efficiency, while serving the needs of their rural population as we move closer toward the implementation of health reforms.

Quality of Care in Critical Access Hospitals—Reply

Quality of Care in Critical Access Hospitals—Reply

Quality of Care in Critical Access Hospitals—Reply

Quality of Care in Critical Access Hospitals—Reply

Quality of Care in Critical Access Hospitals

Quality of Care in Critical Access Hospitals

Quality of Care in Critical Access Hospitals

Quality of Care in Critical Access Hospitals

Quality of Care in Critical Access Hospitals

Quality of Care in Critical Access Hospitals

Intensive Care in Critical Access Hospitals

Although critical access hospitals (CAHs) have limitations on number of acute care beds and average length of stay, some of them provide intensive care unit (ICU) services. To describe the facilities, equipment, and staffing used by CAHs for intensive care, the types of patients receiving ICU care, and the perceived impact of closing the ICU on CAH staff and the local community. A semistructured interview of directors of nursing at CAHs that provide intensive care services. Two thirds of CAHs that provide intensive care do so in a distinct unit. Most have continuous or computerized electrocardiography and ventilators. Other ICU equipment common in larger hospitals was reported less frequently. Nurse:patient ratio ranged from 1:1 to 1:3, and some or all nursing staff have advanced cardiac life support certification. Most CAHs admit patients to the ICU daily or weekly, primarily treating cardiac, respiratory, gastrointestinal, endocrine, and drug- or alcohol-related conditions. ICUs are also used for postsurgical recovery. Respondents felt that closure of the ICU would be burdensome to patients and families, result in lost revenue, negatively impact staff, and affect the community's perception of the hospital. Intensive care services provided by CAHs fall along a continuum, ranging from care in a unit that resembles a scaled-down version of ICUs in larger hospitals to care in closely monitored medical-surgical beds. Nurse to patient ratio, not technology, is arguably the defining characteristic of intensive care in CAHs. Respondents believe these services to be important to the well-being of the hospital and of the community.