Inappropriate Hospital Research Articles

Polypharmacy and associated factors in the older population in Germany: Results Gesundheit 65+ study

Abstract Background Polypharmacy, the use of 5 or more medications simultaneously, favors the risk of adverse drug events, drug interactions, potentially inappropriate medication (PIM), hospitalizations, falls, frailty, and mortality. This analysis presents the prevalence of polypharmacy and associated factors in people aged 66+ years living in Germany. Methods Data from the nationally representative Study on Health of Older People in Germany (Gesundheit 65+) conducted between 2021-2023 by the Robert Koch Institute, was analyzed. All medicines used, prescribed and over-the-counter, in the 7 days before the interview were documented and classified into anatomical therapeutic chemical codes. Weighted prevalences and associated factors for polypharmacy are presented. Results 96% of the sample (N = 1,474) took at least 1 medication in the 7 days before the interview. Of these, 39% took up to 4 medications, 39% 5-9 and 22% 10+. The overall prevalence of polypharmacy was 61% (95%CI 58-65%) and was significantly higher in women (64%) than in men (59%). Polypharmacy increased with age, from 52% in the age group 66-74 (53% in men, 51% in women), 66% in the age group 75-84 (63% in men, 69% in women) to 81% in the age group 85 + (72% in men, 86% in women). People with low educational level had a polypharmacy prevalence of 63% (58% in men, 66% in women) compared to 56% (55% in men, 58% in women) in those with high educational level. Severe difficulties in organizing daily medication intake were reported in 1% of people taking up to 4 medicines, in 4% of people taking between 5-9 medicines and in 16% of people taking 10+. The prevalence of PIM increased with the number of medicines used: 13% in 1-4 medicines, 31% in 5-9 medicines, and 53% in 10+ medicines. Conclusions Polypharmacy was more frequent in women, older age groups and in people with low educational level. It was associated with increased difficulty in organizing medication intake and with PIM use. Key messages • Polypharmacy is very common, affecting more women, older age groups, people with a low educational level and is associated with PIM use. • Strategies to promote appropriate medication use are needed.

Beyond telehealth in heart failure, how a nurse-led mobile team unit improves management and reduces re-admission in elderly patients living in a rural area

Abstract Introduction Telehealth plays a crucial role in improving access to healthcare for elderly patients with heart failure (HF), particularly those who live in under-resourced geographic areas, have physical disabilities, or have difficulties with transportation. However, extending and improving telehealth faces significant obstacles, primarily due to its inadequacy to fully assess a patient's clinical status. While some components of HF can be measured remotely, others, such as cardiac and lung examinations, require in-person clinical evaluation. This leads to imprecise assessments of HF severity, excessive medical consultations, and inappropriate emergency transfers or hospitalization. We conducted an evaluation of a specialized mobile team unit (MTU) for HF care in a rural area. The team consisted of nurses trained in performing electrocardiograms (ECGs) and point-of-care ultrasound (POCUS) to extend telemonitoring services to elderly patients with HF in the comfort of their homes. This approach offers a direct and optimal evaluation of the patient's condition. Purpose This study aimed to evaluate the added value of an MTU in assessing and optimizing treatment for HF in elderly patients, ultimately leading to decreased hospitalization or medical request rates. Materials and methods This retrospective analysis examined data from elderly patients diagnosed with HF, who participated in a 6-month telemonitoring program, and received MTU visits. MTU was activated by the telemonitoring team, in patients presenting signs of decompensation, with an imprecise assessment of severity based on digital data only. Results During six months, 165 elderly patients were included in the telemonitoring platform after index HF hospitalization. The mobile team traveled over 3,040 kilometers in a rural area with limited cardiological care. They visited 84 patients (50.9%), offering personalized education and physical assessments to all of the patients, 45% received additional imaging (EKG, POCUS). This resulted in 30% therapeutic adjustments, 90% fewer General practitioner (GP) /Cardiologist consultations and 54% avoided readmissions: 20% of hospitalizations were avoided immediately and 34% likely avoided in the near future, demonstrating the intervention's 80% effectiveness. Conclusion Monitoring heart failure (HF) in elderly patients can be challenging, especially in rural areas with limited access to care, few caregivers, cognitive impairments, or difficulty using e-health platforms. This study emphasizes the benefits of a nurse-led mobile team unit in providing a reliable direct assessment of HF severity. This home intervention provides education, strengthens the decision-making capacity of the remote monitoring platform, assists with patient management, and significantly reduces the readmission rate.

Tularemia in Pediatric Patients: A Case Series and Review of the Literature.

Unfamiliar to pediatricians, tularemia can lead to delays in diagnosis and hinder appropriate treatment, as its clinical presentation often shares similarities with other more prevalent causes of lymphadenopathy diseases in children. We conducted a comprehensive literature review to offer contemporary insights into the clinical manifestations and treatment strategies for tularemia infection in children. Three cases of glandular tularemia were diagnosed in the Pediatric Robert Debré Hospital (Paris) between October 2020 and February 2022. In addition, we conducted a literature search using PubMed in December 2023 of cases of tularemia in children published in English. The 94 cases of the literature review highlight the large age range (from 6 weeks to 17 years) and multiple sources of infection, including diverse zoonotic transmission (86.7%) and contact with contaminated water (13.3%). Fever was a consistent symptom. Ulceroglandular (46.7%), glandular (17%) and oropharyngeal forms (18.1%) predominated. The most frequently used diagnostic method was serology (60.6%). The median time to diagnosis for tularemia was 23.5 days. Hospitalization was required in 63.2% of cases, with a median duration of 4 days. Targeted treatment was based on aminoglycosides (37.6%), fluoroquinolones (30.6%) or tetracyclines (12.9%), in accordance with WHO recommendations, with a mainly favorable outcome, although several cases of meningitis were observed. Pediatricians should be aware of the etiology of this febrile lymphadenopathy, notably when experiencing beta-lactam treatment failure, even in young infants, which could help reduce the extra costs associated with inappropriate antibiotic use and hospitalization.

Environmental and Human Health Problems Associated with Hospital Wastewater Management in Zimbabwe.

Wastewater is a term used to describe water that has undergone degradation in quality owing to anthropogenic activities or natural processes. Wastewater encompasses liquid waste originating from academic institutions, households, agricultural sector, industries, mines and hospitals. Hospital wastewater contains potentially hazardous substances including residues of pharmaceuticals, radioisotopes, detergents and pathogens, with detrimental impacts to the environment and human health. Nevertheless, studies related to hospital waste management are limited in Africa, particularly in Southern Africa. This research offers an overview of aspects surrounding hospital wastewater in Southern Africa, focusing on Zimbabwe. Already published and grey literature was reviewed to compile the paper. Number of patients, nature of medical services offered and hospital size influences generation of hospital wastewater. Partially and non-treated hospital wastewater is managed together with municipal wastewater. Management of hospital wastewater is impeded by shortage of resources, lack of co-ordination among responsible authorities and ineffective legal framework enforcement, among other challenges. Inappropriate hospital wastewater management results in environmental contamination, causing human ailments. Attainment of sustainable hospital wastewater management requires clearly defined and enforced legislation, collaboration of accountable stakeholders, sufficient resources and enhanced awareness of involved stakeholders. Application of technologies that uphold recycling and reuse of wastewater is essential to reach Sustainable Development Goals, Zimbabwe Vision 2030 and National Development Strategy 1 targets, particularly those dealing with environmental protection while upholding human health.

A new organizational model of primary healthcare in Liguria, Italy. Insights and implications.

After years of cost-containment policies, the Italian National Health Service (NHS) has now the chance to change and improve, especially thanks to the National Recovery and Resilience Plan (NRRP). The plan serves as a catalyst for reform, allocating substantial funds to reinforce proximity networks, facilities, and telemedicine for territorial healthcare. Mission 6, specifically dedicated to health, focuses on integrating primary healthcare, hospital, and specialty care networks, underscoring the importance of a robust primary healthcare system. In alignment with NRRP objectives, the Ligurian model introduces innovative structures, such as Community Houses (CdCs), Community Hospitals (OdCs), and Territorial Operation Centres (COTs). These interconnected components form a dynamic network designed to enhance healthcare accessibility, prevent inappropriate hospital admissions, and facilitate efficient patient transitions. The model prioritizes multidisciplinary collaboration, community engagement, and the integration of socio-healthcare services. Despite substantial NRRP funding for infrastructure, challenges related to staffing and human resources persist. The social and epidemiological context highlights concern about the economic feasibility of the reform, potential workforce shortages, and the imperative for updated regulatory frameworks. The strategic reallocation of personnel from acute hospitals to new facilities is crucial, requiring meticulous workforce planning, role definitions, and trainingIn conclusion, the Ligurian model emerges as a proactive response to the structural vulnerabilities exposed by the pandemic, aligning with international trends in emphasizing primary care, prevention, and community-based services.

999 telephone triage: a comparison of UK ambulance nurse and paramedic case mix, outcomes and audit compliance

PurposeMost UK ambulance services undertake remote assessments of 999 calls with nurses and paramedics to manage demand and reduce inappropriate hospital admissions. However, little is known about the differences in the types of cases managed by the two professions comparatively, their clinical outcomes, and the quality and safety they offer.Design/methodology/approachThe retrospective descriptive study analysed data collected at Welsh Ambulance Services University NHS Trust (WAST) from prioritisation, triage, and audit tools between the 17th May 2022 to 8th November 2022. A total of 21,076 cases and 728 audits were included for review.FindingsThere was little difference in the type and frequency of the presenting complaints assessed, and clinical outcomes reached in percentage terms. Whilst paramedics had more highly compliant call audits and fewer non-compliant call audits, there was, again, little difference in percentage terms between the two, indicating positive levels of safety across the two professional groups.Research limitations/implicationsThere continues to be a substantial difference between UK paramedics to those in the Middle East, the United States, and some African nations, which may limit the applicability of findings. This study also looked at a six-month window from only one UK service using one type of prioritisation and triage tool. Future research could explore longer periods from multiple services using various tools. It is important to note that this study did not link outcome data with primary, secondary or tertiary care settings. Thus, it is impossible to determine if the level of care aligned closely with the final diagnosis.Practical implicationsThe practical implications of this work include better workforce planning for agencies who have perhaps only employed one type of clinician or a reaffirmation to those who have employed both. The authors suggest that the training and education of both sets of clinicians could remain general in nature, with no overt requirement for specificity based on professional registration alone. Commissioners and stakeholders in the wider health economy should consider ensuring equitable access to alternative pathways for patients assessed by both nurses and paramedics.Social implicationsIt has been posited that UK nurses and paramedics are, by virtue of their consistency in education, skill set, licensure, and general experience, both able to achieve safe and effective remote outcomes in 999 settings. This study provides evidence to support that hypothesis. These results say more about the two professions' ability to work together rather than just the professions themselves. The multidisciplinary team approach is well-established in acute care settings, and is broadly considered to improve communication, coordination decision making, adherence to up-to-date treatment recommendations, and be positive for shared learning and development for younger colleagues.Originality/valueMost UK services use a mix of nurses and paramedics; however, little is known about the differences in the types of cases managed by the two professions comparatively, their clinical outcomes, and the quality and safety they each offer. The most recent studies of this nature were published in 2003 and 2004 and looked only at low-acuity 999 calls when remote assessment was not even an established role for UK paramedics. This study updates the literature, identifies areas for future research, and applies to the international setting for the most part.

Solid waste characteristics and management strategies at ST Theresa (STT) and Holy Cross (HC) hospitals in Chirumanzu rural District, Zimbabwe

AbstractManagement of solid waste from rural hospitals is among major problems affecting developing countries. This is mostly attributed to inadequate data related to quantity and quality of hospital solid waste. Similarly, information related to rural hospital solid waste characteristics and management is limited in Zimbabwe. However, SDGs complemented by Zimbabwe Vision 2030, NDS 1 advocates for sustainable solid waste management. Hence, enough data related to characteristics of solid waste from rural hospitals are required to attain sustainability. This research focuses on hospital solid waste characteristics and management strategies at STT and HC rural hospitals. Descriptive cross sectional research design which triangulates qualitative and quantitative paradigms was utilized. Interviews, observations, questionnaires were used to collect data. Quantitative data were analyzed using Statistical Package for Social Sciences whereas qualitative data were subjected to content analysis. Solid waste generated at STT encompasses non-hazardous (77.35%), hazardous waste (22.65%). At HC solid waste consists of non-hazardous (79%) and hazardous waste (21%). Respondents at STT (70.4%) and HC (72.7%) noted that solid waste was increasing. Solid waste was increasing due to various factors namely high use of disposable materials at HC (35.1%), STT (42.5%) and increase of patients at HC (30%) and STT (29.7%). Solid waste was indiscriminately stored in various types of containers although pedal operated bins and sharp containers were highly used at STT (72.4%) and HC (69.1%). Waste receptacles were transported to disposal sites using wheelbarrows and manual handling. Open pits and burning were among disposal strategies but incineration was regarded as the golden approach at STT (44.8%) and HC (41.8%). Inappropriate hospital solid waste management was due to shortage of finance at STT (38.1%) and HC (30.9%) and unawareness among health workers. Although it was worsened by lack of all stakeholder participation at STT (79.0%) and HC (76.4%). Consequently, the study recommended application of strategies which support circular economy, integrated approach, raising awareness of health workers and provision of enough resources to rural hospitals.

Reduction of hospital length of stay through the implementation of SAFER patient flow bundle and Red2Green days tool: a pre–post study

BackgroundIn 2018, the National Health System released the ‘Guide to reducing long hospital stays’ to stimulate improvement and decrease length of stay (LOS) in England hospitals. The SAFER patient flow...

Using machine learning or deep learning models in a hospital setting to detect inappropriate prescriptions: a systematic review

ObjectivesThe emergence of artificial intelligence (AI) is catching the interest of hospital pharmacists. A massive collection of health data is now available to train AI models and hold the promise...

The PRO-HOME Project. A multicomponent intervention for the protected discharge from the hospital of multimorbid and polytreated older individuals by using innovative technologies: A pilot study.

Discharge planning from the hospital of frail older patients is an important step to avoid inappropriate long-stay hospitalizations and to prevent the risks related to the prolonged hospitalization. In this frame, we developed an experimental trial-'PRO-HOME', a multicomponent programme of interventions for multimorbid and polytreated hospitalized older patients. The main aim of the study was to develop a protected discharge facility using a mini apartment equipped with advanced architectural and technological components to reduce the length of hospital stay of older participants (aged 65+ years old) admitted to the hospital for an acute event, deemed stable and dischargeable. This is a pilot randomized controlled study, comparing 30 hospitalized participants included in a multidimensional, transitional care programme based on information and communication technologies to 30 patients in standard usual care until hospital discharge. We presented the study design of the PRO-HOME programme, including architectural and technological components, the enrolment procedures, the components of the intervention that is physical activity, cognitive training and life-style education and the evaluation method of the intervention based on the Comprehensive Geriatric Assessment to explore the changes in the individual domains that are target of the multicomponent intervention. The final results will suggest whether the PRO-HOME programme represents a useful and feasible intervention to reduce the length of hospital stay of multimorbid and polytreated hospitalized older patients and improve their physical and cognitive performances and overall quality of life. Due to the characteristics of the population of interest of the PRO-HOME study, we involved in the study design and programme of the activities the participants enrolled in a previous smart home-based project named MoDiPro carried-out during a 3-year period. The elderly participants from the local population involved were asked, by means of focus groups, for feedback on their experience in MoDiPro, and their suggestions were integrated into the design phase of the current PRO-HOME project. The focus groups included open group interviews with a qualitative collection of the patients' feedback so that the participants could interact with each other.

Territorial Coordination Centres and Telenursing: innovation and digitalisation of home care in Italy

Abstract Issue After Covid-19, Italy approved the National Recovery and Resilience Plan (NRRP) to boost public health, sustainability and digital innovation, which promotes ecological and digital transition reforms. The strategic health reform redesigned territorial healthcare network by introducing new models of proactive care, as Territorial Coordination Centres (TCCs) and Telenursing. Description of the problem TCC is an innovative organisational model, that coordinates taking care by linking services and professionals involved in different care settings. In TCCs are involved nursing staff, that performs a telemedicine service called Telenursing, a way of delivering nursing care directly to the patient's home, through digital health tools. How will TCCs be implemented, using NRRP funds? How will Telenursing impact on home care? Results By 2024, 600 TCCs are planned to be implemented and fully operational, across the Country, financed by NRRP (280 bln €). The standard set by the NRRP reform is 1 TCC each 100,000 inhabitants, with 4-6 primary nurses involved (2,400-3,600 nationally). TCCs are organised to be interconnected with every healthcare network setting, including home care. Telenursing, within the TCCs, aims to guarantee proactive, personalised and proximity care, enhancing the home as a privileged place of care. Nurses of TCCs perform health monitoring, assessment, promotion, prevention and education by Telenursing, in order to reduce inappropriate hospital admissions and to increase patient satisfaction, safety and empowerment. By 2026, at least 200,000 people will be assisted through telemedicine tools, as planned in NRRP reform (funding 1 bln €). Lessons Italy, pursuing better health outcomes for the population, is investing in strengthening public primary care services and digitalization of services. New strategy aims to improve health of population and decrease health inequalities, while reducing geographical variations. Key messages • Telenursing performed by nurses working in TCCs is aimed at improving proactive, personalised and proximity care, supporting patients and caregivers at home. • By 2024, TCCs will be fully operating to guarantee an innovative system of public primary care, that uses digital tools to manage population in home care, reducing inappropriate hospitalization.

86 Meitheal programme (MP) phase 2 supporting the needs of nursing home staff delivering palliative care (PC) to the older person

Abstract Background There was a need identified within residential settings to build staff awareness of palliative care, to improve PC provision and to reduce inappropriate hospital transfers of residents. Acknowledging the absence of training undertaken in palliative care, the MP was designed to facilitate and support staff to integrate an early PC approach. This is undertaken by the Meitheal Clinical Nurse Specialist (CNSp) attending the residential setting, facilitating education and clinical support. Methods A structured programme was designed offering flexibility, in recognition of the many demands within a nursing home setting. The Meitheal CNSp facilitates multi-modal interactive education through workshops and support sessions, including live case scenario discussions of residents’ care. Informal clinical support facilitates further learning and integration of person-centred PC to enhance better quality of living. Resources to support and help sustain the programme learning are provided. Results Our current programme was adapted from the results of the Evaluation of the Meitheal Programme Phase 1. This highlighted five main themes: (i) Support, (ii) Teamwork, (iii) Communication, (iv) Knowledge and (v) Quality of life. Participants reported: (i) Strong need for support for all, including bereavement, (ii) Enhanced awareness of importance of teamwork and recognition of roles, (iii) Improved communication with residents and families and less fear of sensitive conversations, (iv) Increased confidence, knowledge and understanding of early palliative care and (v) Greater understanding of appropriate medications and earlier intervention for symptom management. Conclusion The Meitheal Programme is different to other PC programmes, as it provides ‘onsite’ education & ‘on the ground’ clinical support. The Meitheal CNSp is present within the nursing home, enhancing the application of theory to practice in real time with real case scenarios. It is evident that the Meitheal Programme has initiated significant improvements to date. However, there are many challenges to overcome as we continue Phase 2 Meitheal Programme delivery and rolling evaluation.

Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study

BackgroundAll health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were the following: (1) to analyze the association between IHA and the development of subsequent AEs; (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions.MethodsAn observational cross-sectional study was conducted on hospitalized patients in May 2019 in a high-complexity hospital in Madrid, Spain. The Appropriateness Evaluation Protocol was used to measure IHA, and the methodologies of the Harvard Medical Practice Study and the European Point Prevalence Survey of Healthcare-associated Infections were used to detect and characterize AEs. The association between IHA and the subsequent.ResultsA total of 558 patients in the hospital ward were studied. IHA increased the risk of subsequent occurrence of AEs (OR [95% CI]: 3.54 [1.87 to 6.69], versus appropriate) and doubled the mean AEs per patient (coefficient [95% CI]: 0.19 [0.08 to 0.30] increase, versus appropriate) after adjusting for confounders. IHA was a predictive variable of subsequent AEs and the number of AEs per patient. AEs developed after IHA were associated with scheduled admissions (78.9% of AEs, versus 27.9% after appropriate admissions; p < 0.001). Compared with AEs developed after appropriate admissions, AEs after IHA added 2.4 additional days of stay in the intensive care unit and incurred an extra cost of €166,324.9 for the studied sample.ConclusionsPatients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns.

The impact of a point-of-care visual clinical decision support tool on admissions for cellulitis in the University of Maryland medical system.

Cellulitis is commonly diagnosed in emergency departments (EDs), yet roughly one third of ED patients admitted for presumed cellulitis have another, usually benign, condition instead (eg, stasis dermatitis). This suggests there is an opportunity to reduce health care resource use through improved diagnosis at the point of care. This study seeks to test whether a clinical decision support (CDS) tool interoperable with the electronic medical record (EMR) can reduce inappropriate hospital admissions and drive more appropriate and accurate care. This study was a trial of an EMR-interoperable, image-based CDS tool for evaluation of ED patients with suspected cellulitis. At the point of assigning a provisional diagnosis of cellulitis in the EMR, the clinician was randomly prompted to use the CDS. Based on the patient features entered into the CDS by the clinician, the CDS provided the clinician a list of likely diagnoses. The following were recorded: patient demographics, disposition and final diagnosis of patients, and whether antibiotics were prescribed. Logistic regression methods were used to determine the impact of CDS engagement on our primary outcome of admission for cellulitis, adjusted for patient factors. Antibiotic use was a secondary end point. From September 2019 to February 2020 (or 7 months), the CDS tool was deployed in the EMR at 4 major hospitals in the University of Maryland Medical System. There were 1269 encounters for cellulitis during the study period. The engagement with the CDS was low (24.1%, 95/394), but engagement was associated with an absolute reduction in admissions (7.1%, p=0.03). After adjusting for age greater than 65 years, female sex, non-White race, and private insurance, CDS engagement was associated with a significant reduction of admissions (adjusted OR=0.62, 95% confidence interval (CI): 0.40-0.97, p=0.04) and antibiotic use (Adjusted OR=0.63, 95% CI: 0.40-0.99, p=0.04). CDS engagement was associated with decreased admissions for cellulitis and decreased antibiotic use in this study, despite low levels of CDS engagement. Further research should examine the impact of CDS engagement in other practice environments and measure longer-term outcomes in patients discharged from the ED.

Level of Care Appropriateness in VA Inpatient Surgery Cases.

Within the Veterans Health Administration, utilization management (UM) focuses on reducing unnecessary or inappropriate hospitalizations by applying evidence-based criteria to evaluate whether the patient is placed in the right level of care. This study examined inpatient surgery cases to classify reasons for not meeting criteria and to identify the appropriate level of care for admissions and subsequent bed days of care. There were 129 VA Medical Centers in which inpatient UM reviews were performed during that time, of which 109 facilities had UM reviews conducted in Surgery Service. All admissions to surgery service during fiscal year 2019 (October 1, 2018 to September 30, 2019) that had a UM review entered in the national database were extracted, including current level of care, recommended level of care, and reasons for not meeting criteria. The following demographic and diagnostic fields were supplemented from a national data warehouse: age, gender, marital status, race, ethnicity, and service connection status. Data were analyzed with descriptive statistics. Characteristics of patient demographics were compared using the χ2 test for categorical variables and the Student's t test. A total of 363,963 reviews met conditions to be included in the study: 87,755 surgical admission reviews and 276,208 continued stay reviews. There were 71,274 admission reviews (81.22%) and 198,521 (71.87%) continued stay reviews that met the InterQual criteria. The primary reason for not meeting admission criteria was clinical variance (27.70%), followed by inappropriate level of care (26.85%). The leading reason for not meeting continued stay criteria was inappropriate level of care (27.81%), followed by clinical instability (25.67%). Of the admission reviews not meeting admission criteria, 64.89% were in the wrong level of care and 64.05% of continued stay reviews were also in the wrong level of care. Half of the admission reviews not meeting criteria had a recommended level of care as home/outpatient (43.51%), whereas nearly one-third (28.81%) continued stay reviews showed a recommended level of care of custodial care or skilled nursing. This study identified system inefficiencies through admission and continued stay reviews of surgical inpatients. Patients admitted for ambulatory surgery or for preoperative testing prior to day of surgery resulted in avoidable bed days of care that may have contributed to patient flow issues and limited the available hospital beds for other patients. Through early collaboration with case management and care coordination professionals, alternatives can be explored that safely address the patient needs, such as temporary lodging options. There may be conditions or complications that can be anticipated on the basis of patient history. Proactive efforts to address these conditions may help avoid unnecessary bed days and extended lengths of stay.

Estrategias para mejorar el flujo de ingresos y estancias hospitalarias: adaptación del cuestionario Appropriateness Evaluation Protocol (AEP): estudio Delphi

Introduction and aimThe Appropriateness Evaluation Protocol (AEP) tool analyzes inappropriate hospital stays and admissions. This study aimed to adapt the AEP questionnaire in order to analyze the appropriateness of hospital admissions and stays in our healthcare reality. MethodsA study was conducted using the Delphi method in which 15 experts in clinical management and hospital care participated. The initial questionnaire items were taken from the first version of the AEP. In the first round, the participants contributed new items that they considered relevant in our current reality. In rounds 2 and 3, they evaluated 80 items according to their relevance using a Likert scale from 1 to 4 (maximum usefulness). Pursuant to the study's design, AEP items were considered adequate if the mean score according to the experts’ evaluation was greater than or equal to 3. ResultsThe participants defined a total of 19 new items. In the end, 47 items earned a mean score greater than or equal to 3. The resulting modified questionnaire include 17 items in “Reasons for Appropriate Admissions”, 5 in “Reasons for Inappropriate Admissions”, 15 in “Reasons for Appropriate Hospital Stays”, and 10 in “Reasons for Inappropriate Hospital Stays”. ConclusionsThe identification according to expert opinion of priority items to determine the appropriateness of admissions and extended stays could be used in the future to help create an instrument to be used in our setting.

Strategies to improve the flow of admissions and hospital stays: a Delphi study of an adaptation of the Appropriateness Evaluation Protocol (AEP)

Introduction and aimThe Appropriateness Evaluation Protocol (AEP) tool analyzes inappropriate hospital stays and admissions. This study aimed to adapt the AEP questionnaire in order to analyse the appropriateness of hospital admissions and stays in our healthcare reality. MethodsA study was conducted using the Delphi method in which 15 experts in clinical management and hospital care participated. The initial questionnaire items were taken from the first version of the AEP. In the first round, the participants contributed new items that they considered relevant in our current reality. In rounds 2 and 3, they evaluated 80 items according to their relevance using a Likert scale from 1 to 4 (maximum usefulness). Pursuant to the study’s design, AEP items were considered adequate if the mean score according to the experts’ evaluation was greater than or equal to 3. ResultsThe participants defined a total of 19 new items. In the end, 47 items earned a mean score greater than or equal to 3. The resulting modified questionnaire include 17 items in “Reasons for Appropriate Admissions,” 5 in “Reasons for Inappropriate Admissions,” 15 in “Reasons for Appropriate Hospital Stays,” and 10 in “Reasons for Inappropriate Hospital Stays.” ConclusionsThe identification according to expert opinion of priority items to determine the appropriateness of admissions and extended stays could be used in the future to help create an instrument to be used in our setting.

Prediction of inappropriate pre-hospital transfer of patients with suspected cardiovascular emergency diseases using machine learning: a retrospective observational study

BackgroundThis study aimed to develop a prediction model for transferring patients to an inappropriate hospital for suspected cardiovascular emergency diseases at the pre-hospital stage, using variables obtained from an integrated nationwide dataset, and to assess the performance of this model.MethodsWe integrated three nationwide datasets and developed a two-step prediction model utilizing a machine learning algorithm. Ninety-eight clinical characteristics of patients identified at the pre-hospital stage and 13 hospital components were used as input data for the model. The primary endpoint of the model was the prediction of transfer to an inappropriate hospital.ResultsA total of 94,256 transferred patients in the public pre-hospital care system matched the National Emergency Department Information System data of patients with a pre-hospital cardiovascular registry created in South Korea between July 2017 and December 2018. Of these, 1,770 (6.26%) patients failed to be transferred to a capable hospital. The area under the receiver operating characteristic curve of the final predictive model was 0.813 (0.800–0.825), and the area under the receiver precision-recall curve was 0.286 (0.265–0.308).ConclusionsOur prediction model used machine learning to show favorable performance in transferring patients with suspected cardiovascular disease to a capable hospital. For our results to lead to changes in the pre-hospital care system, a digital platform for sharing real-time information should be developed.

Geographic disparities in the care and outcomes in adult chronic immune thrombocytopenia

IntroductionDespite expert-based recommendations, real-world adherence to immune thrombocytopenia (ITP) guidelines is unclear. The impact of geographic and socioeconomic disparities on the quality of care and outcomes is unknown. We sought to determine the association between geographic remoteness and material deprivation on ITP care and outcomes. MethodsWe conducted a multi-centre retrospective cohort study of adults with chronic ITP requiring a second-line therapy between 2012 and 2019 in the province of Alberta, Canada. Socioeconomic status was measured using the Pampalon material deprivation index quintiles. Geographic disparities were assessed by the driving distance to a major centre, with geographic remoteness defined as >200 km from major centre. We examined the impact of geographic and material deprivation on quality of care, resource utilization (hospitalizations, transfusions), and outcomes (major bleeding, all-cause mortality and ITP-related mortality). Cox proportional hazards models were used to examine the impact of geographic remoteness, rural residence and material deprivation on overall survival and ITP-related survival. ResultsWe included 326 ITP patients, median age of ITP diagnosis was 57 years, 182 (56 %) were female. Most patients (58 %) lived within 20 km of a major centre, whereas 49 (15 %) lived in a geographically remote area (>200 km). Geographic remoteness was significantly associated with material deprivation and lower likelihood of management by hematologists (84 % vs 99 %, P = 0.0001). It was also associated with lower rates of hepatitis C (71 % vs 89 %, P = 0.005) and hepatitis B testing (69 % vs 86 %, P = 0.03), and a non-significant trend towards lower rates of HIV testing (73 % vs 83 %, P = 0.051) compared with those <20 km from a major centre. Incomplete hyposplenic vaccinations among splenectomized patients (52 %), early splenectomy within 12 months of ITP diagnosis (35 %), inappropriate platelet transfusions (41 %), and inappropriate hospitalizations for asymptomatic thrombocytopenia (16 %) were common regardless of geographic distribution. There were 28 (9 %) ITP-related deaths (major bleeding or infections), most occurred within the first year of ITP diagnosis. Material deprivation, but not geographic remoteness, was an independent predictor of all-cause mortality (aHR 1.9, 95 % CI 1.1–3.3 in the most deprived quintile vs least deprived quintile). Rural residence trended towards increased hazard of ITP-related deaths (aHR 1.7, 95 % CI 0.9–3.2). ConclusionWe demonstrated substantial deviations of ITP care from consensus guidelines, and geographic disparities in access to care and diagnostic workup. Future quality improvement initiatives are critical to improve the quality of care and reduce inequities.

Uptake of pharmacist recommendations by patients after discharge: Implementation study of a patient-centered medicines review service

BackgroundPolypharmacy and potentially inappropriate medicine use is common in older people, resulting in harm increased by lack of patient-centred care. Hospital clinical pharmacy services may reduce such harm, particularly prevalent at transitions of care. An implementation program to achieve such services can be a complex long-term process.ObjectivesTo describe an implementation program and discuss its application in the development of a patient-centred discharge medicine review service; to assess service impact on older patients and their caregivers.MethodAn implementation program was begun in 2006. To assess program effectiveness, 100 patients were recruited for follow-up after discharge from a private hospital between July 2019 and March 2020. There were no exclusion criteria other than age less than 65 years. Medicine review and education were provided for each patient/caregiver by a clinical pharmacist, including recommendations for future management, written in lay language. Patients were asked to consult their general practitioner to discuss those recommendations important to them. Patients were followed-up after discharge.ResultsOf 368 recommendations made, 351 (95%) were actioned by patients, resulting in 284 (77% of those actioned) being implemented, and 206 regularly taken medicines (19.7 % of all regular medicines) deprescribed. ConclusionImplementation of a patient-centred medicine review discharge service resulted in patient-reported reduction in potentially inappropriate medicine use and hospital funding of this service. This study was registered retrospectively on 12th July 2022 with the ISRCTN registry, ISRCTN21156862, https://www.isrctn.com/ISRCTN21156862.