Intensive Services Research Articles

Learning From Existing Services: Developing an Intensive Outpatient Services for Children and Adolescents With Eating Disorders

AimsGain an insight into learnings/pitfalls that existing services have met whilst setting up/running intensive outpatient pathways/ services (IOS).Methods4 Focus Groups (FGs) were conducted virtually through MS Teams from December 2022- January 2023 of duration 90 minutes each for health professionals involved in a leadership role in IOS pathways across England. The FGs were recorded with participant consent, transcribed and analysed with an inductive approach for thematic analysis.Results4 main themes emerged including (i) patient and (ii) team considerations, (iii) approach and (iv) commissioning. A key sub-theme emphasised the importance of flexible and creative approaches in IOS to supplement existing evidence base therapies as well as the importance of a well-rounded MDT approach with good communication across the board. Key set-ups include: enhanced outpatient offers, home treatments, in-reach, and hybrid.ConclusionIntensive outpatient services for EDs allows an enhanced community offer that is needs led and flexible and individualised approach.

Proportion and prognosis of ICU-admitted coronavirus disease 2019-infected patients in relation to all hospitalized cases in Abbasia Chest Hospital, Cairo

Abstract Background Because of the outbreak of coronavirus disease 2019 (COVID-19), there has been an increase in the demand for intensive care services all over the world. Severe cases fulfill one of the following criteria: respiratory rate more than 30/min, oxygen saturation less than or equal to 93%, and PaO2/FiO2 less than or equal to 300 mmHg. ICU admission is required for seriously ill patients who require high-flow nasal cannula, intubation, or more oxygen to treat hypoxemia or multiple organ dysfunctions. However, it is unclear whether patients with COVID-19 who are admitted to the ICU will survive. Aim To estimate the proportion and prognosis of ICU-admitted COVID cases in relation to whole COVID cases admitted at Abbassia Chest Hospital and estimation of risk factors responsible for mortality. Patients and methods This retrospective observational study was conducted on all cases of COVID-19-infected patients admitted at respiratory ICU of Abbassia Chest Hospital in relation to all hospitalized cases during the period between January 2021 and June 2021. All of the cases were subjected to full history taking, laboratory investigations, and radiological assessment with chest radiograph and computed tomography. The reported outcomes included weaning from mechanical ventilation, discharge, mortality, and cause of death. Results The study included 76 patients with COVID-19. Overall, 43 (56.6%) were males and 33 (43.4%) were females, with a mean age of 57.17 ± 12.54 years. The incidence of mortality was 32.9%. The acute respiratory distress syndrome (ARDS) was the most common cause for ICU admission and encountered in 57.4% of the cases. All of the dead cases had severe ARDS. The use of invasive mechanical ventilation was reported in 76.5% of the included died cases, and this was statistically significantly higher as compared with the survived group. On the contrary, the length of ICU stay was statistically significantly higher in the survived group. Conclusion COVID-19 infection is associated with a high percentage of ICU admission with a high mortality rate. Many factors are associated with the high risk of mortality among the ICU admitted COVID-19-infected patients including severe ARDS, deterioration of the systemic organ functions, and the utilization of invasive mechanical ventilation.

Delirium related distress experienced by nurses

Background: Delirium is described as a distressful experience by patients and their families. Also, among healthcare staff, nurses caring for patients with delirium are the most at risk of high distress related to this syndrome. Aims: To assess nurses’ distress related to delirium and its specific symptoms and severity. To identify factors nurses’ sociodemographic and psychological characteristics and professional experience, that may be associated to this distress. Methods: A prospective study was carried out with nurses caring older adults with delirium in Intensive Care Medicine Service. Distress related to delirium, global psychological distress and burnout in nurses were measured with Delirium Experience Questionnaire, Kessler Psychological Distress Scale and Copenhagen Burnout Inventory, respectively. Results: Eighteen nurses were included (mean age=32 years; 89% women). About 46% of the nurses classified the experience of caring for patients in delirium as moderately distressing. Disorientation and psychomotor agitation were the most distressing symptoms. High distress related to delirium was associated with greater personal (p=0.040) and work-related burnout (p=0.020), and more global psychological distress (p=0.007). Conclusion: Caring for patients with delirium is distressing for nurses, particularly if the disorientation and psychomotor agitation are present and if nurses presented high burnout or psychological distress. This study highlights the need for development of education and support strategies for all professionals dealing with these patients.

의료관광 서비스품질에 관한 IPA 분석 연구

Purpose – After breaking the three-year hiatus in medical tourism due to COVID-19, the medical tourism industry is looking forward to reopening. This study conducted an empirical study on the importance and performance of medical tourism service quality to provide implications in accelerating the revitalization of the medical tourism industry. Design/Methodology/Approach – Existing studies related to the service quality of medical tourism have been conducted mainly targeting foreign patients. In order to balance this point of view, 50 medical tourism employees in Bucheon city were set as targets. Then, IPA analysis on medical tourism service quality was conducted. Findings – The medical infrastructure and system, intensive service for foreign patients only, and professional manpower have excellent service quality, and areas to be improved are the foreign patient telemedicine system of the medical system and the foreign language homepage of the service system. In order to revitalize medical tourism, it is necessary to consider priorities in the relevant areas. Research Implications – This study is meaningful as data for comparison with previous studies on medical tourism service quality before COVID-19. In addition, research on service quality for medical tourism employees was conducted to balance the implications of medical tourism research.

Case managers' reflections of a brief case management intervention in Canada.

As demand for intensive case management services continues to outpace supply, community mental health agencies in Toronto, Ontario, introduced Short-Term Case Management (STCM). This study sought to explore case managers' perspectives and experiences with this new service delivery model. Focus groups were conducted with twenty-one case managers, and transcripts analyzed using thematic analysis. Emerging themes suggest that despite embracing a recovery approach, case managers expressed mixed views on the acceptability and appropriateness of this service delivery model as an intervention. The ideal population for this intervention are adults with mental health issues in need of system navigation, and those motivated to address their goals. Further research is needed to establish fidelity criteria.

Strengthening Nutrition Interventions during Antenatal Care Improved Maternal Dietary Diversity and Child Feeding Practices in Urban Bangladesh: Results of a Quasi-Experimental Evaluation Study

BackgroundBangladesh is urbanizing rapidly, facing challenges of malnutrition, low coverage and poor quality of urban nutrition services. ObjectivesWe assessed the effect of integrating maternal, infant, and young child nutrition interventions, delivered at urban Maternal Neonatal and Child Health facilities, on maternal dietary diversity, iron and folic acid (IFA) and calcium consumption, and child feeding practices. MethodsWe used a quasi-experimental design with a nonrandom assignment of 20 health care facilities in Dhaka to intensive and standard service arms. We conducted facility-based observations and community-based surveys at baseline (2020) and endline (2022) (n = 2455 observations and surveys with 1678 pregnant women [PW] or recently delivered women [RDW] at endline). We derived difference-in-difference (DID) estimates, adjusted for characteristics that differed at baseline or endline, and accounted for clustering. ResultsExposure to antenatal care (ANC) was similar in both arms: two-thirds of RDW received ANC during the first trimester and three-fourths received ≥4 ANC checkups. Compared to the standard arm, a higher proportion of PW in the intensive arm received counseling on dietary diversity (DID: 45 percentage points [pp]), and a higher proportion of RDW received IFA (25 pp) and calcium supplementation (19 pp), showed adequate weight gain (44 pp), and recorded appropriate child feeding (27 pp). Improvements were greater in the intensive than the standard arm for the number of food groups consumed (DID: 1.1 food groups) and minimum dietary diversity (23 pp); no effect was observed for IFA and calcium consumption during pregnancy. However, effects were observed for early initiation of (20 pp) and exclusive breastfeeding (45 pp), introduction of solid or semisolid foods (28 pp), and egg and/or flesh food consumption (33 pp) among children. Minimum dietary diversity and acceptable diet remained low in both arms. ConclusionsIntensifying nutrition in government-aligned health care services delivered by experienced nongovernmental organization-run facilities is a feasible model to address the urban health gap, nutrition services coverage, and improve practices.The trial was registered at clinicaltrials.gov as NCT03882268.

The Fono's 'Alert Level 4' Story

During the 1970s and 1980s, Pacific people tended to seek medical care from Accident and Emergency centres only when they were in an acute condition. As a result, Pacific mortality rates were high and Pacific people were unnecessarily suffering with poorer health outcomes. By 1987, a group of Pacific community leaders in Auckland came together and formed The Fono (originally known as Pasifika Health Care), to provide a Pacific community-led health practice and improve access to high quality, culturally appropriate primary care services. By 2020, The Fono had nine sites with four medical clinics, three dental clinics, a vast range of public health and social services, and a trades training academy. Aotearoa New Zealand’s initial Covid-19 Alert Level 4 period was a time of intensive service delivery and significant innovation at The Fono. As a result, incubation projects were catapulted into life, transforming key aspects of the organisation. For The Fono, this transformation occurred on the following timeline: pre-Covid (time before Alert Level 4, before 26/03/2020); Covid (Alert Level 4 period, 26/03/2020–3/05/2020); post-Covid (the time after Alert level 4, 13/05/2020 onwards). This viewpoint outlines the projects that contributed to organisational change at The Fono with the first Covid wave in 2020.

Distinct Clinical Presentations and Outcomes of Hospitalized Adults with the SARS-CoV-2 Infection Occurring during the Omicron Variant Surge.

The COVID-19 Omicron variant has imposed a tremendous burden on healthcare services. We characterized the types of the Omicron variant-associated hospitalizations and their associations with clinical outcomes. Consecutive adults hospitalized with COVID-19 during the Omicron variant surge period of 1-14 January 2022, were classified into one of three groups based on their clinical presentations on admission: Group 1-primary COVID-19; Group 2-extrapulmonary manifestations of COVID-19; and Group 3-incidental COVID-19. Of the 500 patients who were hospitalized, 51.4% fell into Group 1, 16.4% into Group 2, and 32.2% into Group 3. The patients in Groups 1 and 2 were older, with higher proportions of comorbidities than patients in Group 3. The Group 1 patients had the highest mortality rate (15.6%), followed by Group 2 (8.5%), and Group 3 (0.6%), with adjusted odds ratios (OR) of 22.65 (95% confidence interval [CI], 2.75-239.46; p = 0.004) and 10.95 (95% CI, 1.02-117.28; p = 0.048), respectively, compared to Group 3. Those in Group 1 showed a greater utilization of intensive care services (15.9%), followed by Group 2 (10.9%), and Group 3 (2.5%), with adjusted ORs of 7.95 (95% CI, 2.52-25.08; p < 0.001) and 5.07 (95% CI, 1.34-19.15; p = 0.017), respectively, compared to Group 3. The patients in Groups 1 and 2 had longer hospitalization stays than the patients in Group 3 (p < 0.001 and p = 0.002, respectively). Older age (≥65 years) was an independent factor associated with longer hospital stays (OR = 1.72, 95% CI, 1.07-2.77). These findings can help hospitals prioritize patient care and service planning for future SARS-CoV-2 variants.

Coding Hotline

This month’s Coding Hotline addresses coding for neonatal intensive care services and patients in observation status.

EE478 Cost-Effectiveness Analysis of Procalcitonin Compared to C-Reactive Protein (CRP) in Patients with Exacerbations of Chronic Obstructive Pulmonary Disease (COPD) in the Intensive Care Unit (ICU) in Medellín – Colombia

to estimate the cost effectiveness of the tests available for the detection of bacterial infections in patients diagnosed with chronic obstructive disease (COPD) and presenting an exacerbation of their pathology that requires attention in the intensive care unit service. Procalcitonin is the intervention and CRP the comparator

An Examination of School District Reopening Plans for Mental Health Supports amid COVID-19 School Reopening

Abstract The purpose of this exploratory qualitative study was to understand the types of mental health supports described in school district reopening plans in one southeastern state, and to understand school social workers’ involvement in developing these plans during the first full academic year of the COVID-19 pandemic. Publicly accessible school district reopening plans were collected from the 80 school districts in South Carolina, and 15 school social workers participated in virtual interviews. Out of the 80 school districts, 67 had reopening plans, and of those, only 43 percent mentioned mental health services and supports. Most school district reopening plans described Tier 1 universal prevention services and supports and a process for mental health assessment, identification, and referral. Fewer included Tier 2 early intervention and Tier 3 targeted and intensive services. Of the school social workers interviewed, only four were involved in helping to develop their school district reopening plans, and when involved, advocated for mental health services and supports for their students. The article concludes with a discussion of the study's implications for school social work practice.

Speech and language therapy service provision to UK intensive care units: A national survey

BACKGROUND: The role of Speech and Language Therapists (SLTs) in intensive care units (ICUs) has become increasingly recognised. This survey was developed in response to concern amongst UK SLTs that service provision was insufficient. OBJECTIVE: The primary objective was to benchmark and describe UK pre-pandemic SLT ICU service provision. Secondary objectives included: identifying factors which might explain differences in SLT service provision, identifying unmet needs and good practice, and informing recommended SLT staffing levels. METHODS: An online survey was distributed through UK SLT networks and social media. Quantitative data were reported descriptively, and content analysis was conducted with qualitative data. RESULTS: Responses were received from 64 hospitals, representing three paediatric services and 61 adult services. Average staffing ratios of 0.03 and 0.01 whole time equivalent (WTE) were reported for these respectively. Most services (77&amp;) received no funding from their ICU for SLT staffing. Few reported an adequate SLT service for communication (12&amp;), swallowing (16&amp;) and tracheostomy weaning interventions (11&amp;). Compliance with national guidance for SLT-led communication and swallowing input for all tracheostomised patients was achieved by 27&amp; of sites. CONCLUSIONS: Staffing levels at many sites were insufficient to provide a consistent and responsive service. The findings contributed to a recommendation of 0.1 WTE SLT per ICU bed, which was incorporated into Edition 2 of the Guidelines for the Provision of Intensive Care Services. This survey identified barriers and facilitators to providing an adequate SLT service for critically ill patients that may assist service development initiatives and guide further research.

EFEKTIVITAS KONSELING KELOMPOK REALITA UNTUK MENGURANGI SISWA KECANDUAN GADGET DI MADRASAH ALIYAH DARUL ULUM WARU

The phenomenon of gadget addiction nowadays is not difficult to find among children. Those who have responsibility have also made efforts to reduce addiction, but it is not sufficient to provide more intensive services. The strategy that can be carried out in this study is using the want, direction, evaluation, planning (WDEP) reality counseling model in a group setting. The research objective was to determine the effectiveness of reality group counseling to reduce students' gadget addiction at Madrasah Aliyah Darul Ulum Waru. Research methods include quantitative, experiments using pretest and posttest. Subjects set 7 students. The selected subject is included in the category of high gadget addiction. Data was collected through gadget addiction instruments, expert tests and trials have been carried out. Data analysis used the Wilcoxon sign rank test.Based on the results of the analysis using the Wilcoxon sign rank test, it was found that z count = -2.936, and z table = 1.96, meaning that z count is greater than z table (-2.936&gt; 1.96), then Ha is accepted meaning effective reality group counseling to reduce students addicted to gadgets at Madrasah Aliyah Darul Ulum Waru.

The impact of rural status on pediatric chronic kidney disease.

Children and adolescents in rural areas with chronic kidney disease (CKD) face unique challenges related to accessing pediatric nephrology care. Challenges to obtaining care begin with living increased distances from pediatric health care centers. Recent trendsof increasing centralization of pediatric care mean fewer locations have pediatric nephrology, inpatient, and intensive care services. In addition, access to care for rural populations expands beyond distance and encompasses domains of approachability, acceptability, availability and accommodation, affordability, and appropriateness. Furthermore, the current literature identifies additional barriers to care for rural patients that include limited resources, including finances, education, and community/neighborhood social resources. Rural pediatric kidney failure patients have barriers to kidney replacement therapy options that may be even more limited for rural pediatric kidney failure patients when compared to rural adults with kidney failure. This educational review identifies possible strategies to improve health systems for rural CKD patients and their families: (1) increasing rural patient and hospital/clinic representation and focus in research, (2) understanding and mediating gaps in the geographic distribution of the pediatric nephrology workforce, (3) introducing regionalization models for delivering pediatric nephrology care to geographic areas, and (4) employing telehealth to expand the geographic reach of services and reduce family time and travel burden.

Improving connections to early childhood systems of care via a universal home visiting program in Massachusetts

Welcome Family is a universal, short-term nurse home visiting program designed to promote optimal maternal and infant physical and mental well-being and provide an entry point into the early childhood system of care to all families with newborns up to 8 weeks old living in defined communities in Massachusetts. The present study examines whether: 1) Welcome Family meets its goal of successfully connecting families to two early childhood programs—evidence-based home visiting (EBHV) and early intervention (EI)—relative to families with similar background experiences who do not participate in Welcome Family, and 2) whether these impacts are conditional on families’ race and ethnicity and their primary language—two characteristics that are related to structural racism and health inequities. The study used coarsened exact matching (CEM) based on birth certificate data to match Welcome Family participants who enrolled during 2013–2017 to mothers and their infants living in the home visiting catchment areas who did not receive home visiting during the study period. Primary study outcomes included enrollment in any EBHV program supported by the Massachusetts Maternal, Infant, and Early Childhood Home Visiting (MA MIECHV) program up to age 1 year, measured using MA MIECHV home visiting program data, and EI service receipt for children aged up to age 3 years, measured using EI program data. Impacts were assessed by fitting weighted regression models adjusted for preterm birth, maternal depression, and substance use. Mothers’ race, ethnicity, and language were included in the model as moderators of Welcome Family impacts on enrollment in EBHV and EI. Welcome Family participants (n = 3,866) had more than double the odds of EBHV enrollments up to age 1 and had 1.39 greater odds of receiving EI individualized family service plans (IFSPs) up to age 3 relative to the comparison group (n = 46,561). Mothers’ primary language moderated Welcome Family impacts on EBHV enrollments. Universal, short-term programs such as Welcome Family may be an effective method of ensuring families who could benefit from more intensive early childhood services are identified, engaged, and enrolled.

Metformin use before COVID-19 vaccination and the risks of COVID-19 incidence, medical utilization, and all-cause mortality in patients with type 2 diabetes mellitus

AimsWe designed this study to determine whether metformin use before COVID-19 vaccination influences the risk of COVID-19 infection, medical utilization, and mortality. MethodsWe used the US collaborative network of TriNetX to identify 123,709 patients with type 2 diabetes mellitus fully vaccinated against COVID-19 between January 1, 2020, and November 22, 2022. The study selected 20,894 pairs of metformin users and nonusers by propensity score matching. The Kaplan-Meier method and Cox proportional hazards models were used to compare the risks of COVID-19 infection, medical utilization, and mortality between the study and control groups. ResultsNo significant difference was noted between metformin users and nonusers in the risk of COVID-19 incidence (aHR = 1.02, 95% CI = 0.94–1.10). Compared to the control cohort, the metformin cohort exhibited a significantly lower risk of hospitalization (aHR = 0.85, 95% CI = 0.81–0.89), critical care services (aHR = 0.81, 95% CI = 0.70–0.94), mechanical ventilation (aHR = 0.75, 95% CI = 0.60–0.95), and mortality (aHR = 0.75, 95% CI = 0.63–0.89). The subgroup analyses and sensitivity analysis showed similar results. ConclusionThe present study showed that metformin use before COVID-19 vaccination could not reduce COVID-19 incidence; however, it was associated with significantly lower risks of hospitalization, intensive care service, mechanical ventilation, and mortality in fully vaccinated type 2 diabetes mellitus patients.

Degradation of lithium-ion batteries that are simultaneously servicing energy arbitrage and frequency regulation markets

Lithium-ion batteries are currently deployed around the world to provide both energy intensive and power intensive electricity grid services. Because of this, there is interest in simultaneously servicing multiple markets to maximize the use of both the energy and power operating envelope of a given battery. To evaluate the long-term economic potential of such strategies, many researchers apply degradation curves based on a simple cycling regimen rather than a complex grid services profile. Building upon previous work that examined single service battery degradation, this study evaluates the degradation patterns of simultaneous services by superimposing energy arbitrage and frequency regulation signals. This new methodology was applied to two common lithium-ion chemistries (NMC and LFP) and the results were compared to single service degradation results obtained from the same cell types. Frequency regulation alone caused the least amount of capacity degradation. The simultaneous services increased the degradation rate as the energy arbitrage proportion increased, with the highest degradation rate caused by energy arbitrage alone. Degradation rate is highest throughout the first 1000 cycles and becomes constant after that (up to the 2500 cycles tested), suggesting that as batteries are cycled, they are less sensitive to the severity of the service profile. From this a degradation factor is derived to inform developers on the impacts of different service profiles. Energy efficiency only marginally declined throughout the cycling period. This information will improve the fidelity of economic models by increasing degradation modeling accuracy for simultaneous services.

A Comprehensive Coalition-Based Regional Approach to Pediatric Disaster Planning

Introduction:Children, who comprise 25% of the US population, are frequently victims of disasters and have special needs during these events. To prepare NYC for a large-scale Pediatric Disaster, NYCPDC has worked with an increasing number of providers that initially included only a small number of hospitals and agencies. Through a cooperative team approach, stakeholders now include local public health, emergency management and emergency medical services, 28 hospitals, community-based providers, and the Medical Reserve Corps.Method:The NYCPDC utilized an inclusive iterative process model whereby a desired plan was achieved by stakeholders reviewing the literature and current practice through repeated discussion and consensus building. NYCPDC used this model in developing a comprehensive regional pediatric disaster plan.Results:The plan included disaster scene triage (adapted for pediatric use) to transport (with prioritization) to surge and evacuation. Additionally, site-specific plans utilizing guidelines and templates now include Pediatric Long-Term Care Facilities, Hospital Pediatric Departments including Pediatric and Neonatal Intensive Care Services and Outpatient/Urgent Care Centers. A force multiplier course in critical care for non-intensivists has been provided. An extensive Pediatric Exercise program has been used to develop, operationalize and revise plans based on lessons learned. This initially included pediatric tabletop, functional and full-scale exercises at individual hospitals leading to citywide exercises at 13 and subsequently all 28 hospitals caring for children.Conclusion:The NYCPDC has comprehensively planned for the special needs of children during disasters utilizing a pediatric coalition based regional approach that matches pediatric resources to needs to provide best outcomes.The NYCPDC has responded to real time events (H1N1, Haiti Earthquake, Superstorm Sandy, Ebola), and participated in local (NYC boroughs and executive leadership) and nationwide coalitions (including the National Pediatric Disaster Coalition). The NYCPDC has had the opportunity to present their Pediatric Disaster Planning and Response efforts at local, national and International conferences.

Developing a Program Model for School-Based Day Treatment for Social, Emotional, and Behavioral Difficulties

School-based day treatment is an intensive mental health service for children with social, emotional, and behavioral difficulties. Research on day treatment is scarce and descriptions of program models are lacking. We used stimulated recall interviews to explore the moment-to-moment processes and strategies of classroom staff in a day treatment program for children in kindergarten and Grade 1 in Canada. Several processes and strategies used by staff emerged from the thematic analysis of the interviews. These included a process of individualized intervention, characterized by a continual and cyclical process of attunement, responsiveness, assessment, and evaluation, using a team-based approach, noticing positives about children, a climate of positive relationships, staff regulating their own emotions, being flexible while also being firm and consistent, and seeing children from a developmental perspective. More specific strategies used by staff (e.g., token economy) also emerged from the interviews. Implications for future research and teacher training are discussed.

Needs of Family Members of Intensive Care Patients.

This article reports the results of a research project designed to identify the needs of family members and others who are coping with hospitalization of loved one in the intensive care unit, thus alleviating stress. The health care provider's viewpoints were also considered. Study participants were 9 family members of intensive care unit patients and 24 health care providers working in intensive care units. Data were collected and analyzed from 24 individual interviews (average of 35 minutes per interview) and 1 focus group interview (1 hour). The findings revealed 2 basic needs: (1) reducing concerns and (2) being supported. The first need could be addressed by open visitation, access to information, assurance of quality of care, and empowerment via education and involvement. The second need could be met by emotional support, access to facilities, and postdischarge support. Health care providers and decision makers can use these results to respond to these needs and increase people's satisfaction of intensive care unit services.