Higher Hospital Research Articles

Traffic-Related Air Pollution and Childhood Asthma—Are the Risks Appropriately Mitigated in Australia?

Childhood asthma is a major health issue in Australia, and traffic emissions play a causative role. Two urban planning policies that impact children’s exposure to traffic emissions are considered in terms of the potential health risks to children in a Melbourne suburb with high truck volumes and hospital attendances for childhood asthma. Firstly, the health impact assessment component of the state planning approval of a major road project, and secondly, local government placement of childcare centres and schools in relation to freight routes. Three sources of air quality monitoring data were examined: (i) a Victorian EPA reference site; (ii) a site with planning approval for development into a childcare centre; and (iii) five sites within the boundary of the West Gate Tunnel Project, an AUD 10 billion road and tunnel project. The Australian Urban Research Infrastructure Network data was utilised to assess distances of childcare centres and schools from major truck routes. A range of cconcentration–response functions for childhood asthma (0–18 years) from international systematic meta-analyses and a smaller Australian cross-sectional study were applied to comparative elevations in fine particulate matter (PM2.5) and nitrogen dioxide (NO2) concentrations between the EPA reference monitor (used for project risk assessment) and local roadside data. It was found that comparative elevations in NO2 concentrations were associated with the following risk increases: developing asthma 13%, active asthma 12%, and lifetime asthma 9%. Overall, 41% of childcare centres (n = 51) and 36% of schools (n = 22) were ≤150 m to a high-density truck route. Truck emissions likely make a substantial contribution to childhood asthma outcomes in the project area. This study exemplifies how current practices may not be commensurate with guiding policy objectives of harm minimisation and equitable protection.

What influences the use of seclusion? A cross-sectional study of forensic mental health nurses in a UK high secure hospital

PurposeIncidents of violence and aggression are a regular occurrence within adult forensic mental health inpatient settings and often lead to the use of restrictive practices such as seclusion. Such events are frequently attributed to the complexity of the patients. Research commonly focuses on patient’s characteristics and their association with seclusion use. Less attention has been centred on forensic mental health nurses’ attitudes to seclusion and the association of nursing staff characteristics.Design/methodology/approachA cross-sectional survey was undertaken using a standardised questionnaire, “Survey of Nurses’ Attitudes to Seclusion”. Responses were received from n = 147 nurses at a high secure forensic mental health hospital in the UK.FindingsKey findings indicate that most participants believed seclusion should remain part of clinical practice. A correlation was identified between forensic mental health nurses’ attitudes to seclusion use and their characteristics: gender, age range, educational level and experience.Practical implicationsThis paper presents novel information on seclusion reduction opportunities through modifiable workforce factors such as gender-sensitive rostering and staff training and development. Furthermore, recruitment and retention strategies should be prioritised so forensic mental health is perceived as an attractive career and a safe workplace.Originality/valueThe paucity of research in this area has prompted calls for further research to explore nursing staff characteristics and seclusion use. This is particularly important now due to the current global difficulty in the recruitment and retention of mental health nurses.

What Is the Epidemiology of Cervical and Thoracic Spine Fractures?

Vertebral fractures are associated with enduring back pain, diminished quality of life, as well as increased morbidity and mortality. Existing epidemiological data for cervical and thoracic vertebral fractures are limited by insufficiently powered studies and a failure to evaluate the mechanism of injury. What are the temporal trends in incidence, patient characteristics, and injury mechanisms of cervical and thoracic vertebral fractures in the United States from 2003 to 2021? The United States National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) database collects data on all nonfatal injuries treated in US hospital emergency departments and is well suited to capture epidemiological trends in vertebral fractures. As such, the NEISS-AIP was queried from 2003 to 2021 for cervical and thoracic fractures. The initial search by upper trunk fractures yielded 156,669 injuries; 6% (9900) of injuries, with a weighted frequency of 638,999 patients, met the inclusion criteria. The mean age was 62 ± 25 years and 52% (334,746 of 638,999) of patients were females. Descriptive statistics were obtained. Segmented regression analysis, accounting for the year before or after 2019 when the NEISS sampling methodology was changed, was performed to assess yearly injury trends. Multivariable logistic regression models with age and sex as covariates were performed to predict injury location, mechanism, and disposition. The incidence of cervical and thoracic fractures increased from 2.0 (95% CI 1.4 to 2.7) and 3.6 (95% CI 2.4 to 4.7) per 10,000 person-years in 2003 to 14.5 (95% CI 10.9 to 18.2) and 19.9 (95% CI 14.5 to 25.3) in 2021, respectively. Incidence rates of cervical and thoracic fractures increased for all age groups from 2003 to 2021, with peak incidence and the highest rate of change in individuals 80 years or older. Most injuries occurred at home (median 69%), which were more likely to impact older individuals (median [range] age 75 [2 to 106] years) and females (median 61% of home injuries); injuries at recreation/sports facilities impacted younger individuals (median 32 [3 to 96] years) and male patients (median 76% of sports facility injuries). Falls were the most common injury mechanism across all years, with females more likely to be impacted than males. The proportion of admissions increased from 33% in 2003 to 50% in 2021, while the proportion of treated and released patients decreased from 53% to 35% in the same period. This epidemiological study identified a disproportionate increase in cervical and thoracic fracture incidence rates in patients older than 50 years from 2003 to 2021. Furthermore, high hospital admission rates were also noted resulting from these fractures. These findings indicate that current osteoporosis screening guidelines may be insufficient to capture the true population at risk of osteoporotic fractures, and they highlight the need to initiate screening at an earlier age. Level III, prognostic study.

Clinical Profile and Predictors Affecting Outcome in Community-Acquired Acute Kidney Injury: A 3 Months Follow-Up Study.

Community-Acquired Acute Kidney Injury (CA-AKI) is often a devastating clinical syndrome allied with high hospital mortality. Moreover, only limited prospective data exist on the outcomes of CA-AKI. Hence, this follow-up study was conducted to assess clinical profiles and the factors affecting outcomes in CA-AKI. A prospective study enrolling 283 participants was conducted from the year 2021 to 2022. AKI patients defined as per Kidney Disease Improving Global Outcomes (KDIGO) criteria were included. Data were collected on demographics, clinical features, and etiological factors. Patients were followed for three months. Univariate and multinomial analyses were done to predict outcomes. The Cox regression model was fitted to identify predictors of mortality. The mean age of patients was 41.67±16.21 years with male predominance. Most of the patients required non-ICU (81.9%) care. Around 36% and 39.6 % of AKI patients were oliguric and required dialysis, respectively. Most patients had a single etiology, with sepsis being the most common cause. Most patients were in KDIGO stage 3, followed by stage 2. At three months of follow-up, 40.6%, 12.3%, and 4.2% had complete, partial, and non-recovery, respectively, and 30.4% died. Age, single etiology, hepatorenal syndrome, sepsis, requirement of mechanical ventilation and vasopressors, comorbidities and glomerulonephritis were significantly associated with mortality. CA-AKI is significantly associated with higher mortality, even for those patients who require non-ICU care on presentation. This highlights the pressing need for AKI prevention, early detection, and intervention to mitigate reversible risk factors and optimize clinical outcomes.

Impact of hospital-administered extended-release naltrexone on readmission rates for patients with alcohol use disorder.

Alcohol use disorder (AUD) is a persistent public health concern, contributing significantly to mortality and morbidity. This study aims to evaluate the impact of in-hospital extended-release naltrexone (XR-NTX) administration on alcohol-related outcomes. This retrospective cohort study, conducted at an academic medical centre, included 141 adult patients with AUD who received XR-NTX between December 2020 and June 2021. Primary and secondary outcomes were assessed 90 days before and after XR-NTX administration to identify number of alcohol-related hospitalisations, emergency department (ED) visits and average length of hospital stay. Subgroup analyses assessed outcomes in high hospital utilisers and marginally housed or unhoused populations. There was a significant decrease in ED visits and length of hospital stay post XR-NTX and no significant difference in the number of rehospitalisations. Subgroup analysis showed significant reduction in hospital readmissions and ED visits among high hospital utilisers. Our sample was a predominantly middle-aged, male and white patient population. In-hospital initiation of XR-NTX for AUD was associated with a significant decrease in ED visits and length of hospital stay. While no significant impact on the number of hospitalisations was observed overall, there was a substantial reduction in hospital readmissions and ED visits among high utilisers. Our findings suggest the potential benefits of in-hospital XR-NTX, emphasising the need for further research to establish causal relationships, assess cost-effectiveness and explore effectiveness across diverse patient populations. Effective in-hospital interventions, such as XR-NTX, hold promise for improving patient outcomes and reducing the healthcare burden associated with AUD.

Concentration of High-Cost Head and Neck Cancer Surgical Patients.

Health care costs are disproportionately concentrated among a small number of patients. We sought to identify variables associated with high-cost patients and high hospital concentration of high-cost patients and to examine associations with short-term outcomes in head and neck cancer (HNCA) surgery. The Nationwide Inpatient Sample was used to identify 170,577 patients who underwent HNCA surgery in 2001-2011. High-cost patients were defined as patients whose costs of care were in the top decile, and high-concentration hospitals were defined as those whose percentage of high-cost patients was in the top decile. Multivariable regression was used to evaluate associations between cost and patient and hospital variables, postoperative complications, and in-hospital mortality. Costs associated with high-cost patients were 4.47-fold greater than the remaining 90% of patients. High-concentration hospitals treated 36% of all high-cost patients. High-cost patients were more likely to be non-white (OR = 2.08 [1.45-2.97]), have oral cavity cancer (OR = 1.21 [1.05-1.39]), advanced comorbidity (OR = 1.53 [1.31-1.77]), Medicaid (OR = 1.93 [1.62-2.31]) or self-pay payor status (OR = 1.72 [1.38-2.14]), income>50th percentile (OR = 1.25 [1.05-1.51]), undergo major procedures (OR = 3.52 [3.07-4.05]) and have non-routine discharge (OR = 7.50 [6.01-9.35]). High-concentration hospitals were more likely to be teaching hospitals (OR = 3.14 [1.64-6.05]) and less likely to be urban (OR = 0.20 [0.04-0.93]). After controlling for all other variables, high-cost patients were associated with an increased odds of mortality (OR = 8.00 [5.89-10.85]) and postoperative complications (OR = 5.88 [5.18-6.68]). High-concentration hospitals were associated with an increased odds of postoperative complications (OR = 1.31 [1.08-1.61]) but were not associated with increased mortality (OR = 0.98 [0.67-1.44]). High-cost HNCA surgical patients are associated with increased postoperative morbidity and mortality, and are disproportionately concentrated at teaching hospitals. 4 Laryngoscope, 2024.

My Reasons for Living: A Descriptive Study of the Motives for Not Committing Suicide Among Patients Diagnosed With Schizophrenia.

Background and objective Reasons for Living (RFL) constitute a construct that enables identifying the reasons for not committing suicide. These reasons are based on significant aspects of life, on the commitment to some ideals which may inhibit the impulse of committing suicide. The present study aimed to explore the RFL in a sample of patients with chronic schizophrenia; analyze the associationof RFL with the duration of illness, previous suicide attempts, hospitalizations, and schooling; and describe the potential differences between male and female patients in this context. Materials and methods A total of 94 patients with schizophrenia were assessed. TheReasons for Living Inventory (RFLI) was applied and a structured interview for clinical and sociodemographic data was performed to gather data. Frequencies and descriptive statistics were calculated, and Spearman's correlation analysis was employed. Results The mean score among thesample was 3.9, with 3.8 as the cut-off point under which the presence of suicide risk is significant. The RFLsindicated as most important by patients were those in the domains of Survival and Coping Beliefs and Responsibility to Family. Non-significant differenceswere observed between groups. An association was observed in terms of age, duration of illness, number of hospitalizations, and RFLI scores. Conclusions The sample in the present study obtained high scores in the RFL domain of Survival and Coping Beliefs and low scores in the domain of Fear of Suicide, reflecting aspecific response pattern that contrasts with other high suicidal-risk populations. We suggest that this construct could represent a protective factor for schizophrenia patients, including chronic patients with previous suicide attempts and high hospitalization rates, which were common variables observed in our clinical sample.

Characteristics of HIV-associated cryptococcal meningitis in a tertiary Chilean hospital: An observational retrospective study

BackgroundCentral nervous system opportunistic infections can be the first presentation of an HIV infection. Our aim is to describe clinical and laboratory characteristics of HIV-associated Cryptococcal Meningitis (CM), in-hospital outcomes and analyze associations of these parameters with adverse outcomes. MethodsObservational study of local cohort of HIV-associated cryptococcal meningitis in a high complexity tertiary urban hospital in Santiago, Chile.Descriptive analysis through chart review of all episodes of HIV-associated CM in adults, from 1995 to 2019.Inclusion criteria were confirmed CM with cerebrospinal fluid culture or India ink in the appropriate clinical context and HIV diagnosis. We selected relevant variables that have been described as predictors of adverse outcomes in the literature and explore associations in our cohort. ResultsThere were 37 HIV associated CM cases, occurring from 2000 to 2019. Majority were men (86 %) with a median age of 35 years. CM was the first HIV manifestation in 32 %. Opening pressure was measured in 10 % of patients at admission. Most CSF parameters were mildly altered, and two patients presented with completely normal CSF findings. Most patients −94,4 %- suffered adverse events secondary to antifungal therapy. Despite of recommendations against their use, steroids were frequently prescribed. Mortality was 18,9 %, and was associated with older age, and more days of headache prior to admission. ConclusionsCM clinical presentation and CSF characteristics are variable at presentation, which can lead to delayed diagnosis. Inappropriate use of corticosteroids, antifungal toxicity and suboptimal management of elevated intracranial pressure are key aspects to improve.

A Quality Improvement-based Approach to Implementing a Remote Monitoring–Based Bundle in Transitional Care Patients for Heart Failure

Congestive heart failure (HF) is a leading cause of hospitalization and readmission, leading to increased health care utilization and cost. This is complicated by high incidence, prevalence, and hospitalization rates among racial and ethnic minorities, with a widening in the mortality disparity gap. Remote patient monitoring (RPM) has the potential to proactively engage patients after discharge to optimize medication management and intervene to avoid rehospitalization. However, it also may widen the equity gap due to technological barriers and bias. A prospective, observational quality improvement (QI) initiative leveraging an amended tool from the Institute for Healthcare Improvement Model for Improvement was incorporated with an equity lens and five Plan-Do-Study-Act (PDSA) cycles at a single site. The intervention used an HF bundle that included RPM, clinical telepharmacy, remote therapeutic monitoring, and community paramedicine. Between May 2022 and March 2023, five PDSA cycles were run involving 90 enrolled patients. In total, 38 (42.2%) patients received the complete HF bundle, 42 (46.7%) a partial bundle, and 10 (11.1%) only RPM. The patients with the complete bundle had a readmission rate of 2.6% compared to 14.3% in the partial bundle and 20.0% in RPM alone. The biggest impact of this program was the incorporation of community paramedicine. The program also noted an improvement in equitable enrollment after adjusting mid-program by avoiding cellular phone-enabled devices and transitioning to a hub-based model. This single-site QI-based initiative implemented an HF-based RPM program that leveraged clinical telepharmacy and community paramedicine. This program identified a disparity of care gap regarding the equitable distribution of services and made mid-study adjustments to improve the disparity gap. The program found that use of the HF bundle resulted in a decreased hospital readmission rate.

Repeat laparoscopic liver resection after an initial open hepatectomy

BackgroundRepeat open hepatectomy (ROH) for recurrent liver tumors is the preferred approach especially after initial open hepatectomy (OH). The aim of this study is to assess feasibility and safety of repeat laparoscopic hepatectomy (RLH) after initial OH in 2 high volume hepato-biliary hospitals. MethodsPatients were retrieved from prospective data bases from 2012 to 2020. The patients were divided into two groups according to the approach used for repeat hepatectomy, ROH and RLH groups. ResultsSixty-seven patients matched the criteria, 20 in RLH and 47 in ROH. Diagnoses were hepatocellular carcinoma in 52.3%, intrahepatic cholangiocarcinoma in 7.7% and colorectal liver metastases in 40%. Median operative time and blood loss were lower in RLH (199 vs 260 min, and 100 vs 400 ml respectively), as well as overall postoperative complications (20% vs 49%). There were 2 conversions (10%) due to adhesions and one died of postoperative pancreatitis in RLH. Median hospital stay was lower in RLH (5 vs 9 days). ConclusionRLH is a feasible, safe technique and a realistic option to be considered in selected patients after previous OH. Early conversion should be considered when adhesions are more severe than expected.

КОРОНАВИРУСНАЯ ИНФЕКЦИЯ COVID-19 У ПАЦИЕНТОВ С ОСТРЫМ МИЕЛОИДНЫМ ЛЕЙКОЗОМ СТАРШЕЙ ВОЗРАСТНОЙ ГРУППЫ: ОБЗОР ЛИТЕРАТУРЫ И СОБСТВЕННЫЙ ОПЫТ

The presented literature review presents studies, including our own, on the characteristics of the course of coronavirus infection in patients with acute myeloid leukemia in the older age group. Patients with acute leukemia, myelodysplastic syndrome are often over 65 years of age and have a burdened comorbid background and have profound immunodeficiency due to the underlying disease and the antitumor treatment received, and delaying treatment is often impossible due to the urgent need to start antitumor therapy. Management of this cohort of patients with concomitant COVID-19 is a challenge for hematologists around the world and requires interdisciplinary collaboration between hematologists and infectious disease specialists, clinical pharmacologists. There is a need to develop criteria to determine clear indications for starting antitumor treatment against the background of COVID-19 and the optimal timing for resuming the next course of chemotherapy after a coronavirus infection. The analysis of the literature and our own experience showed high hospital mortality taking into account the state of deep immunodeficiency of patients, despite the treatment of COVID-19, secondary bacterial and fungal infections and demonstrated the need to develop, first of all, preventive strategies in elderly patients with acute leukemia.

The impact of deprivation on colorectal cancer-stage distribution in a setting with high hospital bed density: A Japanese multilevel study.

A methodology for determining the appropriate balance between medical access and combating poverty remains undetermined. To address the boundary conditions for exceedingly good medical access, this study examined whether the impact of deprivation on cancer stage distribution could be eliminated in Japan, which has the highest hospital bed density in the world. A nationwide medical claims-based database was used to evaluate the influence of municipality-level hospital bed density and the postal code-level areal deprivation index on cancer stage at diagnosis. Given the limited number of similar studies in Japan, we focused on colorectal cancer (CRC), for which disparities have been reported in a prefecture-level study. Multilevel multivariate logistic regression models were used, with odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for baseline and socioeconomic factors. Regardless of the early/advanced-stage definitions, CRC consistently tended to be detected at more advanced stages in more deprived areas. In the analysis of stages 0-I/II-IV, the OR (95% CI) was 1.09 (1.05, 1.14) (p < 0.001). In the analyses of stages 0-I/II-IV and 0-II/III-IV, gradients were observed, and later detections were observed for more deprived segments. Hospital bed density was not significantly associated with the stage distribution. The results indicate that inequalities in CRC detection due to deprivation persist even in the country with the highest hospital bed density worldwide, suggesting that poverty measures remain indispensable regardless of hospital bed access. Further investigation of various regions and cancers is required to develop a practical framework.

Coronary artery disease multivessel not amenable to revascularization: contemporary cohort

Severe diffuse coronary artery disease with anatomy that is not amenable to revascularization represents a poorly studied entity, with a poorly defined prognosis and prevalence, associated with high morbidity and mortality, poor quality of life and high hospitalization rates. Due to the limited evidence in this clinical field and the absence of contemporary studies, we decided to explore this line of research, determining epidemiological, clinical and prognostic aspects. Analytical, retrospective observational cohort study, carried out in a National Medical Center. The prevalence of three-vessel coronary artery disease not susceptible to revascularization was 12.2%, the majority were men (66%), over 65 years of age, with a high burden of comorbidities: pharmacological management consisted of beta blockers (91.5 %), antiplatelet aggregation (95.3%) and statins (95.3%): cardiovascular mortality was 9.4%, with myocardial infarction occurring in 10.4%: the predictor variables of mortality were chronic kidney disease, age over 70 years, insufficiency mitral valve. Coronary artery disease of three vessels not susceptible to revascularization continues to be a frequent entity, with a high-risk clinical and anatomical profile, with a better contemporary prognosis despite the multiple gaps in knowledge that limit its understanding and treatment.

Expediting Discharges on the Inpatient Medicine Teaching Services

Introduction: Delayed discharges can adversely affect patient flow throughout the hospital. Late afternoon discharges may lead to high hospital occupancy, admission bottlenecks, ER overcrowding, and disrupted ICU transfers. Discharge by noon (DBN) is key to enhancing hospital capacity, bed utilization, and patient satisfaction and outcomes. Last year, DBN for patients returning home with or without home care services (HHC) was chosen as one of three annual priorities for our hospital medicine division. This was implemented in October 2023 but did not gain momentum among the medical resident teaching services (MTS), paving the way for our QI project. Model for Improvement: Baseline data on the percentage of MTS DBN to home and HHC were available from November 2023 to January 2024. We surveyed our residents/faculty and conducted a root-cause analysis. The main barriers to DBN included a lack of planning and motivation, delayed communication with case management, and prolonged rounding. Aims Statement: Our goal was to increase the median percentage of MTS discharge orders placed by noon to home and HHC from 22% to 35% within 3 months. Measures: Our primary outcome measure was the percentage of MTS DBN to home and HHC. Weekly EMR-generated reports were collected. The outcome measure was then calculated and uploaded weekly on a run chart for analysis. Qualitative process measures included assessing if residents were planning discharges and documenting the number of discharges completed before noon. Changes: Our interventions targeted the lack of planning and motivation. These included introducing the expedited initiative and its importance to residents/faculty through conferences. In addition, a process was created where potential next-day discharges were discussed at afternoon sign-out and a tracking chart of DBN orders was designed for each team room. Tests of Change: Our pre-intervention median percentage of MTS DMB to home and HHC was 22% and improved to 40% post-intervention. While we observed a variation in discharge practice based on the rounding attending, we had notably sustained an upward shift in practice from our baseline when data was plotted on a run chart. We are currently continuing data collection to track sustainability and variability among rounding physicians. Conclusion: We attained an upward shift in the percentage of MTS DBN to home and HHC post-intervention. Although an upward shift has been achieved, we are looking to sustain and further improve it. In future PDSA cycles, we will look at individualizing feedback and optimizing interdisciplinary rounds. We plan on further investigating balancing measures such as bed availability, discharge timing for rehabilitation destinations, and patient and staff satisfaction.

Acute Care Use Among Patients With Multiple Chronic Conditions Receiving Care From Nurse Practitioner Practices in Health Professional Shortage Areas.

Patients with multiple chronic conditions often have many care plans, polypharmacy, and unrelieved symptoms that contribute to high emergency department and hospital use. High-quality primary care delivered in practices that employ nurse practitioners can help prevent the need for such acute care services. However, such practices located in primary care health professional shortage areas face challenges caring for these patients because of higher workloads and fewer resources. We examined differences in hospitalization and emergency department use among patients with multiple chronic conditions who receive care from practices that employ nurse practitioners in health professional shortage areas compared to practices that employ nurse practitioners in non-health professional shortage areas. We performed an analysis of Medicare claims, merged with Health Resources and Services Administration data on health professional shortage area status in five states. Our sample included 394,424 community-dwelling Medicare beneficiaries aged ≥65 years, with at least two of 15 common chronic conditions who received care in 779 practices that employ nurse practitioners. We used logistic regression to assess the relationship between health professional shortage area status and emergency department visits or hospitalizations. We found a higher likelihood of emergency department visits among patients in health professional shortage areas compared to those in non-health professional shortage areas and no difference in the likelihood of hospitalization. Emergency department use differences exist among older adults with multiple chronic conditions receiving care in practices that employ nurse practitioners in health professional shortage areas, compared to those in non-health professional shortage areas. To address this disparity, the health professional shortage area program should invest in recruiting and retaining nurse practitioners to health professional shortage areas to ease workforce shortages.

Risk management or racial Bias? The disparate use of restraints in the Emergency Department of an Urban Safety-Net Hospital

ObjectivesLimited data exist on racial-ethnic differences in the application of restraints for patients visitng the emergency department (ED). This study examines whether there is an association between race and patient ED visit type with the application of four-point mechanical restraints in a high acuity safety-net urban academic hospital. MethodsThe study retrospectively reviewed 198,610 visits to the ED at Boston Medical Center made by patients between 18 and 89 years old between May 1, 2014 and May 1, 2019. ED visit type was categorized based on primary billing code for the visit as either medical or behavioral; behavioral visits were further categorized into 5 groups based on corresponding primary psychiatric billing code category. The relationships between race/ethnicity and four-point mechanical restraints were analyzed using binary logistic regression models in SPSS. Results1.4% of unique visits involved the use of four-point mechanical restraints. Patients with a behavioral visit were significantly over 16 times more likely to be restrained than those with a medical visit. Black patients were significantly more likely to be restrained than white patients for behavioral visits but less likely for medical visits. Black and Hispanic patients were also significantly more likely to be restrained for a behavioral visit regardless of psychiatric diagnosis. Asian patients were less likely to be restrained regardless of ED visit type. ConclusionsSignificant racial differences in restraints for White patients with medical visits and Black and Hispanic patients with behavioral visits prompts further investigation on the role of clinician bias when managing acute patients.

Development of a Complex Care Transition Team to Improve the Transition of Patients With Complex Care Needs to the Community.

Health care systems have historically struggled to provide adequate care for patients with complex care needs that often result in overuse of hospital and emergency department resources. Patients with complex care needs generally have increased expenses, longer length of hospital stays, an increased need for care management resources during hospitalization, and high readmission rates. Mayo Clinic in Arizona aimed to ensure successful transitions for hospitalized patients with complex care needs to the community by developing a complex care transition team (CCTT) program. With typical care management models, patients are assigned to registered nurse case managers and social workers according to the inpatient nursing unit rather than patient care complexity. Patients with complex care needs may not receive the amount of time needed to ensure an efficient and effective transition to the community setting. Furthermore, after transitioning to the community, patients with complex care needs often do not have access to care management resources if further care coordination needs arise. Acute care hospital in the US Southwest. The CCTT was composed of a registered nurse case manager, social worker, and care management assistant, with physician advisor support. The CCTT followed patients with complex care needs during their hospitalization and transition to the community for 90days after discharge. The number of inpatient admissions and hospital readmission rates were compared between 6months before and after enrollment in the CCTT program. Cost savings for decreased hospital length of stay, emergency department visits, and hospital readmissions were also determined. The CCTT selected patients according to a complex care algorithm , which identified patients who required high use of the health care system. The CCTT then followed this cohort of patients for an average of 90days after discharge. A total of 123 patients were enrolled in the CCTT program from July 1, 2019, to April 30, 2021, and 80 patients successfully graduated from the program. Readmission rates decreased from 51.2% at 6months before the intervention to 22.0% at 6months after the intervention. This reduced readmission rate resulted in a cost savings of more than $1 million. The outcomes resulting from implementation of the multidisciplinary CCTT highlight the need for a patient-specific approach to transitioning care to the outpatient setting. The patient social determinants of health that often contributed to overuse of health care resources included poor access to outpatient specialists, difficulty navigating the health care system due to illness or poor health literacy, and limited social support. The success of the CCTT program prompted the implementation of other specialty-specific pilot programs at Mayo Clinic in Arizona. The investment of time and resources, including dedicated personnel to follow patients with high hospital service usage, allows health care systems to reduce emergency department visits and hospital admissions and to provide patients with the best opportunity for success as they transition from the inpatient to outpatient setting.

Differential effects of a social work staffing intervention on social work access among rural and highly rural Veterans: A cohort study.

To evaluate the impact on rural Veterans' access to social work services of a Department of Veterans Affairs (VA) national program to increase social work staffing, by Veterans' rurality, race, and complex care needs. Data obtained from VA Corporate Data Warehouse, including sites that participated in the social work program between October 1, 2016 and September 30, 2021. The study outcome was monthly number of Veterans per 1000 individuals with 1+ social work encounters. We used difference-in-differences to estimate the program effect on urban, rural, and highly rural Veterans. Among rural and highly rural Veterans, we stratified by race (American Indian or Alaskan Native, Asian, Black, Native Hawaiian or Other Pacific Islander, and White) and complex care needs (homelessness, high hospitalization risk, and dementia). We defined a cohort of 740,669 Veterans (32,434,001 monthly observations) who received primary care at a participating site. Average monthly social work use was 8.7 Veterans per 1000 individuals. The program increased access by 49% (4.3 per 1000; 95% confidence interval, 2.2-6.3). Rural Veterans' social work access increased by 57% (5.0; 3.6-6.3). Among rural/highly rural Veterans, the program increased social work access for those with high hospitalization risk by 63% (24.5; 18.2-30.9), and for Veterans experiencing homelessness, 35% (13.4; 5.2-21.7). By race, the program increased access for Black Veterans by 53% (6.1; 2.1-10.2) and for Asian Veterans by 82% (5.1; 2.2-7.9). At rural VA primary care sites with social work staffing below recommended levels, Black and Asian Veterans and those experiencing homelessness and high hospitalization risk may have unmet needs warranting social work services.

Variability in Practice of Buprenorphine Treatment by Emergency Department Operational Characteristics.

We sought to describe emergency department (ED) buprenorphine treatment variability among EDs with varying operational characteristics. We performed a retrospective cohort study of adult patients with opioid use disorder discharged from 12 hospital-based EDs within a large healthcare system as a secondary data analysis of a quality improvement study. Primary outcome of interest was buprenorphine treatment rate. We described treatment rates between EDs, categorized by tertile of operational characteristics including annual census, hospital and intensive care unit (ICU) admission rates, ED length of stay (LOS), and boarding time. Secondary outcomes were ED LOS and 30-day return rates. There were 7,469 unique ED encounters for patients with opioid use disorder between January 2020-May 2021, of whom 759 (10.2%) were treated with buprenorphine. Buprenorphine treatment rates were higher in larger EDs and those with higher hospital and ICU admission rates. Emergency department LOS and 30-day ED return rate did not have consistent associations with buprenorphine treatment. Rates of treatment with ED buprenorphine vary according to the operational characteristics of department. We did not observe a consistent negative relationship between buprenorphine treatment and operational metrics, as many feared. Additional funding and targeted resource allocation should be prioritized by departmental leaders to improve access to this evidence-based and life-saving intervention.

The hospitalization burden of inflammatory bowel disease in a southwestern highland region of China: a territory-wide study from 2015 to 2020.

Yunnan, a southwest highland and newly industrialized region of China, has an unknown hospitalization burden of inflammatory bowel disease (IBD). The study was conducted to explore territorial hospitalization burden of IBD. The formatted medical records of patients with IBD were collected from a territory-wide database in Yunnan Province, China, from 2015 to 2020. General characteristics of the study population were reported using descriptive statistics. To evaluate the length of stay, hospitalization costs, surgery, complications, and trends in patients with inflammatory bowel disease. The logistic regression analysis was established to explore the factors affecting the hospitalization costs. A total of 12,174 records from 8192 patients were included. The annual hospitalization cost of IBD in Yunnan Province increased significantly from 2015 to 2020. From 2015 to 2020, the regional hospitalization burden of IBD increased, but it represented a decline in cost per hospitalization (r = -0.024, P = 0.008) and the length of stay (r = -0.098, P < 0.001). Surgery rates for hospitalized patients with Crohn's disease (CD) did not decrease (r = -0.002, P = 0.932), and even increased for patients with ulcerative colitis (UC) (r = 0.03, P = 0.002). The costs per hospitalization were $ 827.49 (540.11-1295.50) for UC and $ 1057.03 (644.26-1888.78) for CD. Among the identifiable cost items during the period, drug costs accounted for the highest proportion, accounting for 33% and 37.30% in patients with UC and CD, respectively. Surgical intervention [OR 4.87 (3.75-6.31), P < 0.001], comorbidities [OR 1.72 (1.52-1.94), P < 0.001], complications [OR 1.53 (1.32-1.78), P < 0.001], and endoscopy [OR 2.06 (1.86-2.28), P < 0.001] were predictor of high hospitalization costs. The increasing burden of IBD is noteworthy a newly industrialized region of China. Interventions targeting surgery, complications, and comorbidities may be effective means of controlling the increasing hospitalization costs of IBD in the regions.