Care In Rural Hospitals Research Articles

Differences in Receipt of Neurologist Evaluation During Hospitalization for Ischemic Stroke by Race, Sex, Age, and Region: The REGARDS Study.

Improving access to health care providers with clinical expertise in stroke care may influence the use of recommended strategies for reducing disparities in quality of care. Few studies have examined differences in the receipt of evaluation by neurologists during the hospital stay. We examined the proportion of individuals hospitalized for acute ischemic stroke who received evaluation by a neurologist during the hospital stay and characterized differences in receipt of neurologist evaluation by race (Black vs White), sex, age, and study region (Stroke Belt residence vs other) among those experiencing a stroke who were participating in a national cohort study. This cross-sectional study was conducted using medical record data abstracted from 1,042 participants enrolled in the national Reasons for Geographic and Racial Differences in Stroke cohort study (2003-2007) who experienced an adjudicated ischemic stroke between 2003 and 2016. Participants with a history of stroke before baseline, in-hospital death, hospice discharge following their stroke, or incomplete records were excluded resulting in 839 cases. Differences were assessed using modified Poisson regression adjusting for participant-level and hospital-level factors. Of the 839 incident strokes, 722 (86%) received evaluation by a neurologist during the hospital stay. There were no significant differences by age, race, or sex, yet Stroke Belt residents and those receiving care in rural hospitals were significantly less likely to receive neurologist evaluation compared with non-Stroke Belt residents (relative risk [RR] 0.95; 95% CI 0.90-1.01) and participants receiving care in urban hospitals (RR 0.74; 95% CI 0.63-0.86). Participants with a greater level of poststroke functional impairment (modified Rankin scale) and those with a greater number of risk factors were more likely to receive neurologist evaluation compared with those with lower levels of poststroke functional impairment (RR 1.04; 95% CI 1.01-1.06) and fewer risk factors (RR 1.02; 95% CI 1.00-1.04). While differences in access to neurologists during the hospital stay were partially explained by patient need in our study, there were also significant differences in access by region and urban-rural hospital status. Ensuring access to neurologists during the hospital stay in such settings may require policy-level and/or system-level changes.

234: ASSOCIATION OF RURAL RESIDENCE WITH SHORT-TERM MORTALITY IN CRITICALLY ILL PATIENTS WITH COVID-19

Introduction: Rural residence has been associated with increased risk of COVID-19-related mortality. However, the population-level prognostic implications of rural residence among critically ill patients with COVID-19 are lacking, and the impact of inter-hospital transfer and hospitals’ location on the outcomes of these patients is unknown. Methods: We used a statewide dataset to identify ICU admissions aged ≥18 years with a diagnosis of COVID-19 in Texas during April 1-December 31, 2020. COVID-19 was defined by ICD-10 code U07.1. We used dichotomized (rural vs urban) ZIP Code-level Rural-Urban Commuting Area categories, linked to hospitalization data, to identify rural residence. Hierarchical, mixed-effects models were fit to estimate the association of rural residence with short-term mortality (defined as in-hospital death or discharge to hospice) for the whole cohort and among hospitalizations with and without transfer from another hospital. Similar modeling was used to examine the association of care in rural hospitals among rural residents without transfer to another facility with short-term mortality. Results: Among 58,485 ICU admissions with COVID-19, 9,495 (16.2%) were rural residents. Among rural residents, 8,607 (90.6%) were managed in non-rural hospitals, and 1,827 (19.2%) were transferred from another hospital. The unadjusted short-term mortality among rural and urban residents was 25.9% vs 23.9%, respectively. Following adjustment for confounders, rural residence was associated with higher short-term mortality for the whole cohort (adjusted odds ratio [aOR] 1.093 [95% CI 1.003-1.191]) and among those transferred from another hospital (aOR 1.349 [95% CI 1.106-1.646]), but not among those without inter-hospital transfer (aOR 1.052 [95% CI 0.955-1.159]). Management of critically ill rural residents with COVID-19 in rural hospitals, without inter-hospital transfers was not associated with short-term mortality on adjusted analyses (aOR 0.672 [95% CI 0.393-1.149]). Conclusions: The observed increased short-term mortality among critically ill patients with COVID-19 residing in rural areas is confounded by inter-hospital transfers and the geographic location of hospitals, with no adverse prognostic impact of rural residence in non-transferred patients and those managed in rural facilities.

Doctors’ experiences of providing care in rural hospitals in Southern New Zealand: a qualitative study

ObjectiveTo explore rural hospital doctors’ experiences of providing care in New Zealand rural hospitals.DesignThe study had a qualitative design, using qualitative content analysis.SettingThe study was conducted in South Island, New...

Express improvement of acute stroke care accessibility in large regions using a centralized telestroke network.

Acute ischemic stroke therapy has improved in recent decades, decreasing the rates of disability and death among stroke patients. Unfortunately, all health care systems have geographical disparities in infrastructure for stroke patients. A centralized telestroke network might be a low-cost strategy to reduce differences in terms of geographical barriers, equitable access, and quality monitoring across different hospitals. We aimed to quantify changes in stroke patients' geographic access to specialized evaluation by neurologists and to intravenous acute stroke reperfusion treatments following the rapid implementation of a centralized telestroke network in the large region of Andalusia (8.5 million inhabitants). We conducted an observational study using spatial and analytical methods to examine how a centralized telestroke network influences the quality and accessibility of stroke care for a large region. In the pre-implementation period, 5,005,477 (59.72% of the Andalusian population) had access to specialized stroke care in less than 30 min. After the 5-month process of implementing the telestroke network, 7,832,988 (93.5%) inhabitants had an access time of less than 30 min, bridging the gap in acute stroke care in rural hospitals. A centralized telestroke network may be an efficient tool to reduce the differences in stroke care access and quality monitoring across different hospitals, especially in large regions with low population density.

Within-Hospital Concordance of Opioid Exposure Diagnosis Coding in Mothers and Newborns

We measured within-hospital concordance of mothers with opioid use disorder (OUD) and newborns with neonatal abstinence syndrome (NAS) or opioid exposure (OE). Secondarily, we described the demographics of mothers and newborns with and without opioid-related diagnoses. We used hospital discharge abstracts from California, Florida, New Jersey, and Pennsylvania in 2016. Descriptive statistics were used to compare newborns and mothers with and without opioid-related diagnoses. Within-hospital frequencies of mothers with OUD and newborns with NAS and OE were compared. Pearson's correlation coefficients were calculated. In 474 hospitals, we found 896 702 mothers (0.6% with OUD) and 910 867 newborns (0.47% with NAS, 0.85% with OE, and 0.07% with both). Although the frequency of mothers and newborns with opioid-related diagnoses in a hospital was strongly correlated (r = 0.81), more infants were identified than mothers in most hospitals (68.3%). Mothers with OUD were more likely to be white (79% vs 40.9%), on Medicaid (75.4% vs 44.0%), and receive care in rural hospitals (20.6% vs 17.6%), compared with mothers without OUD. Newborns with NAS had demographics similar to women with OUD. Newborns with OE were disproportionately Black (22% vs 7%) or Hispanic (22% vs 9%). More newborns are diagnosed with opioid-related disorders than mothers are. Although infants diagnosed with NAS had demographics similar to mothers with OUD, infants with OE were more likely to be Black or Hispanic. The lack of diagnostic coding of maternal OUD and the racial differences in diagnoses warrant attention.

Nurse Managers’ Perspectives on Care Quality and Safety in Rural Hospitals in Uganda

Rural hospitals in sub-Saharan African countries play a key role in dealing with a high level of disease burden, but are usually poorly equipped with resources. Ward nurse managers in rural hospitals are in an ideal position to negotiate resources and bridge gaps in quality improvements. The aim of this study was to explore nurse managers’ perspectives on quality and safe care in rural hospitals in Uganda. This was a qualitative interpretive study in which 11 ward nurse managers with at least two years’ experience in the role were purposively selected to participate in the study. In-depth interviews using a semi-structured interview guide were applied for data collection. Thematic analysis was applied to analyse the data. Four themes were identified from the interviews. These themes explained how nurse managers engaged stakeholders in quality and safe care for patients; supported staff through supervision; improvised practices to cope with resource and equipment constraints; and being constrained by poor working conditions. Nurse managers in rural hospitals in sub-Saharan Africa face unique challenges in ensuring quality and safe care for patients due to a lack of basic human and material resources. The strategies they apply in quality improvements have implications for policy and resource development.

Specialist care in rural hospitals: From Emergency Department consultation to hospital discharge

In urban and rural hospitals, congested Emergency Departments (EDs) are filled with patients boarding in the ED awaiting admission to inpatient wards. We study this problem beyond the walls of the ED, examining the multi-departmental process managed by specialists. In rural hospitals, an Internal Medicine Specialist (Internist) commonly serves simultaneously as both the Intensive Care Unit (ICU) physician and Internist on call. We develop a stochastic dynamic programming framework for specialists’ workflow decisions and apply it to data sets developed from two rural hospitals. One uses the dual role approach and the other, similar to urban hospitals, staffs the ICU with another physician, each with a single role. Our empirical results show that, excluding an overnight batch, arrivals of ED consultation requests for rural specialists follow a homogeneous Poisson process. Our models help identify better policies and determine how much better off a hospital is with two rather than one Internist on call. Although current guidelines suggest an early inpatient discharge strategy, we find that specialists should give higher priority to ED consultations unless a threshold number of patients are boarding in the ED or until a threshold time of day when specialists should give higher priority to inpatient discharges.

The Role of Telemedicine in Providing Nephrology Care in Rural Hospitals

Rural hospitals rarely have the capacity and expertise to deliver timely and appropriate care for patients with ESKD because providing effective dialysis care requires a staff nephrologist readily available to coordinate care for patients on dialysis as well as proper infrastructure for water treatment systems and dialysis equipment. For these reasons, clinicians in rural hospitals typically transfer patients requiring dialysis to other, larger hospitals, sometimes hundreds of miles away. These transfers reflect broader deficits in access to timely and effective specialty care services, and may lead to poorer outcomes for rural residents (1). An analysis of the hospital admission data from the state of Georgia revealed that almost all patients with ESKD were admitted to regional or tertiary care hospitals, even when the patient resides in the primary service area of a nearby rural hospital (J. Tannenbaum, J. Lea, D. Brunn, unpublished data). Telemedicine is the delivery of healthcare services using information and communication strategies for the exchange of valid data for the diagnosis and treatment of disease to advance the health of individuals in remote areas (2,3). Tele-nephrology uses these technologies to provide care to patients with kidney disease. Asynchronous telehealth occurs when medical data are transmitted between participants for assessment when convenient and oftentimes uses remote monitoring devices such as BP monitors. This store-and-carry-forward telehealth method in the form of e-consults (electronic clinician-to-clinician communications) has been the most used form of tele-nephrology in ambulatory settings (4) and has the potential to overcome limited specialist availability, travel distance, and other barriers to expert specialty care for rural residents. In nephrology, active United States–based telehealth programs include those in specialized populations, such as veterans and the Zuni tribe in New Mexico, and others primarily in outpatient clinic settings (4–⇓⇓⇓8). However, there is very …

Are Rural Hospitals in Pakistan Responding to the Global Surgery Movement? An Analysis of the Gaps, Challenges and Opportunities.

Access to essential surgical care is vital for reduction in mortality and morbidity as a result of surgical conditions. These account for 28-32% of the overall global burden of disease, yet billions of people lack access to safe, affordable surgical and anesthesia care when needed. The purpose of this study was to assess the capacity for surgical care in rural hospitals across four provinces of Pakistan. This was a cross-sectional study undertaken in 10 rural hospitals across four provinces of the country. Of these, six were district and four sub-district hospitals that were purposively selected in consultation with the government. Data were gathered using the WHO-PGSSC Surgical Assessment Tool. This study estimated 3 of the 6 indicators proposed by the Lancet Commission on Global Surgery. While most hospitals had basic provisions of infrastructure and equipment, severe shortage of specialists was observed with 0.56 specialists (surgeons, gynecologists and anesthetists) present per 100,000 population. Two-hour access was possible for the catchment population of 7 out of the 10 hospitals. Of the 43 essential surgical procedures assessed, 13 or 30% procedures were available per hospital. The three Bellwether procedures were provided by only 1 hospital. Mean number of surgeries performed was 753 ± 979 per 100,000 population. Our study has demonstrated major gaps in the provision of surgical care in rural hospitals in Pakistan. While developing a strategy and national action plan is necessary, implementation can immediately begin at the local level to address the gaps that need urgent attention.

Capacity for Essential Surgical Care in Rural Hospitals of Pakistan: Mixed Methods Study

Siddiqi, Sameen MBBS; Sohaib Khan, Muhammad MBBS; Rizvi, Narjis MBBS; Naeem, Imran MBBS; Khan, Sadaf MBBS, FACS Author Information

The contribution of non-physician clinicians to the provision of surgery in rural Zambia\u2014a randomised controlled trial

BackgroundThe global shortage of surgeons disproportionately impacts low- and middle-income countries. To mitigate this, Zambia introduced a ‘task-shifting’ solution and started to train non-physician clinicians (NPCs) called medical licentiates (ML) to perform surgery. The aim of this randomised controlled trial was to assess their contribution to the delivery of surgical care in rural hospitals in Zambia.MethodsSixteen hospitals were randomly assigned to intervention and control arms of the study. Nine MLs were deployed to eight intervention sites. Crude numbers of selected major surgical procedures between intervention and control sites were compared before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals, between NPCs and surgically active medical doctors (MDs).ResultsThere was a significant increase in the numbers of caesarean sections (CS) in the intervention hospitals (+ 15.2%) and a drop by almost half in the control group (− 47%) (P = 0.015), between the two time periods. There were marginal shifts in the numbers of index procedures: a small drop in the intervention group (− 4.9%) and slight increase in the control arm (+ 4.8%) (P = 0.505). In all pairs, MLs had higher mean number of CS and other major surgical cases done in the intervention period compared with MDs. There was no significant difference in postoperative wound infection rates for CS (P = 0.884) and other major surgical cases (P = 0.33) at intervention hospitals between MLs and MDs.ConclusionThis study provided evidence that the ML training programme in Zambia is an effective and safe way to bridge the gap in rural hospitals between the demand and the limited availability of surgically trained workforce in the country. Such evidence is greatly needed as more developing countries are developing national surgical plans.Trial registrationISRCTN66099597 Registered: 07/01/2014

Compassionate Technology: Palliative Care Telemedicine in the Rural Hospital Setting (QI741)

1.Recognize the challenges of providing palliative care in rural hospitals.2.Describe the use of telemedicine to improve access to palliative care in our organization.3.Reflect on how a similar approach may be used in other rural medical organizations. Early hospital-based palliative care is associated with significant improvement in patient quality of life and lower hospital costs. Although there is a robust presence of palliative care services in urban centers, there is a substantial disparity of care for seriously ill patients in rural areas. The medical literature demonstrates that telemedicine has been successful in the hospital setting for treatment of disease and in the home setting for palliative care. There is currently no available literature describing the use of telemedicine to address inpatient palliative care at rural hospitals. The purpose of the program is to determine the feasibility of utilizing telemedicine with palliative care services for adult inpatients at a rural community hospital. An interdisciplinary team was formed at Valley View Hospital consisting of local providers, social workers, chaplains, and physicians from the University of Colorado Anschutz Medical Campus via teleconferencing. Palliative care consultations were performed with adult inpatients with a focus on advance care planning, symptom management, communication and prognostication. At subsequent visits, the patients were asked about the perceived value of the service and acceptability of the teleconferencing component. The program launched in January 2018, and 19 patients were seen in the initial 4 months of the service. 95% of patients tolerated teleconferencing well and reported satisfaction with the service. There was a 26% increase in completion and documentation of advance care plans following the visit. 30 patients were identified as needing palliative care services but could not be seen due to limited staff and time. Telemedicine may be an option for rural healthcare facilities needing inpatient specialized palliative care services. Key components to program success include concurrent education for involved providers, adequate staffing, and sufficient technological support for telemedicine equipment and software.

Does Missed Care in Isolated Rural Hospitals Matter?

Missed care is associated with adverse outcomes such as patient falls and decreased nurse job satisfaction. Although studied in populations of interest such as neonates, children, and heart failure patients, there are no studies about missed care in rural hospitals. Reducing care omissions in rural hospitals might help improve rural patient outcomes and ensure that rural hospitals can remain open in an era of hospital reimbursement dependent on care outcomes, such as through value-based purchasing. Understanding the extent of missed nursing care and its implications for rural populations might provide crucial information to alert rural hospital administrators and nurses about the incidence and influence of missed care on health outcomes. Focusing on missed care within rural hospitals and other rural health care settings is important to address the specific health needs of aging rural U.S. residents who are isolated from high-volume, urban health care facilities.

Critical care in rural hospitals in the Indian state of West Bengal (WB)

This paper tries to showcase how critical care facilities can be extended to the remote regions of the state of WB. To set the context, medical management is provided for by the state hospital with the tertiary medical colleges at the upper and of the pyramid with district hospital (DH), sub-divisional Hospital (SDH), state general hospital (SGH), in the middle tier and rural hospitals. The pre-existent set-up has not been functioning satisfactorily. Due to lack of funds and huge workload, the number of referrals from district …

Welcoming a new Associate Editor to The Journal

— William F. Balistreri, MD I t is with regret but warm wishes that I announce that Alan H. Jobe, MD, PhD, will be stepping down from his Associate Editor role at the end of 2015. Dr Jobe played, and continues to play, a pivotal role in making The Journal the “go to” journal for high-impact neonatology research. Despite his personal “10-year rule” (“after 10 years for any academic position, new leadership should come from someone else– preferably younger–who is given the opportunity”), he has broken this rule and continued as an Associate Editor for 18 years “because I have very much enjoyed serving as a referee for some of the best research in neonatology that is being submitted to The Journal.” Dr Jobe plans to expand his involvement in international research through the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Research Network. He will continue with active animal model research programs focusing on antenatal corticosteroids, fetal inflammation, and prematurity in association with colleagues at the University of California Davis National Primate Research Center and at the University of Western Australia, and will remain active both clinically and with teaching. Although Dr Jobe will be missed as an Associate Editor, we are pleased that he will continue his relationship with The Journal by serving as an Editorial Board member beginning in 2016. With the approaching departure of an Associate Editor, we started the search for a new Associate Editor to join The Journal’s leadership. After assessing outside candidates as well as the pool of current Editorial Board members, we have chosen someone who we believe will continue to attract high quality neonatology research to The Journal and who will excel as an Associate Editor. We would like to welcome and introduce Robin H. Steinhorn, MD, as The Journal’s newest Associate Editor. Dr Steinhorn began handling newmanuscripts in September. Robin H. Steinhorn, MD, joined Children’s National Medical Center in September 2015 as the Senior Vice President for Hospital Based Specialties. Prior to arriving at Children’s National, she served as Chair of the Department of Pediatrics at the University of California Davis and Pediatrician in Chief for the UC Davis Children’s Hospital. Dr Steinhorn is a member of the Council of the American Pediatric Society and serves on the American Board of Pediatrics for Neonatal Perinatal Medicine. She is an elected Fellow of the American Heart Association and a member of the Perinatal Research Society and American Thoracic Society. Dr Steinhorn’s clinical and academic interests have primarily been focused on the pulmonary vascular development of the fetus and newborn. Her translational work has spanned from in vitro studies to animal models, and she has contributed to numerous multicenter trials that have helped define the clinical treatment of pulmonary hypertension in the neonatal period. Her recent clinical research also has addressed telemedicine support of neonatal care in rural hospitals. She is married to a pediatric intensivist and has two children pursuing medical careers. She looks forward to carrying on Dr Jobe’s legacy of publishing high-impact neonatal research in The Journal, and continuing to support trainees and young investigators as they navigate presenting and publishing their research findings.

Serious gaming for neonatal resucitation skills maintainance

During the first moments after birth, neonates undergo dramatic physiological changes to successfully adapt to the extra uterine environment the most important of which is establishment of independent respiration. Although other newborn body systems change their level of functioning gradually, radical and rapid cardiopulmonary adaptation must occur for neonates to survive. For some, the physiological challenge is great. It is estimated that approximately 10% of all newborns require some assistance to begin breathing and less than 1% require extensive resuscitation 3. Live births in the United Kingdom in 2011 were 797,778 therefore around 79,700 babies require assistance each year in the UK to establish independent respiration. Although early neonatal depression is common, it may not be always predicted prior to birth. The need for resuscitation may only be anticipated in around 50% of cases therefore, the presence of personnel adequately prepared to perform resuscitation is an important first step in newborn resuscitation. A rapid, knowledgeable, and skilful response by all caregivers is essential. However, there can be significant variation in the presence of skilled personnel at newborn resuscitation. Maternity Care professionals who have attended simulation training have demonstrated that they retain knowledge, but alarming loss 8 of skill performance occurs by 6 months after training for resuscitation. This situation is exacerbated when professionals have relatively few opportunities to use their skills. Midwives and Doctors in large urban maternity units usually perform resuscitations on a regular basis, which reinforces their knowledge and skills gained during participation in simulation training. Professionals providing care in rural hospitals usually practise as generalists and are challenged in maintaining their resuscitation skills because the number of births to which they attend is small. Scottish remote and rural maternity service teams face increasing challenges in maintaining a broad range of skills in the context of isolated clinical practice and a dispersed patient population. Skills may not be honed when the unexpected need to use them occurs. Incomplete or erroneous knowledge, skills that are out of practice and lack of confidence or belief in the effectiveness of an intervention may all contribute to delayed initiation of resuscitation or ineffective performance. National clinical skills training through the SMMDP exists to support such teams but ways of extending the effective lifespan of training and maintaining skills were sought by SMMDP. There is increasing evidence that serious games that are designed to solve a problem may be of use to today’s practitioners. It has been demonstrated that video game skill correlates with International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116505– http://www.ijic.org/ laparoscopic surgical skills. Training programmes that include video games may help in the technical interface between surgeons and screen-mediated applications, such as laparoscopic surgery. There are many advantages to using simulated or computer based environments, including: they present no risk to human patients, they provide structured learning opportunities with defined learning objectives. They enable practice without interruption or interference and can be scheduled at times convenient to users. They also facilitate practice of routine and rare situations and foster integration of cognitive, technical and behavioural skills. The SMMDP has developed a neonatal serious game with a number of resucitation scenarios and is exploring the world of computer games and mobile apps in the light of the considerable body of evidence to prove that regular play has a beneficial impact on spatial awareness and coordination. Playing this game on PC, and on ipads and mobile phones, may be practical teaching tools to help maternity care professionals maintain their skills.

Birth Volume and the Quality of Obstetric Care in Rural Hospitals

Childbirth is the most common reason for hospitalization in the United States. Assessing obstetric care quality is critically important for patients, clinicians, and hospitals in rural areas. The study used hospital discharge data from the Statewide Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, for 9 states (Colorado, Iowa, Kentucky, New York, North Carolina, Oregon, Vermont, Washington, and Wisconsin) to identify all births in rural hospitals with 10 or more births/year in 2002 (N = 94,356) and 2010 (N = 103,880). Multivariate logistic regression was used to assess the relationship between hospital annual birth volume, measured as low (10-110), medium (111-240), medium-high (241-460) or high (>460), and 3 measures of obstetric care quality (low-risk cesarean rates for term, vertex, and singleton pregnancies with no prior cesarean; nonindicated cesarean; and nonindicated induction) and 2 patient safety measures (episiotomy and perineal laceration). The odds of low-risk and nonindicated cesarean were lower in medium-high and high-volume rural hospitals compared with low-volume hospitals after controlling for maternal demographic and clinical factors. In low-volume hospitals, odds of labor induction without medical indication were higher than in medium-volume hospitals, but not significantly different from medium-high or high-volume hospitals. Odds of episiotomy were greater in medium-high or high-volume hospitals than in low-volume hospitals. The likelihood of perineal laceration did not differ significantly by birth volume. Obstetric quality and safety outcomes vary significantly across rural hospitals by birth volume. Better performance is not consistently associated with either lower or higher volume facilities.

Factors Influencing RNs’ Perceptions of Quality Geriatric Care in Rural Hospitals

The rapidly aging population and their frequent use of hospital services will create substantial quality challenges in the near future. Redesigning rural hospital work environments is the key to improving the quality of care for older adults. This study explored how the work environment influences registered nurses' (RNs') perceived quality of geriatric care in rural hospitals. We used an exploratory mixed-methods research design emphasizing the qualitative data (in-depth, semi-structured interviews). Quantitative data (questionnaire) measuring the RN work environment were also collected to augment qualitative data. Four themes emerged: (a) collegial RN relationships, (b) poor staffing/utilization, (c) technology benefits/challenges, and (d) RN-physician interactions, which were identified as key factors influencing the quality of geriatric care. We concluded that rural hospital work environments may not be optimized to facilitate the delivery of quality geriatric care. Targeted interventions are needed to improve overall quality of care for hospitalized older adults in rural settings.

Evaluation of Rural Stroke Services

The quality of hospital care for stroke varies, particularly in rural areas. In 2007, funding to improve stroke care became available as part of the Rural Stroke Project (RSP) in New South Wales (Australia). The RSP included the employment of clinical coordinators to establish stroke units or pathways and protocols, and more clinical staff. We aimed to describe the effectiveness of RSP in improving stroke care and patient outcomes. A historical control cohort design was used. Clinical practice and outcomes at 8 hospitals were compared using 2 medical record reviews of 100 consecutive ischemic or intracerebral hemorrhage patients ≥12 months before RSP and 3 to 6 months after RSP was implemented. Descriptive statistics and multivariable analyses of patient outcomes are presented. pre-RSP n=750; mean age 74 (SD, 13) years; women 50% and post-RSP n=730; mean age 74 (SD, 13) years; women 46%. Many improvements in stroke care were found after RSP: access to stroke units (pre 0%; post 58%, P<0.001); use of aspirin within 24 hours of ischemic stroke (pre 59%; post 71%, P<0.001); use of care plans (pre 15%; post 63%, P<0.001); and allied health assessments within 48 hours (pre 65%; post 82% P<0.001). After implementation of the RSP, patients directly admitted to an RSP hospital were 89% more likely to be discharged home (adjusted odds ratio, 1.89; 95% confidence interval, 1.34-2.66). Investment in clinical coordinators who implemented organizational change, together with increased clinician resources, effectively improved stroke care in rural hospitals, resulting in more patients being discharged home.

The implications of the patterns of error associated with acute trauma care in rural hospitals in South Africa for quality improvement programs and trauma education

IntroductionThis audit uses error theory to analyze inappropriate trauma referrals from rural district hospitals in South Africa. The objective of the study is to inform the design of quality improvement programs and trauma educational programs. MethodsAt a weekly metropolitan morbidity and mortality meeting all trauma admissions to the Pietermaritzburg Metropolitan Trauma Service are reviewed. At the meeting problematic and inappropriate referrals and cases of error are identified. We used the (JCAHO) taxonomy to analyze these errors. ResultsDuring the period July 2009–2011 we received 1512 trauma referrals from our rural hospitals. Of these referrals we judged 116 (13%) to be problematic. This group sustained a total of 142 errors. This equates to 1.2 errors per patient. There were 87 males and 29 females in this group. The mechanism of injury was as follows, blunt trauma (66), stabs (32), gunshot wounds (GSW) (13) and miscellaneous five. The types of error consisted of assessment errors (85), resuscitation errors (26), logistics errors (14) and combination errors (17). The cause of the errors was planning failure in 68% of cases and execution failure in the remaining 32% of cases. The assessment errors involved the abdomen (50), chest (9), vascular system (8) and miscellaneous (18). The resuscitation errors involved airway (4), chest (11), vascular access (8) and cervical spine immobilization (3). ConclusionsRural areas are error prone environments. Errors of execution revolve around the resuscitation process and current trauma courses specifically address these resuscitation deficits. However planning or assessment failure is the most common cause of error with blunt trauma being more prone to error of assessment than penetrating trauma.