Hospital Census Research Articles

A prospective audit of bed utilisation and delays in care across London.

A prospective bed utilisation census of acute London hospitals using an established Day of Care Survey (DoCS), which quantified adult patients not meeting criteria for in-hospital care. Twenty-three hospitals were surveyed over two weeks in October/November 2017 using supervised trained hospital staff. Pairs of staff visited wards, reviewed all patients and identified those not meeting inpatient care criteria, recording reasons for delay. Patient demographics, length of stay (LOS), ward specialty and delay reasons were collected. Overall - In total, 8,656 in-patients were studied (overall occupancy 96%, range 82-117%): 800 definite discharges were excluded, leaving 7,856 patients for analysis; seven hospitals had °100% occupancy; 1,919/7,856 patients (24%, range 12-43%) did not meet criteria; 56% of patients were over 70 years; five hospitals had higher number of patients <70yo 56% patients had LOS 0˛7days. Delayed patients - Number of delayed patients increased with age, but three hospitals had more patients <70yo; 53% had LOS˛14 days and 47% LOS<14 days; 13 hospitals had greater/equal number of patients in ˛14 days LOS. For delayed patients in ˛14 days group, most were within seven days of admission (627 ˛7days, 393 8-14 days). In total 34% (range 11-54%) of delays were related to acute hospital reasons (AHR) and 61% (range 46-83%) to wider system reasons (WSR). Eight common themes accounted for 67% of recorded reasons and were equally split between AHR and WSR. Data showed high occupancy levels with insufficient discharges. This study suggests policies selecting age and/or LOS alone as cut offs to tackle delays in care may miss a large proportion of patients requiring more timely interventions. Adopting a proactive thematic approach to improvement using the top eight delay reasons provides an obvious opportunity to reduce delays while noting the inter site variation. All metrics analysed emphasized the need for informed local data to help support local change.

Internal Medicine Resident Work Absence During the COVID-19 Pandemic at a Large Academic Medical Center in New York City

Montefiore Medical Center (MMC) is a large tertiary care center in the Bronx, New York City, with 245 internal medicine residents. Beginning on February 29, 2020, residents became ill with COVID-19-like illness (CLI), which required absence from work. There was initially a shortage of personal protective equipment and delays in SARS-CoV-2 testing, which gradually improved during March and April 2020. We evaluated the relationship between CLI-related work absence rates of internal medicine residents and MMC's COVID-19 hospital census over time. Data on resident work absence between February 29 and May 22 were reviewed along with MMC's COVID-19 hospital census data. To determine the effect of patient exposure on resident CLI incidence, we compared the mean incidence of CLI per patient exposure days (PED = daily hospital census × days pre- or post-peak) before and after peak COVID-19 hospital census. Forty-two percent (103 of 245) of internal medicine residents were absent from work, resulting in 875 missed workdays. At the peak of resident work absence, 16% (38 of 245) were out sick. Residents were absent for a median of 7 days (IQR 6-9.5 days). Mean resident CLI incidence per PED (CLI/PED) was 13.9-fold lower post-peak compared to pre-peak (P = .003). At the beginning of the COVID-19 pandemic in New York City, a large portion of internal medicine residents at this single center became ill. However, the incidence of CLI decreased over time, despite ongoing exposure to patients with COVID-19.

Forecasting the Probability That Each Surgical Case Will Either Be Ambulatory or the Patient Will Remain in the Hospital Overnight Versus Having a Length of Stay of Two or More Days.

When the hospital census is high, perioperative medical directors or operating room (OR) managers sometimes need to review with surgical departments as to which surgical cases scheduled to be performed within the next three days may need to be postponed. Although distributions of hospital length of stay (LOS) are highly skewed, a surprisingly effective summary measure is the percentage of patients previously undergoing the same category of procedure as that scheduled whose LOS was zero or one day. We evaluated how to forecast each hospital's percentage of cases with LOS of <2 days, segmented by category of surgical procedure. The large teaching hospital studied included several inpatient adult surgical suites, an ambulatory surgery center, and a pediatric surgical suite.We included 98,540 cases in a training dataset to predict 24,338 cases in a test dataset. For each category of procedure, we calculated the cumulative count of cases among quarters, from the most recent quarter, second most recent quarter, and so forth up to the quarter resulting in at least 800 cases. If every quarter combined had fewer than 800 cases for a given category of procedure, we included all cases for that category. For each combination of category and quarter, we used the cumulative counts of cases and cases with LOS of <2 days, excluding the current quarter. Then, for each category of procedure, and for each of the preceding quarters included for the category, we used the cumulative counts to calculate the asymptotic standard error (SE) for the proportion of cases with LOS of <2 days. If all preceding quarters combined provided a sample size such that the estimated SE for the proportion exceeded 1.25%, we included all preceding quarters. The observed absolute percentage error was 0.76% (SE: 0.12%). This error was nearly 100-fold smaller than the percentage of cases to which it would be used (i.e., 0.76% versus 73.1% with LOS of <2 days). The principal weakness of the forecasting methodology was a small bias caused by a progressive reduction in the overall LOS over time. However, this bias is unlikely to be important for predicting cases’ LOS when the hospital census is high. When performing these time series calculations quarterly, a reasonable approach is to perform calculations of both case counts and SEs for each category of procedure. We recommend using the fewest historical quarters, starting with the most recent quarter, either with at least 800 cases or an estimated asymptotic SE for the estimated percentage no greater than 1.25%. Applying our methodology with local LOS data will allow OR managers to estimate the number of patients on the elective OR schedule each day who will be hospitalized for longer than overnight, facilitating communication and decision-making with surgical departments when census considerations constrain the ability to run a full surgical schedule.

S0149 Clostridioides difficile Infection Trends in a Health System During COVID-19 Pandemic

INTRODUCTION: Clostridioides difficile Infection (CDI) is a common nosocomial infection with significant disease burden. From 2011 to 2017, a decline in nosocomial spread with stable community spread of CDI was observed. With the current coronavirus disease 2019 (Covid-19) pandemic, many healthcare systems noted dramatic shifts in hospital census along with changes in infection control. We conducted a retrospective single-center study to determine whether changes in hospital census and infection control during Covid-19 affected rates of CDI. METHODS: Monthly inpatient admissions and outpatient visits from 11/1/2019 through 5/31/2020 were obtained from University of Virginia health analytics database. We included all patients who had Clostridioides difficile PCR, noting the PCR result and the setting from which it was obtained. Rates of CDI during preCovid-19 (11/1/2019–2/31/2020) and postCovid-19 (3/1–5/31/2020) periods were compared. A sample of primary care providers (PCPs) were surveyed regarding empiric CDI prescribing habits to determine if empiric treatment was offered in lieu of testing during COVID-19. RESULTS: Our institution had a decline in hospital census in the postCovid-19 period (Tables 1 and 2). In the inpatient setting, the number of positive CDI tests decreased postCovid-19 (mean = 10) compared to preCovid-19 (mean = 19) (P = 0.007) (Figure 1). The proportion of positive CDI tests over monthly admissions decreased in the postCovid-19 period (P = 0.04). After controlling for age and gender, logistic regression analysis showed that the odds of testing positive for CDI decreased postCovid-19 (OR = 0.62, CI = 0.39–0.98). In the outpatient setting, the number of positive CDI tests per month was unchanged preCovid-19 (mean = 8.25) compared to postCovid-19 (mean = 7.67) (P = 0.83). A physician survey (n = 13) showed that 1 out of 13 PCPs empirically prescribed antibiotics for CDI during Covid-19. CONCLUSION: There was a significant decrease in number and proportion of inpatient CDI during Covid-19 while outpatient CDI rates remained stable. The majority of surveyed PCPs did not prescribe empiric treatment for CDI. Reasons for inpatient CDI downtrend may include decrease in elective procedures/admissions that pose risk for CDI or heightened awareness of infection control best-practices due to Covid-19. Further research is necessary to evaluate CDI trends as hospital census fluctuates and to assess outcomes of Covid19 infection control policy changes on CDI and other healthcare infections.Table 1.: Inpatient Summary DataTable 2.: Outpatient Summary DataFigure 1.: CDI Testing Results by Month.

Surgery and Resource Utilization Trends for Pediatric Intussusception From 2005 Through 2014.

Background: Air or barium enema reduction is becoming increasingly common and safer for pediatric intussusception. However, little is known about trends of pediatric intussusception requiring surgical intervention in the United States. Methods: National Inpatient Sample database was analyzed from 2005-2014 to identify pediatric (≤18 years) intussusceptions along with procedures such as enema and/or surgical intervention. Trends in the rates of surgical intervention were examined according to encounter-level (age, gender, race, comorbidities) and hospital-level (hospital census region, teaching status) characteristics. Outcomes of pediatric intussusception requiring surgical intervention were analyzed in terms of length of stay and cost of hospitalization. Factors associated with surgical intervention were also analyzed. P value of < 0.05 was considered significant. Results: Out of 21,835 intussusception hospitalizations requiring enema or surgical intervention, 14,415 (66%) had surgical intervention; 90% of which (12,978) had no preceding enema. Surgical intervention rates among intussusception hospitalizations varied by age (highest < 1 year), gender (male > females) and race (Hispanics > Whites and Blacks). During the study period, overall surgical intervention rate remained stable (2.2 to 1.7, P=0.07) although it declined in those under 1 year of age. Children with severe disease, gastrointestinal comorbidities over the age of 4 years had increased odds of surgical intervention, whereas hospitalization in large and urban teaching hospitals had decreased odds of surgical intervention. Length of stay and hospital cost remained stable from 2005-2014.Conclusion: The rates of surgical intervention and resource utilization for pediatric intussusception remained stable from 2005-2014, however they declined significantly in infants. The proportion of intussusception hospitalization requiring surgery remains high and further studies are needed to explore the possible factors.

Antibiotic prescribing for lower UTI in elderly patients in primary care and risk of bloodstream infection: A cohort study using electronic health records in England

Research has questioned the safety of delaying or withholding antibiotics for suspected urinary tract infection (UTI) in older patients. We evaluated the association between antibiotic treatment for lower UTI and risk of bloodstream infection (BSI) in adults aged ≥65 years in primary care. We analyzed primary care records from patients aged ≥65 years in England with community-onset UTI using the Clinical Practice Research Datalink (2007-2015) linked to Hospital Episode Statistics and census data. The primary outcome was BSI within 60 days, comparing patients treated immediately with antibiotics and those not treated immediately. Crude and adjusted associations between exposure and outcome were estimated using generalized estimating equations. A total of 147,334 patients were included representing 280,462 episodes of lower UTI. BSI occurred in 0.4% (1,025/244,963) of UTI episodes with immediate antibiotics versus 0.6% (228/35,499) of episodes without immediate antibiotics. After adjusting for patient demographics, year of consultation, comorbidities, smoking status, recent hospitalizations, recent accident and emergency (A&E) attendances, recent antibiotic prescribing, and home visits, the odds of BSI were equivalent in patients who were not treated with antibiotics immediately and those who were treated on the date of their UTI consultation (adjusted odds ratio [aOR] 1.13, 95% CI 0.97-1.32, p-value = 0.105). Delaying or withholding antibiotics was associated with increased odds of death in the subsequent 60 days (aOR 1.17, 95% CI 1.09-1.26, p-value < 0.001), but there was limited evidence that increased deaths were attributable to urinary-source BSI. Limitations include overlap between the categories of immediate and delayed antibiotic prescribing, residual confounding underlying differences between patients who were/were not treated with antibiotics, and lack of microbiological diagnosis for BSI. In this study, we observed that delaying or withholding antibiotics in older adults with suspected UTI did not increase patients' risk of BSI, in contrast with a previous study that analyzed the same dataset, but mortality was increased. Our findings highlight uncertainty around the risks of delaying or withholding antibiotic treatment, which is exacerbated by systematic differences between patients who were and were not treated immediately with antibiotics. Overall, our findings emphasize the need for improved diagnostic/risk prediction strategies to guide antibiotic prescribing for suspected UTI in older adults.

Risk of COVID-19 infection after cardiac electrophysiology procedures.

BackgroundDuring the COVID-19 pandemic, attempts to conserve resources and limit virus spread have resulted in delay of nonemergent procedures across all medical specialties, including cardiac electrophysiology (EP). Many patients have delayed care and continue to express concerns about potential nosocomial spread of coronavirus.ObjectiveTo quantify risk of development of COVID-19 owing to in-hospital transmission related to an EP procedure, in the setting of preventive measures instituted in our laboratory areas.MethodsWe contacted patients by telephone who underwent emergent procedures in the electrophysiology lab during the COVID-19 surge at our hospital (March 16, 2020, to May 15, 2020, reaching daily census 450 COVID-19 patients,) ≥2 weeks after the procedure, to assess for symptoms of and/or testing for COVID-19, and assessed outcomes from medical record review.ResultsOf the 124 patients undergoing EP procedures in this period, none had developed documented or suspected coronavirus infection. Seven patients described symptoms of chest pain, dyspnea, or fever; 3 were tested for coronavirus and found to be negative. Of the remaining 4, 2 had a more plausible alternative explanation for the symptoms, and 2 had transient symptoms not meeting published criteria for probable COVID-19 infection.ConclusionDespite a high hospital census of COVID-19 patients during the period of hospital stay for an EP procedure, there were no likely COVID-19 infections occurring in follow-up of at least 2 weeks. With proper use of preventive measures as recommended by published guidelines, the risk of nosocomial spread of COVID-19 to patients in the EP lab is low.

Policy Implications for the COVID-19 Pandemic in Light of Most Patients (≥72%) Spending at Most One Night at the Hospital After Elective, Major Therapeutic Procedures.

A large number of inpatients with Coronavirus disease 2019 (COVID-19) in some regions of the United States may interfere with the ability of hospitals to take care of patients requiring treatment for other conditions. Nonetheless, many patients need surgery to improve their quality of life and to prevent deterioration in health. Curtailment of services also negatively affects the financial health of hospitals and health systems. Broad policies to prohibit all “elective” surgical procedures to ensure that there is sufficient hospital capacity for pandemic patients may be unnecessarily restrictive because, for many such procedures, patients are rarely admitted following surgery or only stay overnight. We studied all elective inpatient and ambulatory cases involving major therapeutic procedures performed in the state of Florida in 2018. We mapped the primary procedure to the corresponding Clinical Classification Software (CCS) category. We determined the distributions of lengths of stay overall and as stratified by CCS category, then calculated the percentage of cases that had a hospital length of stay of ≤1 night (i.e., 0 or 1 day). A threshold of one night was selected because patients discharged home on the day of surgery have no effect on the inpatient census, and those staying overnight would either have a transient effect or no effect if observed overnight in the postoperative care unit. Among the 1,852,391 elective cases with one or more major therapeutic procedures, 65.2% (95% lower confidence limit [LCL] = 65.1%) of cases had a length of stay of 0 days and 72.9% (95% LCL = 72.8%) had stay ≤1 day. There were 38 different CCS categories for which at least 95% of patients had a length of stay of ≤1 day. There were 28 CCS codes that identified 80% of the patients who were discharged with a length of stay ≤1 day, showing representation of multiple surgical specialties. Our results show that even in the face of constraints imposed by a high hospital census, many categories of major therapeutic elective procedures could be performed without necessarily compromising hospital capacity. Most patients will be discharged on the day of surgery. If overnight admission is required, there would be an option to care for them in the postanesthesia care unit, thus not affecting the census. Thus, policies can reasonably be based on allowing cases with a substantial probability of at most an overnight stay rather than a blanket ban on “elective” surgery or creating a carve-out for specified surgical subspecialties. Such policies would apply to at least 72% of elective, major therapeutic surgical procedures.

Quality of care in prevention, detection and management of postpartum hemorrhage in hospitals in Afghanistan: an observational assessment

BackgroundHemorrhage is the leading cause of maternal mortality worldwide and accounts for 56% of maternal deaths in Afghanistan. Postpartum hemorrhage (PPH) is commonly caused by uterine atony, genital tract trauma, retained placenta, and coagulation disorders. The purpose of this study is to examine the quality of prevention, detection and management of PPH in both public and private hospitals in Afghanistan in 2016, and compare the quality of care in district hospitals with care in provincial, regional, and specialty hospitals.MethodsThis study uses a subset of data from the 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment. It covers a census of all accessible public hospitals, including 40 district hospitals, 27 provincial hospitals, five regional hospitals, and five specialty hospitals, as well as 10 purposively selected private hospitals.ResultsAll public and private hospitals reported 24 h/7 days a week service provision. Oxytocin was available in 90.0% of district hospitals, 89.2% of provincial, regional and specialty hospitals and all 10 private hospitals; misoprostol was available in 52.5% of district hospitals, 56.8% of provincial, regional and specialty hospitals and in all 10 private hospitals. For prevention of PPH, 73.3% women in district hospitals, 71.2% women at provincial, regional and specialty hospitals and 72.7% women at private hospital received uterotonics. Placenta and membranes were checked for completeness in almost half of women in all hospitals. Manual removal of placenta was performed in 97.8% women with retained placenta. Monitoring blood loss during the immediate postpartum period was performed in 48.4% of women in district hospitals, 36.9% of women in provincial, regional and specialty hospitals, and 43.3% in private hospitals. The most commonly observed cause of PPH was retained placenta followed by genital tract trauma and uterine atony.ConclusionGaps in performance of skilled birth attendants are substantial across public and private hospitals. Improving and retaining skills of health workers through on-site, continuous capacity development approaches and encouraging a culture of audit, learning and quality improvement may address clinical gaps and improve quality of PPH prevention, detection and management.

Reflections on the coronavirus disease 2019 (COVID-19) epidemic: The first 30 days in one of New York’s largest academic departments of surgery

Reflections on the coronavirus disease 2019 (COVID-19) epidemic: The first 30 days in one of New York’s largest academic departments of surgery

COVID-19 Forecast for Chemung County, NY, April 2020

We used an agent-based modeling approach to predict the scope of the COVID-19 outbreak in Chemung County, NY, USA. Chemung County’s first confirmed case was on March 21, 2020. A variety of mitigation efforts were placed prior to announcement of the first confirmed case; this has kept the burden of disease low, in contrast to other areas of New York. Using an agent-based modeling technique, we simulated an outbreak in order to estimate the expected number of total infections and deaths, and the peak hospitalization date and census. This stochastic model is used to assign various attributes to agents (people of Chemung County) and simulate interaction between these agents at various time points. The model simulation took place 256 times; these observations were used to compile key outcomes. Panel A presents our predictions for cumulative values at the mean, 95th, and 5th percentile of the simulations for Exposures (Orange), Illnesses (Red), Recoveries (Green), Hospitalizations (Blue), and Deaths (Black). Panel B presents our predictions for Hospital Census, with a highlight of the mean. We expect there to be a total of 312 (90% CI: 106, 784) combined diagnosed and undiagnosed cases, 19 (90% CI: 10, 33) peak hospital census, and 9 (90% CI: 2, 28) total deaths in Chemung County. Our model indicates the peak hospitalization date to occur on April 17, 2020 (90% CI: April 5, May 16). It is important to note that these estimates do not include data from local assisted living facilities, due to variance and lack of available data. With the continued enforcement of the state-mandated stay-at-home order, we expect that Chemung County health care resources can accommodate the increase in need due to COVID-19, provided other sources such as assisted living facilities do not contribute significantly to the totals. Our analysis of Chemung County serves as an example for modeling rural areas and can inform critical, time-sensitive decisions made by hospital administrators and local officials regarding resource allocation and clinical operation.

114 Emergency Department Factors Associated With Early Rapid Responses Activation After Admission

To assess the impact of emergency department (ED) and Hospital Census on the likelihood of the rapid response team being called to a patient's bedside within 24 hours (Early RR) of their admission from the ED. A retrospective review of all rapid responses and cardiac arrest codes in an academic tertiary care hospital for calendar year 2017. Those responses that occurred within 24 hours of admission from the ED were then identified. The hospital and ED census and bed availability data for 2017 was also reviewed and merged. A total of 21 factors were identified to be studied. Data was presented as mean (standard deviation) or median (interquartile range) for continuous variables and frequency (percentage) for categorical variables. Continuous variables were compared using a t-test or Wilcoxon sum rank test, as appropriate. Categorical data was analyzed using a chi-squared test or Fisher’s exact test, as appropriate. SAS Enterprise Guide 7.15 HF3 (SAS Institute, Inc, Cary, NC) was used to conduct the statistical analysis. A total of 581 rapid responses were documented. Of those, 94 were Early RRs called on 87 unique patients. Half occurred overnight(7P-7A), and half in daylight(7A-7P). Reasons reported for rapid response team activation during the Early RRs included 40 with respiratory, 27 with neurologic and 34 with cardiac. Nineteen were on non- internal medicine services. Only one of the Early RRs converted to a code and the total in-hospital mortality was 17%. During 2017, an early rapid response or an early code occurred on 80 (22%) and 6 (1.6%) days, respectively. On days when an early rapid response occurred, the total number of available beds in the morning (mean (SD): 29 (10)) is significantly higher (p-value = 0.0004) than on days where there were no early rapid responses called (mean (SD): 22 (9.5)). How census and flow affect patient outcomes is a complex question. Given previous literature showing increased mortality associated with increased ED boarding times and delayed ICU admission times, a full hospital is likely to stress resources such that more rapid responses occur. However, our research shows that as bed availability increases, so does the chance of rapid response. This may indicate that easy availability of ready floor beds allow patients to be inappropriately evaluated and dispositioned. This should be kept in mind as metrics for ED quality are developed and measured. As we expand working on this data set we hope to build on this initial analysis. We suspect that that likelihood of rapid response in correlation to time spent in the ED is likely U-shaped rather than linear.

Service environment link and false discovery rate correction: Methodological considerations in population and health facility surveys.

BackgroundGeospatial data are important in monitoring many aspects of healthcare development. Geographically linking health facility data with population data is an important area of public health research. Examining healthcare problems spatially and hierarchically assists with efficient resource allocation and the monitoring and evaluation of service efficacy at different levels. This paper explored methodological issues associated with geographic data linkage, and the spatial and multilevel analyses that could be considered in analysing maternal health service data.MethodsThe 2016 Ethiopia Demographic and Health Survey and the 2014 Ethiopia Service Provision Assessment data were used. Two geographic data linking methods were used to link these two datasets. Administrative boundary link was used to link a sample of health facilities data with population survey data for analysing three areas of maternal health service use. Euclidean buffer link was used for a census of hospitals to analyse caesarean delivery use in Ethiopia. The Global Moran’s I and the Getis-Ord Gi* statistics need to be carried out for identifying hot spots of maternal health service use in ArcGIS software. In addition to this, since the two datasets contain hierarchical data, a multilevel analysis was carried out to identify key determinants of maternal health service use in Ethiopia.ResultsAdministrative boundary link gave more types of health facilities and more maternal health services as compared to the Euclidean buffer link. Administrative boundary link is the method of choice in case of sampled health facilities. However, for a census of health facilities, the Euclidean buffer link is the appropriate choice as this provides cluster level service environment estimates, which the administrative boundary link does not. Applying a False Discovery Rate correction enables the identification of true spatial clusters of maternal health service use.ConclusionsA service environment link minimizes the methodological issues associated with geographic data linkage. A False Discovery Rate correction needs to be used to account for multiple and dependent testing while carrying out local spatial statistics. Examining maternal health service use both spatially and hierarchically has tremendous importance for identifying geographic areas that need special emphasis and for intervention purposes.

Population-based cohort study of hospital delivery volume, geographic accessibility, and obstetric outcomes.

To determine associations between geographic accessibility, delivery volume, and obstetric outcomes. Population-based cohort study of linked hospital administrative, census, and geospatial data (2006-2009) from all Canadian jurisdictions except Quebec. Perinatal mortality and major maternal morbidity/mortality were compared across categories of road distance and hospital delivery volume. Among 820761 mothers delivering 827504 neonates, travel distance had minimal effect on perinatal mortality. Compared with mothers travelling 0-9km, the odds of adverse maternal outcomes was decreased for women travelling modest distances (20-49km, odds ratio, 0.80 [95% confidence interval, 0.75-0.86]), and increased thereafter (50-99km, 0.99 [0.89-1.10]; 200-299km, 1.44 [1.10-1.87]; >400km, 2.22 [1.06-4.63]). Relative to high-volume hospitals (>2500 deliveries/year), adverse maternal outcomes were less likely for hospitals with 1000-2499 (0.90 [0.86-0.95]), and roughly equivalent for hospitals with 200-499 (1.34 [1.22-1.48]) and 500-999 (1.27 [1.17-1.39]) deliveries/year. Odds of perinatal mortality ranged from 1.04 (0.73-1.49; 100-199 deliveries/year) to 1.50 (1.04-2.16; 50-99 deliveries/year); the pattern did not suggest causality. Maternal outcomes worsen when travel distance is greater than 200 km, and improve when delivery volume exceeds 1000 deliveries per year.

Implementing physiotherapy services into fistula care at Panzi Hospital, Bukavu, DRC

Aims: To describe implementation of physiotherapy services in the context of fistula care and report early program observations.&#x0D; Methods: Process evaluation of treatment pathway/protocol implementation and presentation of provider observations of treatment results since January 2016.&#x0D; Results: Dedicated physician, nursing, social work and physiotherapy staff provide various aspects of rehabilitative care to women with fistula, pre- and post-operatively. Following variations in hospital census, 5-50 women participate in group exercise sessions 2-3x/week. Targeted individual physiotherapy is selectively provided to 1-15 women 1-5x/week. Staffing priorities reflect perceived importance and impact of physiotherapy services. Providers offer clinical observations of program successes, including improved post-surgical functional outcomes, and express interest in further training to cultivate advanced clinical skills.&#x0D; Conclusions: Early results indicate value of physiotherapy-informed care in a comprehensive approach to fistula care services. Improving and expanding upon these skills may prove equally useful in addressing the physical impairments associated with other reproductive morbidities, such as POP. In the future, systematic use of standardized tools, such as WHODAS 2.0 is recommended, both to quantify the burden of disability in this population, as well as to measure change with therapeutic interventions, including surgery and rehabilitation.

Maternity care hospital trends in providing postdischarge breastfeeding supports to new mothers-United States, 2007-2015.

Hospitals that provide maternity care can play an important role in providing or directing mothers to postdischarge breastfeeding support, which improves breastfeeding duration especially when providing multiple support modes. This study described 2007-2015 national trends in postdischarge breastfeeding supports among United States maternity care hospitals. Data were from the Maternity Practices in Infant Nutrition and Care survey, a biennial census of maternity care hospitals in the United States and territories. Hospitals reported whether they provided nine support types, which we categorized into three support modes: physical contact (eg, return visits), active reaching out (eg, telephone calls), and referrals (eg, to lactation consultants). We calculated prevalence of each support type, each support mode, and providing all three support modes for each survey year and examined trends over 2007-2015. For 2015, we assessed differences by hospital- and area-level characteristics. Prevalence of providing all three support modes increased from 24% (2007) to 31% (2015). Nearly all (99%) hospitals provided referrals in each survey year. Fewer offered physical contact and active reaching out. However, from 2007 to 2015, the prevalence of physical contact increased from 39% to 46%; active reaching out increased from 54% to 64%. In 2015, smaller and rural hospitals were more likely to provide all three discharge supports. Prevalence of offering referrals was high, but there is room for improvement in providing physical contact and active reaching out to ensure multiple modes of support are available to help mothers reach their breastfeeding goals.

Enterovirus D68 Surveillance, St. Louis, Missouri, USA, 2016

A fall 2016 outbreak of enterovirus D68 infection in St. Louis, Missouri, USA, had less effect than a fall 2014 outbreak on hospital census, intensive care unit census, and hospitalization for a diagnosis of respiratory illness. Without ongoing surveillance and specific testing, these cases might have been missed.

In Situ Simulation to Improve Management of In-Hospital Strokes: Unexpected Challenges

BackgroundIn-hospital strokes are life-threatening emergencies that require prompt and skillful treatment to prevent poor patient outcomes. Currently, however, a national gap in care exists for patients who experience an in-hospital stroke. MethodsMultidisciplinary team training programs have been shown to effectively improve health care provider skills for management of emergency situations, and in situ simulation (ISS) has effectively improved individual, team, and organizational learning. ResultsHowever, ISS can be challenging to execute in the actual inpatient environment when hospital census is high. ConclusionThis discussion focuses on the challenges and benefits of ISS mock in-hospital stroke codes, as well as of alternative methods for improving the management of acute in-hospital strokes.

Political cycles in physician employment: A case of Japanese local public hospitals

A shortage of physicians in local public hospitals is often a heated political issue. When local politicians have the authority to intervene in the management of a public hospital, they may increase the employment of physicians during election years in order to alleviate the shortage. We test this hypothesis empirically using a census of city hospitals in Japan from 2002 to 2011 (N = 4583). Our results support the hypothesis that the number of physicians increases in election years. This effect is stronger in cities with a greater population of elderly residents. We also find that physicians tend to come from university hospitals in the same region. Overall, this paper provides direct evidence of political intervention on physician employment.

233 The Use of High-Fidelity Simulation to Identify Potential Protocol Violations and Latent Risk Threats During Standardized Protocol Training in a Large, Multicenter Study

High-fidelity simulation (HF-SIM) has been used extensively in medical education and quality improvement; however, its role in protocol training for large clinical research trials is not well described. We sought to utilize HF-SIM for protocol training for a large multicenter clinical trial in order to standardize training and identify potential protocol violations (PPVs) or study-related latent risk threats (LRTs) prior to enrolling patients in the Hyperbaric Oxygen Brain Injury Treatment (HOBIT) Trial. LRTs are elements of the health care system that make patient care errors more likely. In addition to having over a dozen study sites, the enrollment and treatment protocols for the HOBIT trial are complex, including interdisciplinary critical care transfers between multiple units and patient care areas. This makes a standardized approach to protocol training critical to success. This was a feasibility study of the use of HF-SIM for standardized protocol training in a large, multicenter study. Prior to onboarding individual study sites, 4 HF-SIM patient care scenarios were developed and run in active patient care areas at the primary study site. The scenarios included: 1) a standard, uncomplicated enrollment process with patient transport through all clinical areas, 2) a ventilator circuit kinking during transport requiring troubleshooting, 3) a pneumothorax during HBO therapy requiring urgent decompression, and 4) a ventilator disconnection during HBO therapy, requiring emergent decompression. The scenarios were thought to represent conditions most likely to result in PPVs or LRTs. After each scenario, PPVs and LRTs discovered during the scenario were documented. The primary site’s HF-SIMs were video recorded as examples, and all other participating sites were required to watch the scenarios and reproduce 2 HF-SIM cases at their individual institutions, including one uncomplicated enrollment case and one complication case. Individual sites were required to submit a recorded video of their simulations and a tracking document that listed any PPVs or LRTs discovered, along with potential solutions, in order to determine site readiness for active enrollment of patients. The PPVs and LRTs discovered were coded by 2 independent raters. Items lacking initial agreement were discussed and subsequently agreed upon. Use of HF-SIM was feasible for protocol training at the initial 2 study sites, as both had in-house simulation centers. One center was forced to run a portion of their scenario in the simulation center instead of the ICU due to hospital census, but was able to run the remainder of their HF-SIMs in patient care areas. No other financial or logistical barriers were reported. Aggregate data from these sites reveals that 34 unique PPVs or LRTs were discovered. Themes included: need for additional medical training n=7 (20.6%), protocol clarifications n=4 (11.8%), equipment issues n=8 (23.5%), and systems issues n=15 (44.1%). Some issues were found in multiple care areas, but only included once in the analysis. HF-SIM can be used as part of a standardized protocol training program for clinical trials. The use of HF-SIM identified multiple training and process deficiencies prior to enrolling patients, and could lead to decreased protocol violations as well as decreased patient safety threats during the actual study period.