Discharge Criteria Research Articles

Rehabilitation after total or hemi elbow arthroplasty: a systematic review.

Total and hemi elbow arthroplasty (TEA/HEA) are relatively uncommon orthopedic procedures, but physiotherapists are involved in both pre- and postoperative treatment of people who undergo TEA/HEA. The purpose of this article is to summarize existing knowledge about the effects of rehabilitation versus standard care after total and hemi elbow arthroplasty (TEA/HEA). A systematic literature review was conducted searching Ovid MEDLINE ®, SweMED+, Cochrane, Embase, AMED and PEDro. "The Preferred Reporting Items for Systematic Review and Meta-Analysis" was followed. No one has studied the effects of rehabilitation after TEA/HEA. The aim of the only study included was to assess the safety and length of hospital stay (LOS) after omission of casting, start of early mobilization and implementation of functional discharge criteria. Results show that the non-casting cohort had a shorter mean LOS (5.4 days) than the index cohort (6.2 days). The cohort with functional discharge criteria had a shorter mean LOS (3.8 days) than the cohort without functional discharge (5.4 days). Effects of rehabilitation components or programs after TEA/HEA are still unknown. It is important to focus on the lack of evidence in this field, and plan for more studies to come.

Preliminary evaluation of behavior technician burnout when working with boarded and traditional psychiatric inpatients diagnosed with developmental disabilities.

The COVID-19 pandemic has led to a youth mental health crisis, with research demonstrating an increased prevalence of depression, anxiety, and disruptive behavior in youth compared to pre-pandemic years. Consequently, the insurgence of emergency psychiatric evaluations has increased the demands for extended inpatient stay (or patient boarding) at various licensed treatment facilities. Questions remain about the extent of burnout being experienced by behavior technicians who are caring for these patients. The Shirom-Melamed Burnout Measure was used to evaluate symptoms of burnout of behavior technicians practicing at a specialized psychiatric inpatient unit. Comparisons were made for instances of caring for boarded (meeting criteria for discharge but unable to be discharged due to disposition) and traditional patients (short-term treatment). Behavior technicians caring for boarded patients reported significantly higher scores in overall stress, physical exhaustion, cognitive fatigue, and emotional exhaustion than those managing patients getting traditional care. Extensive burnout can have adverse impacts at both the personal level (staff well-being, individual staff-patient interactions) and clinic level (daily operations and service, general quality of care). Efforts need to be made to address this issue to prevent staff turnover.

A concise literature survey on the toxic effects of beryllium on aquatic organisms and plants – Notion behind establishing beryllium-based (waste) effluent’s discharge criteria and its adequacy

Abstract In this paper, a concise review of the literature on the effects of beryllium (Be) on aquatic animals, as well as the effect of uptake of Be on the growth of some of the aquatic organisms and plants is compiled when studies are performed in water-based nutrient solutions containing Be. After referring to various important international reports published by different agencies such as the Agency for Toxic Substances and Disease Registry, Environmental Protection Agency, and World Health Organization (WHO), as well as other literature papers available on the topic over last (70–80) years, a compilation of different studies on the effect of toxicity of Be on aquatic animals, organisms, and some plants is reported. Furthermore, information on different limits/levels for the protection of marine and aquatic organisms, as recommended by various international agencies, is included. Based on the studies available in the literature, the reasons behind the establishment of discharge criteria for Be-based effluents are included in the paper. Information on the limits of Be in drinking water, as recommended by various international agencies, are also reported. It is hoped that the compiled information will provide comprehensive details about the effects of Be toxicity on plants, aquatic organisms, etc., and will be useful to researchers worldwide in understanding the toxicology of Be as well as in understanding the reasons behind the selection of 0.10 ppm as the discharge criteria for Be-based effluents adopted previously by countries such as USA, UK, and India. Based on the literature information, it has been argued that the discharge criteria of 0.10 ppm for Be-based waste effluents adopted almost 60 years earlier is still adequate and relevant as adverse effects of Be on aquatic animals, plants, etc., are reported to be at Be concentrations >0.10 ppm or so even for highly sensitive organisms. Be enters the environment mainly through industrial pollution; waste management of Be contaminants is a challenge. The present review also includes the recently reported information on the effective management of Be prevalent in liquid/aqueous media and various studies on behavior of Be in soils, techniques for sorption, and related chemical and physical processes associated.

Impact of food waste addition in energy efficient municipal wastewater treatment by aerobic granular sludge process

Recently, one of the main purposes of wastewater treatment plants is to achieve a neutral or positive energy balance while meeting the discharge criteria. Aerobic granular sludge (AGS) technology is a promising technology that has low energy and footprint requirements as well as high treatment performance. The effect of co-treatment of municipal wastewater and food waste (FW) on the treatment performance, granule morphology, and settling behavior of the granules was investigated in the study. A biochemical methane potential (BMP) test was also performed to assess the methane potential of mono- and co-digestion of the excess sludge from the AGS process. The addition of FW into wastewater enhanced the nutrient treatment efficiency in the AGS process. BMP of the excess sludge from the AGS process fed with the mixture of wastewater and FW (195 ± 17 mL CH4/g VS) was slightly higher than BMP of excess sludge from the AGS process fed with solely wastewater (173 ± 16 mL CH4/g VS). The highest methane yield was observed for co-digestion of excess sludge from the AGS process and FW, which was 312 ± 8 mL CH4/g VS. Integration of FW as a co-substrate in the AGS process would potentially enhance energy recovery and the quality of effluent in municipal wastewater treatment.Graphical abstract

High-Flow Humidified Oxygen as an Early Intervention in Children With Acute Severe Asthma: Protocol for a Feasibility Randomized Controlled Trial.

Acute severe asthma (ASA) is a leading cause of hospital attendance in children. Standard first-line therapy consists of high-dose inhaled bronchodilators plus oral corticosteroids. Treatment for children who fail to respond to first-line therapy is problematic: the use of intravenous agents is inconsistent, and side effects are frequent. High-flow humidified oxygen (HiFlo) is widely used in respiratory conditions and is increasingly being used in ASA, but with little evidence for its effectiveness. A well-designed, adequately powered randomized controlled trial (RCT) of HiFlo therapy in ASA is urgently needed, and feasibility data are required to plan such an RCT. In this study, we describe the protocol for a feasibility study designed to fill this knowledge gap. This study aims to establish whether a full RCT of early HiFlo therapy in children with ASA can be conducted successfully and safely, to establish whether recruitment using deferred consent is practicable, and to define appropriate outcome measures and sample sizes for a definitive RCT. The underlying hypothesis is that early HiFlo therapy in ASA will reduce the need for more invasive treatments, allow faster recovery and discharge from hospital, and in both these ways reduce distress to children and their families. We conducted a feasibility RCT with deferred consent to assess the use of early HiFlo therapy in children aged 2 to 11 years with acute severe wheeze not responding to burst therapy (ie, high-dose inhaled salbutamol with or without ipratropium). Children with a Preschool Respiratory Assessment Measure score ≥5 after burst therapy were randomized to commence HiFlo therapy or follow standard care. The candidate primary outcomes assessed were treatment failure requiring escalation and time to meet hospital discharge criteria. Patient and parent experiences were also assessed using questionnaires and telephone interviews. The trial was opened to recruitment in February 2020 but was paused for 15 months owing to the COVID-19 pandemic. The trial was reopened at the lead site in July 2021 and opened at the other 3 sites from August to December 2022. Recruitment was completed in June 2023. This feasibility RCT of early HiFlo therapy in children with ASA recruited to the target despite major disturbances owing to the COVID-19 pandemic. The data are currently being analyzed and will be published separately. International Standard Randomised Controlled Trial Number Registry ISRCTN78297040; https://www.isrctn.com/ISRCTN78297040. DERR1-10.2196/54081.

Construction and verification of risk prediction model of osteoporotic fractures in patients with osteoporosis in China.

To explore the influencing factors of osteoporotic fractures (OPF) in patients with osteoporosis, construct a prediction model, and verify the model internally and externally, so as to provide reference for early screening and intervention of OPF in patients with osteoporosis. Osteoporosis patients in the First Affiliated Hospital of Soochow University were selected, and the medical records of patients were consulted through the Hospital Information System (HIS) and the data management platform of osteoporosis patients, so as to screen patients who met the criteria for admission and discharge and collect data. SPSS 26.0 software was used for single factor analysis to screen statistically significant variables (p < 0.05). The influencing factors of OPF were determined by multivariate analysis, and a binary Logistic regression model was established according to the results of multivariate analysis. Hosmer-Lemeshow (H-L) goodness of fit and receiver operating characteristic curve (ROC) were used to test the model's efficiency, and Stata 16.0 software was used to verify the Bootstrap model, draw the model calibration curve, clinical applicability curve and nomogram. In this study, the data of modeling set and verification set were 1,435 and 580, respectively. There were 493 (34.4%) cases with OPF and 942 (65.6%) cases without OPF in the modeling set. There were 204 (35.2%) cases with OPF and 376 (64.8%) cases without OPF. The variables with statistically significant differences in univariate analysis are Age, BMI, History of falls, Usage of glucocorticoid, ALP, Serum Calcium, BMD of lumbar, BMD of feminist neck, T value of feminist neck, BMD of total hip and T value of total hip. The area under ROC curve of the risk prediction model constructed this time is 0.817 [95%CI (0.794 ~ 0.839)], which shows that the model has a good discrimination in predicting the occurrence of OPF. The optimal threshold of the model is 0.373, the specificity is 0.741, the sensitivity is 0.746, and the AUC values of the modeling set and the verification set are 0.8165 and 0.8646, respectively. The results of Hosmer and Lemeshow test are modeling set: (χ2 = 6.551, p = 0.586); validation set: [(χ2 = 8.075, p = 0.426)]. The calibration curve of the model shows that the reference line of the fitted curve and the calibration curve is highly coincident, and the model has a good calibration degree for predicting the occurrence of fractures. The net benefit value of the risk model of osteoporosis patients complicated with OPF is high, which shows that the model is effective. In this study, a OPF risk prediction model is established and its prediction efficiency is verified, which can help identify the high fracture risk subgroup of osteoporosis patients in order to choose stronger intervention measures and management.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations.

Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

Alkaline Chemical Neutralization to Treat Acid Mine Drainage with High Concentrations of Iron and Manganese

Due to its high acidity and toxic metal content, acid mine drainage (AMD) needs to be properly treated before being discharged into the environment. This study took the AMD collected from one specific mine in China as a sample and investigated the treatment methodology for AMD. The water quality of the AMD was measured, and the sample was treated with caustic soda (NaOH) and shell powder (one kind of conventional neutralizer, mainly composed of CaCO3) by the neutralization method. The results show that the AMD has a relatively low pH (2.16) and contains high concentrations of Fe (77.54 g/L), Mn (621.29 mg/L), Cu (6.54 mg/L), Ca (12.39 mg/L), and Mg (55.04 mg/L). NaOH was an effective neutralizer to treat the AMD and performed much better than shell powder. Various metals were precipitated, in the order of Fe(III), Cu, Fe(II), Mn, Ca, and Mg. The metal removal mechanisms included precipitation, adsorption, and co-precipitation. The optimal reaction conditions were the reaction duration was selected as 5 min and the mass ratio of NaOH to AMD was 0.16:1 (w:v). By this stage, the pH rapidly increased from 2.16 to 8.53 during AMD-NaOH interactions and various metals were efficiently removed (from 86.71% to 99.99%) by NaOH. The residual mass concentrations of Fe, Mn, Cu, Ca, and Mg after the treatment were 1.52, 1.77, 0.10, 1.65, and 2.17 mg/L, respectively. These data revealed that NaOH was a good treatment regent for this kind of AMD, based on the discharge criteria of China (GB28661 2012). Also, the shell powder was a helpful neutralizer for pH adjustment and copper removal. This neutralization method has the advantages of convenient operation, high speed, good effect, simple equipment, and low infrastructure cost. In addition, the resulting neutralized residue is a valuable and high-quality raw material, which can be used in metal smelting and separation.

Transitioning children using home invasive mechanical ventilation from hospital to home: Discharge criteria, disparities, and ethical considerations.

Children using home invasive mechanical ventilation (HIMV), a valuable therapeutic option for chronic respiratory failure, constitute a growing population. Transitioning children using HIMV from hospital to home care is a complex process that requires a multidisciplinary approach involving healthcare professionals, caregivers, and community resources. Medical stability, caregiver competence, and home environment suitability are essential factors in determining discharge readiness. Caregiver education and training play a pivotal role in ensuring safe and effective home care. Simulation training and staged education progression are effective strategies for equipping caregivers with necessary skills. Resource limitations, inadequate home nursing support, and disparities in available community resources are common obstacles to successful HIMV discharge. International perspectives shed light on diverse healthcare systems and challenges faced by caregivers worldwide. While standardizing guidelines for HIMV discharge may be complex, collaboration among healthcare providers and the development of evidence-based regional guidelines can improve outcomes for children using HIMV and their caregivers. This review seeks to synthesize literature, provide expert guidance based on experience, and highlight components to safely discharge children using HIMV. It further assesses disparities and divergences within regional and international healthcare systems while addressing relevant ethical considerations.

Membrane processes used to treat scrubber gas desulfuration washwater.

Since 2020, hybrid exhaust gas cleaning systems have been installed on container ships to be in line with the International Maritime Organisation regulations. This technology allows the removal of gaseous sulphur oxide compound before atmospheric rejection of exhaust gas with a concentration lower than 0.1% sulphur equivalent. To be also compliant with water discharge criteria, membrane processes used as a water treatment system have been complementary installed onboard maritime vessels. Objectives of our research are to demonstrate the membrane efficiency and performances for this field of application and their reliability for reaching future regulations. Half industrial scale experiments are first carried out in controlled areas. Results allow optimum parameter definition for a sustainable long-term operation as a permeate flux of 60 L h-1 m-2 and a backwash frequency of 40 min. Experiments are scaled up to onboarded units, and previous settings have been validated. The fleet autonomy for a longer period of closed-loop operation is highlighted. Consequently, the fleet is well prepared and able to overcome new regulation for the future sulphur emission area defined for the Mediterranean Sea in 2025. In addition, the usage of membrane processes allows the reduction of pollutants as suspended solid and heavy metal rejection inside the natural environment with a respective retention higher than 100 and 95%.

Remote Dielectric Sensing Before and After Discharge in Patients With ADHF: The ReDS-SAFE HF Trial

BackgroundIncomplete treatment of congestion often leads to worsening heart failure (HF). The remote dielectric sensing (ReDS) system is an electromagnetic energy–based technology that accurately quantifies changes in lung fluid concentration noninvasively. ObjectivesThis study sought to assess whether an ReDS-guided strategy during acutely decompensated HF hospitalization is superior to routine care for improving outcomes at 1 month postdischarge. MethodsReDS-SAFE HF (Use of ReDS for a SAFE discharge in patients with acute Heart Failure) was an investigator-initiated, multicenter, single-blind, randomized, proof-of-concept trial in which 100 patients were randomized to a routine care strategy, with discharge criteria based on current clinical practice, or an ReDS-guided decongestion strategy, with discharge criteria requiring an ReDS value of ≤35%. ReDS measurements were performed daily and at a 7-day follow-up visit, with patients and treating physicians in the routine care arm blinded to the results. The primary outcome was a composite of unplanned visits for HF, HF rehospitalization, or death at 1 month after discharge. ResultsThe mean age was 67 ± 14 years, and 74% were male. On admission, left ventricular ejection fraction was 37% ± 16%, and B-type natriuretic peptide was 940 pg/L (Q1-Q3: 529-1,665 pg/L). The primary endpoint occurred in 10 (20%) patients in the routine care group and 1 (2%) in the ReDS-guided strategy group (log-rank P = 0.005). The ReDS-guided strategy group experienced a lower event rate, with an HR of 0.094 (95% CI: 0.012-0.731; P = 0.003), and a number of patients needed to treat of 6 to avoid an event (95% CI: 3-17), mainly resulting from a decrease in HF readmissions. The median length of stay was 2 days longer in the ReDS-guided group vs the routine care group (8 vs 6; P = 0.203). ConclusionsA ReDS-guided strategy to treat congestion improved 1-month prognosis postdischarge in this proof-of-concept study, mainly because of a decrease of the number of HF readmissions. (Use of ReDS for a SAFE discharge in patients with acute Heart Failure [ReDS-SAFE HF]; NCT04305717)

The application of enhanced recovery after surgery protocol after distal gastrectomy for patients with gastric cancer: a prospective randomized clinical trial

BackgroundThis study aimed to evaluate the clinical outcomes and efficacy of enhanced recovery after surgery (ERAS) protocol in patients undergoing distal gastrectomy for gastric cancer (GC). MethodsPatients were randomly assigned to the ERAS group (EG) and the conventional care group (CG) by stratified randomization according to age and sex. The primary endpoint was adjusted postoperative hospital stay, calculated using discharge criteria developed to evaluate recovery. Nutritional data and quality of life (QoL) (European Organisation for Research and Treatment of Cancer [EORTC] C30 and STO22) during the perioperative period were also analyzed. ResultsWe enrolled 198 eligible patients with GC for the study between June 2017 and January 2019. A total of 147 patients were finally enrolled in this study (full analysis set) and were assigned to EG (n = 71) and CG (n = 76). First flatus was faster significantly in EG (3.6 ± 1.5 vs 4.1 ± 1.2 days, P = .019). EG showed a faster start of the sips and soft diet than CG (1.3 ± 0.7 vs 3.1 ± 0.4 days, P < .001; 2.4 ± 0.9 vs 5.2 ± 0.7 days, P < .001) according to the protocol. The recorded hospital stay was not significantly different; however, adjusted hospital stay was significantly shorter in EG than in CG (6.5 ± 3.1 vs 7.8 ± 2.1 days, P = .005). There was no difference in morbidity, and no mortality occurred in both groups. EG did not show significant superiority in nutritional outcome and QoL improvement, except for pain scale in EORTC-STO22. ConclusionThe application of the ERAS protocol could reduce the adjusted hospital stay without an increase in postoperative complications. There was no significant difference in long-term nutritional outcome and QoL of the 2 groups.

Ambulatory Percutaneous Nephrolithotomy: Initial Series in Iran

Background: Percutaneous nephrolithotomy (PCNL) procedures in the United States typically cost between 9000 to 16000 USD. In developing countries like Iran, healthcare performance is hindered by issues such as high bed occupancy rates. Therefore, performing PCNL in an outpatient setting could significantly reduce surgical costs and improve healthcare outcomes by reducing bed occupancy and associated complications. Objectives: This study aimed to explore the feasibility of same-day discharge for selected PCNL patients. Methods: Out of 142 patients, 32 were discharged within 12 hours post-operation (Study Group), while 32 randomly selected patients from the remaining 110 served as the control group. Same-day discharge criteria included stable vital signs, tolerance to oral intake, appropriate mobility, and normal laboratory results. Exclusion criteria encompassed the need for red blood cell transfusion, hemoglobin drops exceeding 2 mg/dL, and abnormal post-operative laboratory findings. Results: Patient characteristics and medical histories did not significantly differ between the study and control groups. Additionally, stone laterality (P-value = 0.606), location (P-value = 0.731), size (P-value = 0.334), and density (P-value = 0.065) showed no significant differences between the two groups. The post-surgical observation period in the study group (mean: 7.88 hours) was significantly shorter than that in the control group (mean: 62 hours) (P-value &lt; 0.001). The mean hemoglobin level change was 1.48 mg/dL (SD: ± 1.02) in the study group and 1.31 mg/dL (SD: ± 0.91) in the control group. Similarly, the change in creatinine levels was 0.13 ± 0.04 in the study group and 0.23 ± 0.03 in the control group. Conclusions: This study demonstrates that outpatient PCNL procedures are feasible without increasing perioperative complications. However, careful patient selection based on strict criteria is crucial for successful implementation.

Effectiveness of decentralizing outpatient acute malnutrition treatment with community health workers and a simplified combined protocol: a cluster randomized controlled trial in emergency settings of Mali.

Outpatient treatment of acute malnutrition is usually centralized in health centers and separated into different programs according to case severity. This complicates case detection, care delivery, and supply chain management, making it difficult for families to access treatment. This study assessed the impact of treating severe and moderate cases in the same program using a simplified protocol and decentralizing treatment outside health centers through community health workers (CHWs). A three-armed cluster randomized controlled trial under a non-inferiority hypothesis was conducted in the Gao region of Mali involving 2,038 children between 6 and 59 months of age with non-complicated acute malnutrition. The control arm consisted of 549 children receiving standard treatment in health centers from nursing staff. The first intervention arm consisted of 800 children treated using the standard protocol with CHWs added as treatment providers. The second intervention arm consisted of 689 children treated by nurses and CHWs under the ComPAS simplified protocol, considering mid-upper arm circumference as the sole anthropometric criterion for admission and discharge and providing a fixed dose of therapeutic food for severe and moderate cases. Coverage was assessed through cross-sectional surveys using the sampling evaluation of access and coverage (SLEAC) methodology for a wide area involving several service delivery units. The recovery rates were 76.3% in the control group, 81.8% in the group that included CHWs with the standard protocol, and 92.9% in the group that applied the simplified protocol, confirming non-inferiority and revealing a significant risk difference among the groups. No significant differences were found in the time to recovery (6 weeks) or in anthropometric gain, whereas the therapeutic food expenditure was significantly lower with the simplified combined program in severe cases (43 sachets fewer than the control). In moderate cases, an average of 35 sachets of therapeutic food were used. With the simplified protocol, the CHWs had 6% discharge errors compared with 19% with the standard protocol. The treatment coverage increased significantly with the simplified combined program (SAM +42.5%, MAM +13.8%). Implementing a simplified combined treatment program and adding CHWs as treatment providers can improve coverage while maintaining non-inferior effectiveness, reducing the expenditure on nutritional intrants, and ensuring the continuum of care for the most vulnerable children.

Should I stay or should I go: an assessment of criteria for safe day of surgery discharge of displaced supracondylar humerus fractures.

Immobilization type and in-hospital observation following surgical management of displaced supracondylar fractures are subject to surgeon preference and training. Our goal was to determine criteria for immediate discharge and optimal type of immobilization. Medical records of 661 patients with type III, IV or flexion-type displaced supracondylar humerus fractures treated at a level 1 pediatric trauma center from January 2013 to September 2019 were reviewed. Patients were separated into 'admission appropriate' (AA = 113) and 'discharge appropriate' (DA = 548) sub-cohorts. Neurovascular deficit at presentation ( P < 0.001), post-operative physical exam deterioration ( P < 0.001), age ( P < 0.001) and post-operative immobilization modality ( P = 0.02) were significantly different between AA and DA groups. When comparing patients who presented with neurologic deficit to those neurovascularly intact, there was a significant difference in whether circumferential immobilization was used post-operatively ( P < 0.001), IV medication need ( P < 0.001), discharge or admission ( P < 0.001), neurologic decline ( P < 0.001), return to ED ( P = 0.008) and vascular compromise ( P = 0.05). Twenty-four of the 56 (43%) patients who were AA and had no neurovascular finding on presentation had their immobilization adjusted (bivalved or loosened) to accommodate for swelling overnight. Only 1 was initially maintained in a splint or bivalved cast; the other 23 were initially maintained post-operatively in circumferential immobilization ( P = 0.01). Our findings suggest that patients with intact neurovascular exams at presentation are candidates for early discharge, and splinting or bivalved casting may be preferable, especially in patients who are discharged.

Analysis of admissions to intensive care units that could be supported on an intermediate care unit.

Only one third of European countries use intermediate care units (IMCs). An IMC makes it possible to manage patients who do not require intensive care but who need a higher level of nursing care that cannot be provided on the general ward. In Belgium, there are no national criteria for ICU admission or discharge, and no policies regarding IMC care or for differentiating ICU intensity levels. The aim of our study was to analyse the profile of ICU patients in Belgium on the basis of registered nursing activity in order to quantify the number of ICU days potentially transferable to an IMC. The study was conducted on 310 ICU beds. Patients admitted to the study were recruited during two different one-month periods in 2018 and were included into a prospective database that evaluated nursing workload carried out in 15 hospitals in the French-speaking part of Belgium. The number of ICU days that could be supported on an IMC was defined according to the Nursing Activities Score (NAS) items. A total of 3279 ICU patients for a total of 13 942 ICU days were included. 4987 days (35.8%) were considered as "transferable" to an IMC. The proportion of ICU days transferable to an IMC was highly variable among hospitals, ranging from 20.4% to 59.5% of all ICU days. On the day of ICU admission, 665/2142 (31.0%) of the patients were already identified as transferable to an IMC; this percentage significantly increased on day 2 (972/2066, 47.1%) and day 3 (650/1390, 46.7%). In Belgian ICUs, 35.8% of ICU hospital days, as per recorded NAS, do not necessitate intensive monitoring. These 35.8% of days of ICU hospitalization could be supported on an IMC. In this study, a significant number of days spent in the ICU could be supported on an IMC, this could alleviate the workload of nurses and reduce the occupancy rate of intensive care units.

Test Methods for Validating Inductive Transformer Performance during Cable Discharge: Main Principles, Parameters and Testing Procedures

High voltage connections will discharge through inductive voltage and combined transformers when they are switched off. In the past, there was a wide margin between the required capabilities and the actual capabilities of these components. Nowadays, however, this aspect is becoming more prominent due to a higher penetration by cable systems into the grid. Currently, none of the relevant international standards contain any definitions or requirements for line discharge, nor test methods which would validate the ability of the transformer to discharge a line of certain capacitance at a certain voltage. This is why the aim of this paper is to provide a foundation for how to specify, assess and verify the capacitive discharge performance of instrument transformers. This paper will present the basic theory, influencing parameters, multiple test sequences and acceptance criteria for cable discharge. It is clear that capacitive discharges present both thermal and mechanical stress to the unit, which is why this paper will detail how to guarantee both aspects. The idea is that this paper serves as a literal blueprint which can then be transferred to the relevant clauses in upcoming international standards. All conclusions within this paper are achieved through calculations and testing on actual 123 kV inductive voltage transformers and combined units.

Efficacy of a Standardized Process in Optimizing Appropriate Use of Progressive Care Unit Beds in a Tertiary Care Facility.

Poor patient progression from the progressive care unit (PCU) beds has been recognized as a bottleneck, limiting the hospital's ability to optimize capacity for the sickest patients. Improving nurse management on PCU admission and discharge criteria could avoid PCU bottlenecks. Our institution lacked a standard process to identify clinically appropriate patients ready for transfer out of the PCU, causing delays in vacating PCU beds. The aim of this study was to determine if creating a standard process to empower bedside nurses and unit nursing leaders to push readiness information to the provider team improves the appropriateness of PCU stay and transfers patients out of the PCU earlier. The most common causes of delayed transfer out of the PCU were discussed among stakeholders. A process was designed to empower the bedside nurses to partner with a physician leader to send information to the provider team requesting evaluation of the patient's readiness to leave the unit. The improvement of meeting the criteria for PCU was evaluated by comparing 60 patients prior to the intervention phase with 139 patients during the intervention. The primary outcome, percentage of patients meeting PCU criteria, was 53% during the audit phase and 68% during the intervention phase (P = .05). The PCU transfer time was pushed 1 hour earlier in the day. The standard process of empowering bedside nurses to partner with physician leaders to push readiness for transferring patients out of the PCU resulted in a significant improvement in the percentage of patients meeting PCU criteria and earlier discharge of appropriate patients.

Assessing lab-scale hybrid wetland performance for pollutant and pathogen removal from high organic loading septage

A laboratory-scale three-staged hybrid constructed wetland (CW) system was operated for the treatment of septage. The Hybrid-CW, covering an area of 1.92 m2, consisted of a sludge drying bed (SDB) of 0.41 m2, a vertical sub-surface flow bed (VSSF) of 0.58 m2, and a horizontal sub-surface flow bed (HSSF) of 0.93 m2. The SDB, VSSF and HSSF beds were operated at an average hydraulic loading rate (HLR) 22.2, 5.2 and 3.2 cm d−1. With an average organic loading rate (OLR) of 28.8 g d−1 the Hybrid-CW confirmed effective removal of BOD5, COD, TS, and TSS by 99.2 ± 0.3% and 99.4 ± 0.2%, 96.4 ± 0.8% and 86.9 ± 2.4%, respectively. The correlation between effluent TS and TSS concentrations with influent concentrations indicated a dependence of TS and TSS removal on influent concentration. Average total coliform count in influent and effluent was observed as 6.3 × 107 and 1.6 × 103 CFU L−1respectively. Average helminthes eggs count in the influent and effluent was recorded as 5 × 107 and 2 × 104 eggs L−1 respectively. With an inlet TS loading of 177.5 g d−1, the hybrid CW system attained 96.4% TS removal and 87% TSS removal. The sludge drying bed, operating with a remarkably high TS loading of 861.9 ± 77.1 g m−2 d−1, avoided clogging and achieved >90% removal rates for total coliform and helminthes eggs along with around 60% for TS and BOD. Furthermore, the system exhibited excellent removal rates of over 99% for both total coliform (TC) and helminthes eggs (HE). Treated septage meets the Indian wastewater discharge criteria for BOD, COD, TS and TN.

Criteria for discharge of preterm infants from Canadian neonatal intensive care units.

Initial discharge from a neonatal intensive care unit (NICU) to home is a crucial milestone that impacts preterm infants, their families, and NICUs. Standardized discharge programs individualized for family needs can ensure a safe transfer of care to parents, decrease the length of stay and hospital costs, and improve parents' satisfaction. To assess the degree of variability in the current discharge criteria of preterm infants less than 34weeks' gestation among Canadian NICUs, explore different institution-specific guidelines and degree of adherence to the Canadian Paediatric Society (CPS) guidelines. A clinical representative of each of the 117 level 2-4 Canadian NICUs was contacted via email to participate in an anonymous survey link regarding the discharge criteria of preterm infants. Responders from ninety-eight NICUs (84%), representing all Canadian provinces, completed the survey. Most were nurse practitioners (43%) and neonatologists (31%) with > 5years of experience (87%). Level 3 and 4 NICUs represented 63% of responses. Units varied widely in many discharge criteria and in their adherence to CPS guidelines. Most of the units (81%) lack written discharge guidelines; 60% do not have a dedicated discharge coordinator, and 45% do not have a post-discharge clinic. Only 25% routinely teach parents CPR and only half of the surveyed units provide parental support programs. Conclusion: There is a significant heterogeneity in discharge practices of preterm infants among Canadian NICUs. This survey provides a basis for benchmarking and knowledge sharing. What is Known: • Discharging preterm infants from the NICU impacts preterm infants, their families, and NICUs. • All efforts should ensure a safe transfer of care to parents, decrease the length of stay, better utilize resources, and improve parents' satisfaction. What is New: • The discharge criteria of preterm infants vary widely among NICUs. • This survey provides benchmark information and exposes the need to better standardize discharge practices and the subsequent support for infants and parents.