Lower Level Of Care Research Articles

Perceived parenting styles and bonding among adolescents with mental illness: Okasha Institute of Psychiatry experience

BackgroundWorldwide, at least 10% of adolescents have a documented mental illness, which is a leading source of morbidity, mortality, and functional impairment. Among individuals aged between 10 and 24 years, psychiatric disorders account for 45% of all years lived with disability. Parenting discipline styles are fundamental in shaping adolescents’ emotional integrity, cognitive capabilities, and behavioral patterns.To compare parenting styles and parental bonding dimensions in adolescents with different psychiatric disorders versus a group of healthy adolescents matched for age and sex.Patients and methodsA case–control study conducted at Okasha Institute of Psychiatry, Ain Shams University Hospitals, involved 50 participants of adolescents diagnosed with variable psychiatric disorders and 50 matched healthy controls.ResultsAuthoritarian parenting style was evident in mentally ill adolescents, while authoritative parenting style was prevalent in healthy controls. In terms of parental bonding, mentally ill adolescents experienced a low level of care and a high level of overprotection from both parents.ConclusionThe results of the study demonstrated that parenting styles may serve as predictors and predisposing factors for psychiatric disorders in adolescents. Adolescents with psychiatric disorders perceived both parents as more authoritarian, less authoritative. They also received a low level of care and a high level of overprotection from both parents.

Long-term retention and positive deviant practices in Uganda’s community client-led antiretroviral distribution groups (CCLADs): a mixed-methods study

BackgroundHIV testing and starting antiretroviral therapy (ART) are pivotal in treating people living with HIV (PLHIV) but sustaining PLHIV on treatment remains challenging. We assessed retention and attrition in community...

Screening, Brief Intervention and Referral to Treatment (SBIRT): An examination of health disparities

Risky substance use can lead to a variety of negative health outcomes, yet treatment is often underutilized by historically minoritized racial/ethnic groups. Screening, Brief Intervention and Referral to Treatment (SBIRT) is effective in changing substance use patterns across diverse settings and for diverse demographic groups. However, few studies have focused on whether individuals receive the appropriate level of care based on screening criteria. The purpose of this study was to investigate intervention match/mismatch and factors (e.g., service site, gender, race, ethnicity, age, socio-economic status) that predicted the likelihood of being matched/mismatched to an intervention. A sample of N = 3412 were available for analyses and logistic regressions were performed to examine the relationship between matching/mismatching to an intervention and other factors. Of participants, 2222 (65%) were matched to an intervention and 1190 (35%) were mismatched to an intervention. Being older, Hispanic, and receiving SBIRT by health-teams designed to reduce health disparities was related to increased odds of being mismatched. Exploratory results suggested that across predictors, individuals were more likely to receive a lesser intervention than their screening score indicated. Most clients were matched well to intervention as based on screening score. When mismatch occurred, a lower level of care was given. Staff may benefit from attending to more client engagement so that clients return for more intensive interventions; and agencies may need more resources to facilitate client access to services.

Effect of decentralising childhood tuberculosis diagnosis to primary health centre versus district hospital levels on disease detection in children from six high tuberculosis incidence countries: an operational research, pre-post intervention study

Childhood tuberculosis (TB) remains underdiagnosed largely because of limited awareness and poor access to all or any of specimen collection, molecular testing, clinical evaluation, and chest radiography at low levels of care. Decentralising childhood TB diagnostics to district hospitals (DH) and primary health centres (PHC) could improve case detection. We conducted an operational research study using a pre-post intervention cross-sectional study design in 12 DHs and 47PHCs of 12 districts across Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone and Uganda. The intervention included 1) a comprehensive diagnosis package at patient-level with tuberculosis screening for all sick children and young adolescents <15 years, and clinical evaluation, Xpert Ultra-testing on respiratory and stool samples, and chest radiography for children with presumptive TB, and 2) two decentralisation approaches (PHC-focused or DH-focused) to which districts were randomly allocated at country level. We collected aggregated and individual data. We compared the proportion of tuberculosis detection in children and young adolescents <15 years pre-intervention (01 August 2018-30 November 2019) versus during intervention (07 March 2020-30 September 2021), overall and by decentralisation approach. This study is registered with ClinicalTrials.gov, NCT04038632. TB was diagnosed in 217/255,512 (0.08%) children and young adolescent <15 years attending care pre-intervention versus 411/179,581 (0.23%) during intervention, (OR: 3.59 [95% CI 1.99-6.46], p-value<0.0001; p-value=0.055 after correcting for over-dispersion). In DH-focused districts, TB diagnosis was 80/122,570 (0.07%) versus 302/86,186 (0.35%) (OR: 4.07 [1.86-8.90]; p-value=0.0005; p-value=0.12 after correcting for over-dispersion); and 137/132,942 (0.10%) versus 109/93,395 (0.11%) in PHC-focused districts, respectively (OR: 2.92 [1.25-6.81; p-value=0.013; p-value=0.26 after correcting for over-dispersion). Decentralising and strengthening childhood TB diagnosis at lower levels of care increases tuberculosis case detection but the difference was not statistically significant. Unitaid, Grant number 2017-15-UBx-TB-SPEED.

Outpatient Care Service: Predictors Of Current And Future Use Of Outpatient Care Service By Family Members Providing Informal Care To Elderly Persons In Long-Term Home Care

In Germany, people in need of care are usually cared for at home by their informal caregivers. The outpatient care service represents a central pillar in the home care of people in need of care. The aim of this article was to analyse the factors influencing the current as well the future use of outpatient care service. With the cross-sectional study Benefits of Being a Caregiver (October 2019 - March 2020) overall 958 family caregivers of elderly people in need of care from Bavaria were interviewed. In addition to the characteristics of the caregivers and those in need of care, information on the care situation as well as the current and desired future use of outpatient care service were collected. Two binary logistic regression analyses were carried out to determine the predictors of the use. The outpatient care service was used by 368 (38%) care giving relatives or those in need of care currently or recently. 236 family caregivers (40% of current non-users) stated that they would like to use an outpatient care service in the future. As predictors for the current use, the relationship non-partner, a higher care level of the persons in need of care and the perception of caregivers of not being able to manage care-giving were determined. Predisposing factors for the desired future use were the desire for current informal help and a lower care level. Family caregivers using the outpatient care service state that they are less able to cope with home care. Therefore, this service should focus its counselling on the empowerment of the caregivers. Moreover, the users are predominantly employed daughters or daughters-in-law who live in separate households. Therefore, the reliability of the offer is a basic condition for being able to maintain home care. In the future, a considerable increase in the number of informal care givers wishing to use outpatient care services is to be expected. Efforts should therefore be made to enlarge the range of services.

A Novel Continuous Real-Time Vital Signs Viewer for Intensive Care Units: Design and Evaluation Study.

Clinicians working in intensive care units (ICUs) are immersed in a cacophony of alarms and a relentless onslaught of data. Within this frenetic environment, clinicians make high-stakes decisions using many data sources and are often oversaturated with information of varying quality. Traditional bedside monitors only depict static vital signs data, and these data are not easily viewable remotely. Clinicians must rely on separate nursing charts-handwritten or electric-to review physiological patterns, including signs of potential clinical deterioration. An automated physiological data viewer has been developed to provide at-a-glance summaries and to assist with prioritizing care for multiple patients who are critically ill. This study aims to evaluate a novel vital signs viewer system in a level 1 trauma center by subjectively assessing the viewer's utility in a high-volume ICU setting. ICU attendings were surveyed during morning rounds. Physicians were asked to conduct rounds normally, using data reported from nurse charts and briefs from fellows to inform their clinical decisions. After the physician finished their assessment and plan for the patient, they were asked to complete a questionnaire. Following completion of the questionnaire, the viewer was presented to ICU physicians on a tablet personal computer that displayed the patient's physiologic data (ie, shock index, blood pressure, heart rate, temperature, respiratory rate, and pulse oximetry), summarized for up to 72 hours. After examining the viewer, ICU physicians completed a postview questionnaire. In both questionnaires, the physicians were asked questions regarding the patient's stability, status, and need for a higher or lower level of care. A hierarchical clustering analysis was used to group participating ICU physicians and assess their general reception of the viewer. A total of 908 anonymous surveys were collected from 28 ICU physicians from February 2015 to June 2017. Regarding physicians' perception of whether the viewer enhanced the ability to assess multiple patients in the ICU, 5% (45/908) strongly agreed, 56.6% (514/908) agreed, 35.3% (321/908) were neutral, 2.9% (26/908) disagreed, and 0.2% (2/908) strongly disagreed. Morning rounds in a trauma center ICU are conducted in a busy environment with many data sources. This study demonstrates that organized physiologic data and visual assessment can improve situation awareness, assist clinicians with recognizing changes in patient status, and prioritize care.

The association between frailty, care receipt and unmet need for care with the risk of hospital admissions.

Frailty is characterised by a decline in physical, cognitive, energy, and health reserves and is linked to greater functional dependency and higher social care utilisation. However, the relationship between receiving care, or receiving insufficient care among older people with different frailty status and the risk of unplanned admission to hospital for any cause, or the risk of falls and fractures remains unclear. This study used information from 7,656 adults aged 60 and older participating in the English Longitudinal Study of Ageing (ELSA) waves 6-8. Care status was assessed through received care and self-reported unmet care needs, while frailty was measured using a frailty index. Competing-risk regression analysis was used (with death as a potential competing risk), adjusted for demographic and socioeconomic confounders. Around a quarter of the participants received care, of which approximately 60% received low levels of care, while the rest had high levels of care. Older people who received low and high levels of care had a higher risk of unplanned admission independent of frailty status. Unmet need for care was not significantly associated with an increased risk of unplanned admission compared to those receiving no care. Older people in receipt of care had an increased risk of hospitalisation due to falls but not fractures, compared to those who received no care after adjustment for covariates, including frailty status. Care receipt increases the risk of hospitalisation substantially, suggesting this is a group worthy of prevention intervention focus.

Mental health is just an Addendum: Assessing stakeholder's perceptions on COVID-19 and mental health services provision in Malawi.

The World Health Organization declared COVID-19 as a pandemic in March 2020. COVID-19 has since caused a significant increase in mental health problems at national and global levels. This study assessed the views of key mental health stakeholders regarding the state of mental health service provision in Malawi and the pandemic's impact on the sector. The study utilised a qualitative approach through key informant interviews (KIIs) conducted using a semi-structured interview guide. The interviews were audio recorded in English language and were manually transcribed for thematic analysis by generating codes re-classified into themes, sub-themes and quotes. The results are categorised into five themes. Firstly, the availability of mental health services. All experts confirmed the lack of availability of the mental health services especially at the lower levels of care. Currently, only 0.3% of facilities offer mental health services in Malawi. Moreover, although mental health services are part of the essential health care package and, therefore, are supposed to be provided for free in public facilities at all levels, the services are centralised and only functional at a tertiary level of care in public facilities. Secondly, funding sources for mental health in public and private facilities. We learnt that public facilities depend on donor sources and there is lack of prioritisation in budget allocation for mental health services. Whereas private facilities, their major source of funding is user fees. Thirdly, government's response in the provision of mental health services during COVID-19. Almost all experts echoed that government took a proactive approach to address the mental health needs of its population during the pandemic. There was increased collaboration between the government and the private sector to provide psychosocial and counselling services to health workers working directly with COVID-19 patients in isolation centres. Furthermore, to increase awareness of the general population on where to seek counselling services. Lastly, challenges in the provision of mental health services were highlighted and how the pandemic acerbated the challenges including shortage in human resources for health and inadequate funding. This study underscores the urgency of addressing mental health challenges in Malawi. Policymakers must prioritize the decentralization of mental health services, explore funding opportunities, and build on the successful collaboration with the private sector. These measures will not only enhance the accessibility and quality of mental health services but also ensure that mental well-being is a central component of public health efforts in Malawi.

Participation of private providers in the National TB Programme in South India

SETTING: India has the highest number of new TB cases worldwide. The participation of private providers (PPs) in the National TB Elimination Programme (NTEP) has remained suboptimal.OBJECTIVE: To explore the experiences, barriers and facilitators about their participation in the NTEP as perceived by PPs working in varied settings.DESIGN: Focus group discussions and in-depth interviews were used to engage PPs to obtain their views on participation in the NTEP. Framework and thematic content analysis was used to analyse qualitative data.RESULTS: Non-availability of a comprehensive range of diagnostics and lack of flexibility in the NTEP were barriers to participation in NTEP. PPs were predisposed to think that NTEP was for those who could not afford to purchase medications. Attitudes and previous experiences with NTEP made them sceptical about the NTEP regimen. Although more frequent interactions were sought with NTEP, some bitterness about previous interactions was perceived.CONCLUSION: Challenges identified by PPs for the NTEP include improvement of the quality of TB care, especially at the lower levels of care, availability of a comprehensive range of diagnostics, being friendly to PPs and patients, more frequent interactions with PPs, and more caring conversations with patients at NTEP centres.

Abstract 11905: Real-World Clinical Impact of High-Sensitivity Troponin for Chest Pain Evaluation in the Emergency Department

Background: The impact of high-sensitivity cardiac troponin (hs-cTn) implementation on clinical practice in emergency departments in the United States is not well characterized. Research Questions: We sought to assess the effect of hs-cTn on length of stay, hospital admissions, and utilization of cardiac testing and consultations. Methods: Adult patient visits to the emergency department (ED) for chest pain with ≥ 1 troponin result were identified in electronic health record data from a large academic health system encompassing one suburban hospital and two urban hospitals including a quaternary referral center. Patients were included 15 months before and 11 months after the implementation of hs-cTn on April 6, 2022. Associations between hs-cTn implementation and clinical metrics were evaluated using both univariable and multivariable linear models. Results: Among 27,313 unique patients, there were 17,267 and 14,809 encounters before and after the implementation of hs-cTn, respectively. Using hs-cTn, a greater proportion of patients were discharged from the ED (59.5 % vs. 64.9 %, p &lt;0.0001), and total length of stay ( Figure 1 ) was shorter (6.6 h, IQR 3.9 - 29.5 vs. 6.0 h, IQR 4.0 - 27.1, p = 0.039). Similar results were observed in urban vs. suburban settings and in quaternary care vs. lower levels of care. There were lower rates of cardiology consults (-1.2 per 100 patient visits, adjusted odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.86 - 0.97), echocardiograms (-2.8 per 100 patient visits, adjusted OR: 0.86, 95% CI: 0.82 - 0.91), stress tests (-1.9 per 100 patient visits, adjusted OR: 0.74, 95% CI: 0.67 - 0.81), and coronary angiograms (-2.0 per 100 patient visits, adjusted OR: 0.77, 95% CI: 0.70 - 0.83) after hs-cTn implementation. Conclusions: In real-world data, implementation of hs-cTn was associated with a higher rate of discharges from the ED and shorter total length of stay with small reductions in utilization of cardiac testing.

Defining levels of care in cardiogenic shock.

Expert opinion and professional society statements have called for multi-tier care systems for the management of cardiogenic shock (CS). However, little is known about how to pragmatically define centers with different levels of care (LOC) for CS. Eleven of 23 hospitals within our healthcare system sharing a common electronic health record were classified as different LOC according to their highest mechanical circulatory support (MCS) capabilities: Level 1 (L-1)-durable left ventricular assist device, Level 1A (L-1A)-extracorporeal membrane oxygenation, Level 2 (L-2)-intra-aortic balloon pump and percutaneous ventricular assist device; and Level 3 (L-3)-no MCS. All adult patients treated for CS (International Classification of Diseases, ICD-10 code R57.0) between 2016 and 2022 were included. Etiologies of CS were identified using associated diagnostic codes. Management strategies and outcomes across LOC were compared. Higher LOC centers had higher volumes: L-1 (n = 1): 2,831 patients, L-1A (n = 4): 3,452, L-2 (n = 1): 340, and L-3 (n = 5): 780. Emergency room admissions were more common in lower LOC (96% at L-3 vs. 46% L-1; p < 0.001), while hospital transfers were predominant at higher LOC (40% at L-1 vs. 2.7% at L-3; p < 0.001). Men comprised 61% of the cohort. Patients were younger in the higher LOC [69 (60-78) years at L-1 vs. 77 (67-85) years at L-3; p < 0.001]. Patients with acute myocardial infarction (AMI)-CS and acute heart failure (AHF)-CS were concentrated in higher LOC centers while other etiologies of CS were more common in L-2 and L-3 (p < 0.001). Cardiac arrest on admission was more prevalent in lower LOC centers (L-1: 2.8% vs. L-3: 12.1%; p < 0.001). Patients with AMI-CS received more percutaneous coronary intervention in lower LOC (51% L-2 vs. 29% L-1; p < 0.01) but more coronary arterial bypass graft surgery at higher LOC (L-1: 42% vs. L-1A: 23%; p < 0.001). MCS use was consistent across levels for AMI-CS but was more frequent in higher LOC for AHF-CS patients (L-1: 28% vs. L-2: 10%; p < 0.001). Despite increasing in-hospital mortality with decreasing LOC, no significant difference was seen after multivariable adjustment. This is the first report describing a pragmatic classification of LOC for CS which, based on MCS capabilities, can discriminate between centers with distinct demographics, practice patterns, and outcomes. This classification may serve as the basis for future research and the creation of CS systems of care.

Stroke epidemiology and outcomes of stroke patients in Nepal: a systematic review and meta-analysis

BackgroundWith an increasing burden of stroke, it is essential to minimize the incidence of stroke and improve stroke care by emphasizing areas that bring out the maximum impact. The care situation remains unclear in the absence of a national stroke care registry and a lack of structured hospital-based data monitoring. We conducted this systematic review and meta-analysis to assess the status of stroke care in Nepal and identify areas that need dedicated improvement in stroke care.MethodsA systematic literature review was conducted to identify all studies on stroke epidemiology or stroke care published between 2000 and 2020 in Nepal. Data analysis was done with Statistical Package for Social Sciences (SPSS) and Comprehensive Meta-analysis (CMA-3).ResultsWe identified 2533 studies after database searching, and 55 were included in quantitative and narrative synthesis. All analyses were done in tertiary care settings in densely populated central parts of Nepal. Ischemic stroke was more frequent (70.87%) than hemorrhagic (26.79%), and the mean age of stroke patients was 62,9 years. Mortality occurred in 16.9% (13-21.7%), thrombolysis was performed in 2.39% of patients, and no studies described thrombectomy or stroke unit care.ConclusionThe provision of stroke care in Nepal needs to catch up to international standards, and our systematic review demonstrated the need to improve access to quality stroke care. Dedicated studies on establishing stroke care units, prevention, rehabilitation, and studies on lower levels of care or remote regions are required.

Moral foundations and criminality: comparing community members to prisoners and violent/non-violent offenders

ABSTRACT Morality is built upon individualizing (i.e. care, fairness) and binding (i.e. loyalty, authority, and purity) moral foundations, which are the systems that help people to make moral decisions and behave accordingly. Past research has found that moral foundations are related to past unethical behaviors, but we are the first to test them among people in prison. Specifically, we investigated individual differences in moral foundations in men and women in prison (N = 382) relative to Poles with no criminal record (N = 382), who were matched to the prisoner sample by sex and age. We showed that prisoners care about moral foundations, but just with a different intensity than people from the general population. We found that prisoners had lower individualizing moral foundations and higher binding moral foundations than participants from the general population. Violent prisoners had lower levels of care and purity than non-violent prisoners. Regarding sex differences, women scored higher in individualizing moral foundations than men, both among prisoners and non-prisoners. Lastly, women in prison scored higher in binding moral foundations than men in prison. Our study adds to the discussion of individual differences in moral foundations, which might help prevent crimes and enable the resocialization process.

Descriptive Study Evaluating Nurses Knowledge and Practices Regarding Tracheostomy Care in ICU Patients.

Background: ICU patient tracheostomy care is a fundamental nursing procedure. The tracheostomy might result in difficulties and causes a great deal of anxiety in patients. A low level of care can have negative consequences such as longer hospital stays, slower recovery times, and greater mortality rates. Aim: To evaluate nurses' tracheostomy care knowledge and practises in ICU patients. Study Design: The descriptive research study design was used. Methodology: 75 nurses who worked in the ICU of three public hospitals in Lahore—Mayo Hospital, Jinnah Hospital, and Shaikh Zayed Hospital—were included in the study's sample. Nurses' practises were assessed by direct observation using a checklist, and their knowledge was assessed using a self-structured questionnaire. The analysis of the data was done using SPSS v 20.0. Results: All participants in the study were ICU nurses. This data makes clear that 0 - 49% of nurses have low knowledge, while 50 - 64% of nurses have average knowledge, and &gt;65% of nurses have adequate knowledge. Conclusion: The majority of participants had sufficient understanding of tracheostomy care. Additionally, it demonstrates that out of 75 nurses, only 0–59% had insufficient skill and &gt; 60% had a sufficient level of performance. Practical Implementation: This study assisted researchers in examining the risk variables related to Tracheostomy treatment in ICU patients because of the increasing number of patients in the ICU. Conclusion: It was concluded that, despite having sufficient information, nurses performed poorly when providing tracheostomy care. Therefore, for the safety of patients, health care facilities must provide organized clinical guidelines and practices. Keywords: Assessment, Knowledge, Practice, Nursing Care and Tracheostomy.

Acute kidney injury among hospitalised patients who died due to COVID-19 in the Eastern Cape, South Africa.

Acute kidney injury (AKI) commonly occurs in coronavirus disease 2019 (COVID-19) patients who have been hospitalised and is associated with a poor prognosis. This study aimed to determine the incidence of AKI among COVID-19 patients who died in a regional hospital in South Africa. This retrospective record review was conducted at the Mthatha Regional Hospital in South Africa's Eastern Cape province. Data were collected between 10 July 2020 and 31 January 2021. The incidence of AKI was 38% among the hospitalised patients who died due to COVID-19. Most study participants were female, with a mean age of 63.3 ± 16 years. The most common symptom of COVID-19 at the time of hospitalisation was shortness of breath, followed by fever and cough. Half of the patients had hypertension, while diabetes, human immunodeficiency viruses (HIV) and tuberculosis (TB) were other comorbidities. At admission, the average oxygen saturation was 75.5% ± 17. The study revealed a high incidence of AKI among hospitalised patients who died due to COVID-19. It also found that those received adequate crystalloid fluids at the time of admission had a lower incidence of AKI.Contribution:Acute kidney injury can be prevented by adequate fluid management during early stage of COVID-19. Majority of COVID-19 patients were referred from lower level of care and primary care providers have their first encounter with these patients. Adequate fluid resuscitation in primary care settings can improve the outcome of hospitalised COVID-19 patients.

Implementing the intensity of care model in a surgical department: an evaluation

Background/Aims The authors' hospital implemented an intensity of care model in the surgical department, grouping patients by the level of care they required (low, high or intensive) and creating a short-stay unit for patients requiring a low level of care. This study evaluated care quality, along with staff and patient perceptions, in the department 3 years after this model was implemented. Methods Data were collected from mandatory national databanks regarding organisation, economic, staff and patient factors relating to care quality and efficiency. The department's performance according to National Outcome Programme indicators was also assessed. Data from staff and patient satisfaction questionnaires used for routine audit were analysed retrospectively. Both questionnaires asked respondents to rate their satisfaction to items on a 5-point Likert scale so their scores could be analysed. Satisfaction scores for staff in the short-stay unit were compared with those working in general surgery using a t-test, with P&lt;0.05 indicating a significant difference. Results Some improvements were found 3 years after the model was implemented, including increased elective activity and reduced length of stay. Patient satisfaction with the short-stay unit was generally high. However, staff satisfaction was generally low and turnover rates were high. Conclusions The intensity of care model and the use of a short-stay unit can lead to benefits for surgical care, but further research is needed to determine its effects on all aspects of care quality and, especially, staff satisfaction.

Abstract 300: Evaluation Of An Electrocardiogram Based Analytic For Predicting Future Episodes Of Hemodynamic Instability

Background: Clinicians rely on vital signs (tachycardia with hypotension) to identify hemodynamically unstable patients. The Analytic for Hemodynamic Instability (AHI) System provides an indication of hemodynamic deterioration before it is evident via vital signs. It uses only routinely collected ECG monitor data to generate a simple binary output (indicating signs of hemodynamic instability-Red or stability-Green) and is automatically updated every two minutes. Hypothesis: Continuous real-time hemodynamic status obtained from analysis of ECG signals can predict an episode of hemodynamic instability before it's evident via vital signs, with clinically actionable lead time. Methods: In this retrospective observational study, an episode of hemodynamic instability (EHI) was defined as 10 continuous minutes or more where hypotension (systolic BP&lt;90 mmHg or mean BP&lt;70 mmHg) combined with tachycardia (heart rate ≥ 100 bpm) was present. The AHI System processed continuous ECG data from 362 consecutive adult ICU patient encounters (146, 40.3% female) undergoing continuous BP and HR monitoring via arterial line and ECG, who experienced at least one EHI. In this analysis, only the first occurrence of an EHI per patient encounter was used to see if the AHI System predicted the episode before vital signs showed any indication. Results: Of the 362 patients, AHI correctly predicted the first EHI in 85% of the patients (308/362). Of those, AHI’s median lead time (predominantly repeating AHI-Red indications) was 57 minutes prior to first EHI, with 25th and 75th percentiles at 14 minutes and 3.2 hours, respectively. AHI’s average lead time was 4 hours. Conclusion: Results suggest that this ECG-based analytic can potentially notify healthcare providers of future patient deterioration with clinically actionable lead times. The benefit of this analytic could extend further for ECG monitored patients in lower levels of care where hemodynamic status is typically evaluated manually and intermittently. This potentially enables appropriate preemptive clinical action, thereby reducing failure to rescue and increasing vigilance for unseen at-risk patients. Footnote: AHI is an FDA-cleared device for sale in the US.

Validation and Scoring of the Greek Version of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) Questionnaire

The aim of this study was to validate the Greek version of the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) questionnaire. The study was designed as a prospective questionnaire survey. Overall, 210 elective surgical patients were included . SCQIPP consisted of 14 items that were scored on a five point scale. After the translation and linguistic adjustments, the tool was distributed to the surgical wards. Internal consistency reliability was assessed by Cronbach's alpha. The tool construct was generated by a principal axis factoring model with promax rotation. Base Cronbach's alpha was 0.814. Due to low inter-item and item-total correlations and the increase of Cronbach's alpha (0.834) when item two was deleted, 13 items were included in the current tool version. Factor analysis identified three district subscales: nursing care, pain management, and support. Subscale and convergent validity were confirmed. The mean score of the validated tool was 55.2 (Range: 44-63). A low level of care was highlighted in most items. The Greek version of the SCQIPP questionnaire is a valid and efficient tool for the evaluation of the quality of care of postoperative pain management.

Predictors of expressed, felt, and normative needs for informal caregiver counseling : Domestic care for people aged 65+ years.

Informal caregivers (CGs) often fail to recognize or express aneed for informal caregiver counseling (ICC) but ICC is an essential but relatively rarely used support service for CGs. Our aim is to identify predictors of CGs' need for ICC. Stirling etal.'s need model, which includes three needs (expressed, felt, and normative), serves as atheoretical basis. Analyses are based on cross-sectional data (n = 958) from the "Benefits of being acaregiver" study. Predictors of the need to use ICC were analyzed with binary logistic regression. Asensitivity analysis using multiple linear regression was performed for the metric value of normative needs. We found that 6.8% of CGs currently or have recently used ICC. This expressed need was related to higher education and higher effort in instrumental activities; 24.1% of CGs reported an intention to use ICC in the future. This felt need was related to male gender, lower care level, more problem-focused coping, and adesire for more informal help. Objective need for ICC (normative need), which was related to ahigher burden of care, less experienced benefits, and negative relationship quality, was reported by 21.4% of CGs. According to asensitivity analysis, higher education, adesire for informal help, and living in separate households also predicted anormative need for counseling. Current utilization is significantly lower than the subjectively perceived and objectively existing need for ICC. The identified predictors provide initial strategies for motivating more CGs to use ICC.

Quality Perceptions and Choice of Public Health Facilities: A Mediation Effect Analysis of Outpatient Experience in Rural China.

PurposeOutpatients have choices of providers in the hierarchical health service delivery system of China. Understanding how quality perceptions and outpatient experience affect the choice of health facility would help inform decisions about priorities for action aimed at guiding the use of primary care. This study examines how quality perceptions of outpatient service affect the facility level choice in rural China.MethodsHousehold surveys were conducted in 2011, 2012 and 2015 in Ningxia Hui Autonomous Region, China. We selected 968 respondents as the study sample, who had at least two outpatient visits to the public health facilities during each survey period. Prior quality perceptions of the outpatient service at the village clinics, township centers, and county hospitals were reported on an 8-item Quality Indicator questionnaire. Experienced quality perception from the first outpatient visit was also reported. The outcome of interest was outpatients’ facility level choices. We used regression and mediation analysis to explore whether and how outpatient experience at a specific health facility would mediate the relationship between prior quality perceptions and the facility level choice.ResultsOverall, the quality perception was positively and significantly associated with outpatients’ staying at the same or lower levels of care (β=0.265, P=0.007). This effect was fully mediated by experienced quality perception (z=2.985, P=0.003). The indirect effect was significant for three particular dimensions, including quality perceptions of the environment (β=0.075, P=0.025), doctor-patient communication (β=0.065, P=0.022), and physician ability (β=0.062, P=0.021).ConclusionOutpatient quality perceptions—especially positive perceptions regarding environment, doctor-patient communication, and physician ability—could contribute to minimizing upward referral via improvement in outpatient experience. Policymakers and health care providers may need to therefore optimize outpatient experience as they push to develop a more locally responsive primary care system.