Optimal Level Of Care Research Articles

Strategic Aeromedical Evacuations of the French Armed Forces in French Guiana From 2018 to 2020.

The French Armed Forces are deployed in French Guiana (FG) to protect national territory and ensure the security of strategically important sites. Military health support (MHS) provides medical support for missions in this tropical environment, which is hazardous and where confrontations are possible. MHS must organize tactical and strategic evacuations (Strat-AEs), so that an optimal level of care can be delivered. Overall, Strat-AE activity has been described previously but no specific data related to FG has been reported. The main objective of this study was to provide an overview of military Strat-AEs from FG. We conducted a retrospective cohort study from January 01, 2018 through 31 December, 2020. All patients who required a military Strat-AE were included, and we collected sociodemographic characteristics, medical information, service-related injuries and illnesses, and the reason for and conditions of evacuation. We analyzed 210 patients and 199 were included. Most were noncommissioned members (63.3%) and belonged to the Army (75.4%) and the Gendarmerie (15.6%). Injury or illness was duty-related in 66.2% of patients. The main cause for evacuation was nonbattle injury (63.3%), followed by illness (27.1%). Battle stress and injury accounted for 9.5%. The main reasons for evacuation were surgical conditions (58.3%), particularly orthopedic (47.2%). Medical (22.1%), psychiatric (18.6%), and dental (1.0%) disorders followed. Most patients were categorized by the flight surgeon as P3 (98.5%), the lowest level of priority, and D4 (82.9%), the lowest level of dependency. The escort used during evacuation was identical to that recommended by the requester in 83.5% of cases. The final destination was mainly a hospital (89.9%). The time lag between injury or onset of illness and the request for evacuation was significantly longer when local health resources were insufficient. The particularity of FG is a local health care system that provided initial care before the evacuation. To reduce the number of Strat-AEs in FG, the risk of nonbattle injury must be lessened and improvements must be made to the local health care system and to the partnership between civilian and military health services.

Neuralgic amyotrophy: An update in evaluation, diagnosis, and treatment approaches.

Neuralgic amyotrophy (NA) is an underrecognized peripheral nerve disorder distinguished by severe pain followed by weakness in the distribution of one or more nerves, most commonly in the upper extremity. While classically felt to carry a favorable prognosis, updates in research have demonstrated that patients frequently endure delay in diagnosis and continue to experience long term pain, paresis, and fatigue even years after the diagnosis is made. A transition in therapeutic approach is recommended and described by this review, which emphasizes the necessity to target compensatory abnormal motor control and fatigue by focusing on motor coordination, energy conservation strategies, and behavioral change, rather than strength training which may worsen the symptoms. The development of structural hourglass-like constrictions (HGCs) on imaging can help confirm the suspected clinical diagnosis, and in association with persistent weakness and limited recovery on electrodiagnostic testing may be considered for surgical consultation. Given the complex nature of management, a multidisciplinary approach is described, which can provide an optimal level of care and support for patients with persistent symptoms from NA and allow more unified guidance of rehabilitation and surgical referrals.

Pituitary macroadenoma with panhypopituitarism masquerading as schizophrenia: a diagnostic dilemma managed conservatively

Introduction and importance: Secretory pituitary macroadenoma also known as prolactinoma are benign neoplasm comprising very minimal cases of intracranial masses. Among the various presentation suggestive of panhypopituitarism, psychosis, and features of schizophrenia is very rarely seen. In the majority of cases, neurosurgical intervention for the excision of tumor is considered a standard treatment modality but conservative management with dopamine agonist and steroids have also been shown to provide an optimal level of care also improving the quality of level of patient. Case presentation: A 42-year-old Asian male presented with a history of talking to self, delusion of persecution, over talkativeness, hallucination, increased suspiciousness, and history of lost and found in the streets where he was working as a migrant worker. The patient was initially managed in line of schizophrenia with the antipsychotics drug of choice. On further assessment there was no improvement of psychiatric symptoms but they further deteriorated with additional neuropsychiatric symptoms; hence, MRI brain was carried out. Following which, the diagnosis of pituitary macroadenoma was confirmed and further more hormonal analysis was done, which showed findings suggestive of panhypopituitarism. The patient was then managed conservatively with dopamine agonist and steroids, which showed rapid improvement of psychiatric symptoms with a massive reduction in the size of the pituitary macroadenoma. Clinical discussion: With the incidence of 100 per million cases pituitary adenomas are considered locally invading with the characteristic compression of the surrounding structure, presenting as visual hallucinations, olfactory hallucinations, episodes of losing time, apathy, and features suggestive of adrenal insufficiency, hypogonadotrophic hypogonadism, and symptoms secondary to hormonal imbalance such as hypothyroidism. Psychiatric symptomatic presentations are considered a very rare presentation in cases of pituitary macroadenoma. Also, psychiatric features and symptoms of psychosis are associated with prolcatinomas through idiopathic mechanism and the basic casualty has not been established. Surgical intervention such as trans-sphenoidal resection of the mass can be undertaken in case where mass effects is present but long-term remission and prognosis is found not to be fruitful. Conservative treatment with dopamine agonist such as cabergoline and steroids also plays a meaningful role in abrupt management in such cases. Conclusion: Pituitary macroadenoma presenting as a patient of schizophrenia is noted very rarely in medical literature; hence, investigations in view of neurosurgical diagnosis in cases presenting as psychosis should be considered for ideal holistic management. Conservative management can also be a breakthrough treatment modality in complete recovery of pituitary macroadenoma.

Women's needs in their journey towards motherhood via oocyte donation: A mixed methods systematic review.

Given the significant changes in family formation through donation procedures, providing an optimal level of care that is responsive to the needs of mothers who get pregnant via oocyte donation is pivotal to improve their maternal role. Therefore, it is necessary to recognize the needs of oocyte donation mothers to address their specific needs. This study aimed to review the needs of women in their journey towards motherhood via oocyte donation. In this systematic review, which followed the updated Joanna Briggs Institute's methodological guidance for conducting a mixed methods systematic review, the quantitative observational and qualitative studies were searched through databases including PubMed, Web of Science, PsycINFO, the Cochran Library, and Google Scholar search engine. Letters to the editor, commentaries, magazine articles, articles without full text and abstracts presented in congresses were excluded. All English-language articles related to the needs of oocyte donation mothers, without time limitation, were reviewed. The eligible studies were critically appraised independently by 2 researchers. 4649 records were identified from those 18 articles were finally included in the review. The needs of oocyte donation mothers comprised 8 categories: The need for special services in fertility clinics, the need to improve the quality of care, the need for emotional support and psychological consultation, information needs, the need for financial support, the need for disclosure counseling, educational needs, and the need for sociocultural and religious support. This review suggests various needs of oocyte donation mothers. The results can be used in carefully planning supportive programs for this vulnerable population.

How two wrongs may make a right, but four do not – The interesting case of Dutch employers’ liability

Dutch employers’ liability for workplace accidents is a very interesting topic, not only from a legal perspective, but also from a law and economics one. It is one of the few systems in Europe where liability is still based on the fault of the employer, whereas most countries apply a form of strict/no-fault liability or a system of no-fault insurance. It is interesting because the Dutch Civil Code explicitly refers to prevention of work-related losses. Law and economics focuses exactly on the behavioural incentives that are provided by tort liability, instead of on the compensation aspect. In this article, I provide an answer to the question of how Dutch employers’ liability compares to the law and economics desiderata. At first glance, the design of this type of liability (fault liability) is contrary to what law and economics would advocate (strict liability). In addition, the level of care that courts require from the employer seems to be excessively high. Interestingly, both characteristics together result in a situation which, from a law and economics perspective, is almost indistinguishable from the desired strict liability. So, two wrongs may make a right: the ‘wrong’ choice for fault liability combined with the ‘wrong’ level of due care results in the ‘right’ application of (quasi) strict liability. Therefore, at least in theory, employers receive the correct behavioural incentives, which induce them to take the optimal level of care and activity. However, when we subsequently turn our attention to employees, things look less perfect. Law and economics scholars argue that in situations where not only the tortfeasor but also the victim can influence accident probability, both parties should receive behavioural incentives. This implies that a rule of strict liability should be accompanied by a defence of contributory or comparative negligence. The Dutch employer liability regime contains a defence of intent or wilful recklessness on the part of the employee. From a law and economics perspective, this defence provides inadequate incentives to the employee, which is a third wrong. An often-heard response to this line of reasoning is that tort victims will receive behavioural incentives for fear of being involved in an accident in the first place, so the lack of a full defence of contributory or comparative negligence is not problematic. If this is true, then the damages the victims receive do not make them ‘whole’, which introduces a fourth wrong: uncompensated losses. This second set of two wrongs does not make a right, because if victims receive incomplete compensation, tortfeasors do not fully pay for the losses they have caused. This may reduce the behavioural incentives the tortfeasors receive, who may hence not choose optimal levels of care and activity after all.

Uncovering the Model and Philosophy of Care of a Psychiatric Inpatient Mother-Baby Unit in a Qualitative Study with Staff.

The postnatal period is high-risk time for the first onset and recurrence of maternal mental health disorders. Untreated maternal mental illness can have significant adverse impacts on a woman, her baby, and the wider family unit. For women with mental illnesses that cannot be managed in the community, psychiatric inpatient mother-baby units are the gold standard treatment whereby mothers are co-admitted with their infant for specialist perinatal and infant mental health assessment and treatment. The study explores the model of care and examines the philosophies of care that are used within a psychiatric mother-baby unit. Purposive sampling was used to conduct semi-structured focus group and individual interviews with multidisciplinary staff members at a single mother-baby unit. Themes derived from these interviews were coded into two primary themes and a range of sub-themes. The first primary theme focused on the Model of Care consisting of the following sub-themes: mental health care, physical health care, babies’ care, building mother-baby relationship, fostering relationships with supports, and facilitating community support. The second primary theme centered around the Philosophy of Care comprising of: person-centered care, trauma-informed care, compassion-centered care, recovery-oriented care, attachment-informed care, non-judgmental care, strengths-based care and interdisciplinary care. The model can be used to provide consistency across mother-baby units and to support core capabilities of staff in providing an optimal level of care.

Machine learning based forecast for the prediction of inpatient bed demand

BackgroundOvercrowding is a serious problem that impacts the ability to provide optimal level of care in a timely manner. High patient volume is known to increase the boarding time at the emergency department (ED), as well as at post-anesthesia care unit (PACU). Furthermore, the same high volume increases inpatient bed transfer times, which causes delays in elective surgeries, increases the probability of near misses, patient safety incidents, and adverse events.ObjectiveThe purpose of this study is to develop a Machine Learning (ML) based strategy to predict weekly forecasts of the inpatient bed demand in order to assist the resource planning for the ED and PACU, resulting in a more efficient utilization.MethodsThe data utilized included all adult inpatient encounters at Geisinger Medical Center (GMC) for the last 5 years. The variables considered were class of inpatient encounter, observation, or surgical overnight recovery (SORU) at the time of their discharge. The ML based strategy is built using the K-means clustering method and the Support Vector Machine Regression technique (K-SVR).ResultsThe performance obtained by the K-SVR strategy in the retrospective cohort amounts to a mean absolute percentage error (MAPE) that ranges between 0.49 and 4.10% based on the test period. Additionally, results present a reduced variability, which translates into more stable forecasting results.ConclusionsThe results from this study demonstrate the capacity of ML techniques to forecast inpatient bed demand, particularly using K-SVR. It is expected that the implementation of this model in the workflow of bed capacity management will create efficiencies, which will translate in a more reliable, inexpensive and timely care for patients.

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country.

BackgroundCOVID-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources.MethodsA single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23.ResultsAmong 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5).ConclusionThere was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.

Unreasonable: A Strict Liability Solution to the FTC’s Data Security Problem

For over two decades, the FTC creatively employed its capacious statute to police against shoddy data practices. Although the FTC’s actions were arguably needed at the time to fill a gap in enforcement, there are reasons to believe that its current approach has outlived its usefulness and is in serious need of updating. In particular, our analysis shows that the FTC’s current approach to data security is unlikely to instill anything close to optimal incentives for data holders. These shortcomings cannot be fixed through changes to the FTC enforcement approach, as they are largely generated by a mismatch between the tools that Congress gave it over a century ago and what it needs to foster firms’ incentives to mimic socially optimal levels of care for the data they hold. Not only does the current framework likely suffer from informational deficiencies attendant to its focus on “reasonable” security that render liability standards uncertain, it also lacks the ability to obtain the type of relief that will force firms to internalize the costs of their data security decisions. We examine the problem of data security enforcement through the lens of the economics of optimal precautions and identify several reasons why a strict liability regime administered by the FTC, under which firms pay for the expected harm from breaches they cause, is likely to be superior to the current framework that revolves around the concept of reasonableness. The benefits of strict liability flow from the likelihood that firms do not fully internalize the costs and benefits of their data security decisions and the relatively large informational burdens associated with measuring actual and optimal care under a negligence regime. We also show why in this informational environment, strict liability is better than negligence for developing a vibrant cyber insurance market, allowing for data security regulation to be de facto outsourced to insurers who will contract with firms for optimal levels of care. Because these private contracts will harness private information on costs and benefits from precautions, they are likely to incentivize more efficient behavior.

An Evaluation of Severe Anesthetic-Related Critical Incidents and Risks From the South African Paediatric Surgical Outcomes Study: A 14-Day Prospective, Observational Cohort Study of Pediatric Surgical Patients.

Severe anesthetic-related critical incident (SARCI) monitoring is an essential component of safe, quality anesthetic care. Predominantly retrospective data from low- and middle-income countries (LMICs) report higher incidence but similar types of SARCI compared to high-income countries (HIC). The aim of our study was to describe the baseline incidence of SARCI in a middle-income country (MIC) and to identify associated risk for SARCI. We hypothesized a higher incidence but similar types of SARCI and risks compared to HICs. We performed a 14-day, prospective multicenter observational cohort study of pediatric patients (aged <16 years) undergoing surgery in government-funded hospitals in South Africa, a MIC, to determine perioperative outcomes. This analysis described the incidence and types of SARCI and associated perioperative cardiac arrests (POCAs). We used multivariable logistic regression analysis to identify risk factors independently associated with SARCI, including 7 a priori variables and additional candidate variables based on their univariable performance. Two thousand and twenty-four patients were recruited from May 22 to August 22, 2017, at 43 hospitals. The mean age was 5.9 years (±standard deviation 4.2). A majority of patients during this 14-day period were American Society of Anesthesiologists (ASA) physical status I (66.4%) or presenting for minor surgery (54.9%). A specialist anesthesiologist managed 59% of cases. These patients were found to be significantly younger (P < .001) and had higher ASA physical status (P < .001). A total of 426 SARCI was documented in 322 of 2024 patients, an overall incidence of 15.9% (95% confidence interval [CI], 14.4-17.6). The most common event was respiratory (214 of 426; 50.2%) with an incidence of 8.5% (95% CI, 7.4-9.8). Six children (0.3%; 95% CI, 0.1-0.6) had a POCA, of whom 4 died in hospital. Risks independently associated with a SARCI were age (adjusted odds ratio [aOR] = 0.95; CI, 0.92-0.98; P = .004), increasing ASA physical status (aOR = 1.85, 1,74, and 2.73 for ASA II, ASA III, and ASA IV-V physical status, respectively), urgent/emergent surgery (aOR = 1.35, 95% CI, 1.02-1.78; P = .036), preoperative respiratory infection (aOR = 2.47, 95% CI, 1.64-3.73; P < .001), chronic respiratory comorbidity (aOR = 1.75, 95% CI, 1.10-2.79; P = .018), severity of surgery (intermediate surgery aOR = 1.84, 95% CI, 1.39-2.45; P < .001), and level of hospital (first-level hospitals aOR = 2.81, 95% CI, 1.60-4.93; P < .001). The incidence of SARCI in South Africa was 3 times greater than in HICs, and an associated POCA was 10 times more common. The risk factors associated with SARCI may assist with targeted interventions to improve safety and to triage children to the optimal level of care.

Association of Hospital-Level Intensive Care Unit Use and Outcomes in Older Patients With Isolated Rib Fractures

The optimal level of care for older patients with rib fractures as an isolated injury is unknown. To characterize interhospital variability in intensive care unit (ICU) vs non-ICU admission of older patients with isolated rib fractures and to evaluate whether greater hospital-level use of ICU admission is associated with improved outcomes. This cohort study included trauma patients aged 65 years and older with isolated rib fractures who were admitted to US trauma centers participating in the National Trauma Data Bank between January 1, 2015, and December 31, 2016. Patients were excluded if they had other significant injuries, were intubated or had assisted respirations in the emergency department (ED), or had a Glasgow Coma Scale (GCS) score of less than 9 in the ED. Hospitals with fewer than 10 eligible patients were excluded. Data analysis was conducted from May 2019 through September 2020. Admission to the ICU. Composite of unplanned intubation, pneumonia, or death during hospitalization. Among 23 951 patients (11 066 [46.2%] women; mean [SD] age, 77.0 [7.2] years) at 573 hospitals, the median (interquartile range) proportion of ICU use was 16.7% (7.4%-32.0%), but this varied from a low of 0% to a high of 91.9%. The composite outcome occurred in 787 patients (3.3%), with unplanned intubation in 317 (1.3%), pneumonia in 180 (0.8%), and death in 451 (1.9%). Accounting for the hierarchical nature of the data and adjusting for propensity scores reflecting factors associated with ICU admission, receiving care at a hospital with the greatest ICU use (quartile 4), compared with a hospital with the lowest ICU use, was associated with decreased likelihood of the composite outcome (adjusted odds ratio, 0.71; 95% CI, 0.55-0.92). In this study, admission location of older patients with isolated rib fractures was variable across hospitals, but hospitalization at a center with greater ICU use was associated with improved outcomes. It may be warranted for hospitals with low ICU use to admit more such patients to an ICU.

Economic Analysis of Accident Law: A New Liability Rule that Induces Socially Optimal Behaviour in Case of Limited Information

Abstract In accident law, we seek a liability rule that will induce both the parties to adopt socially optimal levels of precaution. Economic analysis, however, shows that none of the commonly used liability rules induce both parties to adopt optimal levels, if courts have access only to ‘Limited Information’ on. In such a case, it has also been established (K. (2006). Efficiency of liability rules: a reconsideration. J. Int. Trade Econ. Dev. 15: 359–373) that no liability rule based on cost justified untaken precaution as a standard of care can be efficient. In this paper, we describe a two-step liability rule: the rule of negligence with the defence of relative negligence. We prove that this rule has a unique Nash equilibrium at socially optimal levels of care for the non-cooperative game, and therefore induces both parties to adopt socially optimal behaviour even in case of limited information.

Patients’ aged ≥65 years dispositions during ambulance assignments, including factors associated with non-conveyance to hospital: a longitudinal and comparative study

ObjectivesPatients ≥65 years old represent 30%–50% of all ambulance assignments (AAs), and the knowledge of which care level they are disposed to is limited and diverging. The aim of this...

Prehospital lactate clearance is associated with reduced mortality in patients with septic shock.

Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, blood lactate measurement is broadly used in combination with the clinical evaluation of patients as the clinical picture alone is not sufficient for assessing disease severity and outcomes. From 15th April 2017 to 15th April 2019, patients with SS requiring prehospital mobile Intensive Care Unit intervention (mICU) were prospectively included in this observational study. Prehospital blood lactate clearance was estimated by the difference between prehospital (time of first contact between the patients and the mICU prior to any treatment) and in-hospital (at hospital admission) blood lactate levels divided by prehospital blood lactate. Among the 185 patients included in this study, lactate measurement was missing for six (3%) in the prehospital setting and for four (2%) at hospital admission, thus 175 (95%) were analysed for prehospital blood lactate clearance (mean age 70±14years). Pulmonary, digestive and urinary infections were probably the cause of the SS in respectively 56%, 22% and 10% of the cases. The 30-day overall mortality was 32%. Mean prehospital blood lactate clearance was significantly different between patients who died and those who survived (respectively 0.41±2.50mmol.l-1 vs 1.65±2.88mmol.l-1, p=0.007). Cox regression analysis showed that 30-day mortality was associated with prehospital blood lactate clearance>10% (HRa [CI95]=0.49 [0.26-0.92], p=0.028) and prehospital blood lactate clearance<10% (HRa [CI95]=2.04 [1.08-3.84], p=0.028). A prehospital blood lactate clearance<10% is associated with 30-day mortality increase in patients with SS handled by the prehospital mICU. Further studies will be needed to evaluate if prehospital blood lactate clearance alone or combined with clinical scores could affected the triage decision-making process for those patients.

Pre-Hospital Lactatemia Predicts 30-Day Mortality in Patients with Septic Shock-Preliminary Results from the LAPHSUS Study.

Background: Assessment of disease severity in patients with septic shock (SS) is crucial in determining optimal level of care. In both pre- and in-hospital settings, the clinical picture alone is not sufficient for assessing disease severity and outcomes. Because blood lactate level is included in the clinical criteria of SS it should be considered to improve the assessment of its severity. This study aims to investigate the relationship between pre-hospital blood lactate level and 30-day mortality in patients with SS. Methods: From 15 April 2017 to 15 April 2019, patients with SS requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were prospectively included in the LAPHSUS study, an observational, non-randomized controlled study. Pre-hospital blood lactate levels were measured at the time of first contact between the patients and the MICU. Results: Among the 183 patients with septic shock requiring action by the MICU drawn at random from LAPHSUS study patients, six (3%) were lost to follow-up on the 30th day and thus 177 (97%) were analyzed for blood lactate levels (mean age 70 ± 14 years). Pulmonary, urinary and digestive infections were probably the cause of the SS in respectively 58%, 21% and 11% of the cases. The 30-day overall mortality was 32%. Mean pre-hospital lactatemia was significantly different between patients who died and those who survived (respectively 7.1 ± 4.0 mmol/L vs. 5.9 ± 3.5 mmol/L, p < 10−3). Using Cox regression analysis adjusted for potential confounders we showed that a pre-hospital blood lactate level ≥ 4 mmol/L significantly predicted 30-day mortality in patients with SS (adjusted hazard ratio = 2.37, 95%CI (1.01–5.57), p = 0.04). Conclusion: In this study, we showed that pre-hospital lactatemia predicts 30-day mortality in patients with septic shock handled by the MICU. Further studies will be needed to evaluate if pre-hospital lactatemia alone or combined with clinical scores could affect the triage decision-making process for those patients.

Hospital-level intensive care unit admission for patients with isolated blunt abdominal solid organ injury.

The optimal level of care for hemodynamically stable patients with isolated blunt hepatic, renal, or splenic injuries (solid organ injuries [SOIs]) is unknown. We sought to characterize interhospital variability in intensive care unit (ICU) admission of such patients and to determine whether greater hospital-level ICU use would be associated with improved outcomes. We conducted a retrospective cohort study using the 2015 and 2016 National Trauma Data Bank. We included adult patients with blunt trauma with SOIs with an Abbreviated Injury Scale score of 2 to 4. We excluded patients with other significant injuries, hypotension, or another indication for ICU admission, and hospitals with less than 10 eligible patients. We categorized hospitals into quartiles based on the proportion of eligible patients admitted to an ICU. The primary outcome was a composite of organ failure (cardiac arrest, acute lung injury/acute respiratory failure, or acute kidney injury), infection (sepsis, pneumonia, or catheter-related blood stream infection), or death during hospitalization. Among 14,312 patients at 444 facilities, 7,225 (50%), 5,050 (35%), and 3,499 (24%) had splenic, hepatic, and renal injuries, respectively. The median proportion of ICU use was 44% (interquartile range, 27-59%, range 0-95%). The composite outcome occurred in 180 patients (1.3%), with death in 76 (0.5%), organ failure in 97 (0.7%), and infection in 53 (0.4%). Relative to hospitals with the lowest ICU use (quartile 1), greater hospital-level ICU use was not associated with decreased likelihood of the composite outcome (adjusted odds ratios, 1.31; 95% confidence interval [95% CI], 0.88-1.95; 0.81; 95% CI, 0.52-1.26; and 0.94; 95% CI, 0.62-1.43 for quartiles 2-4, respectively) or its components. Unplanned ICU transfer was no more likely with lower hospital-level ICU use. Admission location of stable patients with isolated mild to moderate abdominal SOIs is variable across hospitals, but hospitalization at a facility with greater ICU use is not associated with substantially improved outcomes. Therapeutic/care management, Level IV.

An Unreasonable Solution: Rethinking the FTC's Current Approach to Data Security

For over two decades, the FTC creatively employed its capacious statute to police against shoddy data practices. Although the FTC’s actions arguably were needed at the time to fill a gap in enforcement, there are reasons to believe that its current approach has outlived its usefulness and is in serious need of updating. In particular, our analysis shows that the FTC’s current approach to data security is unlikely to instill anything close to optimal incentives for data holders. These shortcomings cannot be fixed through changes to the FTC enforcement approach, as they are largely generated by a mismatch between the tools that Congress gave it over a century ago and what it needs to foster firms’ incentives to mimic socially optimal levels of care for the data they hold. Not only does the current framework likely suffer from informational deficiencies attendant to its focus on “reasonable” security that render liability standards uncertain, it also lacks the ability obtain the type of relief that will force firms to internalize the costs of their data security decisions. We examine the problem of data security enforcement through the lens of the economics of optimal precautions and identify several reasons why a strict liability regime administered by the FTC, under which firms pay for the expected harm from breaches they cause, is likely to be superior to the current framework that revolves around the concept of reasonableness. The benefits from strict liability flow from the likelihood that firms do not fully internalize the costs and benefits of their data security decisions and the relatively large informational burdens associated with measuring actual and optimal care under a negligence regime. We also show why in this informational environment strict liability is better than negligence for developing a vibrant market for cyber insurance, which will allow data security regulation to be de facto outsourced to insurers who will contract with firms for optimal levels of care. Because these private contracts will harness private information on costs and benefits from precautions, they are likely to incentivize more efficient behavior.

POSSUM and P-POSSUM Scoring in Hip Fracture Mortalities.

Introduction:Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) are general surgical tools used to efficiently assess mortality and morbidity risk. Data suggest that these tools can be used in hip fracture patients to predict morbidity and mortality; however, it is unclear what score indicates a significant risk on a case-by-case basis. We examined the POSSUM and P-POSSUM scores in a group of hip fracture mortalities in order to assess their accuracy in identification of similar high-risk patients.Materials and Methods:Retrospective analysis of all consecutive mortalities in hip fracture patients at a single tertiary care center over 2 years was performed. Patient medical records were examined for baseline demographics, fracture characteristics, surgical interventions, and cause of death. Twelve physiological and 6 operative variables were used to retrospectively calculate POSSUM and P-POSSUM scores at the time of injury.Results:Forty-seven hip fracture mortalities were reviewed. Median patient age was 88 years (range: 56-99). Overall, 68.1% (32) underwent surgical intervention. Mean predicted POSSUM morbidity and mortality rates were 73.9% (28%-99%) and 31.1% (5%-83%), respectively. The mean predicted P-POSSUM mortality rate was 26.4% (1%-91%) and 53.2% (25) had a P-POSSUM predicted mortality of >20%. Subgroup analysis demonstrated poor agreement between predicted mortality and observed mortality rate for POSSUM in operative (χ2 = 127.5, P < .00001) and nonoperative cohorts (χ2 = 14.6, P < .00001), in addition to P-POSSUM operative (χ2 = 101.9, P < .00001) and nonoperative (χ2 = 11.9, P < .00001) scoring.Discussion/Conclusion:Hip fracture patients are at significant risk of both morbidity and mortality. A reliable, replicable, and accurate tool to represent the expected risk of such complications could help facilitate clinical decision-making to determine the optimal level of care. Screening tools such as POSSUM and P-POSSUM have limitations in accurately identifying high-risk hip fracture patients.

The Case for Individual Audit Partner Accountability

Despite repeated regulatory interventions, accounting failures continue to persist in companies around the world. In this Article, I explain why current law, private enforcement, and firm-level reputational sanctions are unlikely to induce accountants to take optimal levels of care when auditing corporate financials. Instead, our best chance for improving audit quality lies in establishing a market for individual audit partners’ brands — a market that can hold individual auditors responsible for their mistakes. The Article begins by identifying four key benefits to this approach. First, forcing auditors to be publicly associated with any audit failures occurring on their watch will induce them to increase their effort in order to avoid the stigma of failure. Second, now that a significant portion — frequently more than half—of audit hours are performed overseas, holding a single individual publicly accountable for any audit failures will improve monitoring of auditors in other jurisdictions. Third, in light of significant evidence of variation in the quality of audit partners — even partners within the same firm — exposing that heterogeneity will empower members of audit committees and investors to choose auditors more carefully. Finally, commoditizing individual auditors could increase industry competition without the need for aggressive regulatory action. The Article then argues that, in order to spur the development of a market in auditor reputation, lawmakers should encourage the development of Auditor Scorecards. To do so, regulators should require the disclosure of additional auditor-level information, and should ensure useful information is provided through enforcement actions. Although there are costs to these changes, those costs are likely to be outweighed by giving investors the information they need to develop a common Scorecard for auditor quality. Such Scorecards will help boards and investors make better use of the legal tools already at their disposal to hold auditors accountable when they fail in their gatekeeping function.

A reflective qualitative appreciative inquiry approach to restoring compassionate care deficits at one United Kingdom health care site

Following declining health care practices at one UK health care site the subsequent and much publicized Francis Report made several far-reaching recommendations aimed at recovering optimal levels of care including stringent monitoring of practice. The aftermath of these deliberations have had resounding consequences for quality care both nationally and internationally. A reflective qualitative appreciative qualitative inquiry using a hybrid approach combining case study and thematic analysis outlines the development and analysis of a solution-focused intervention aimed at restoring staff confidence and optimal care levels at one key UK hospital site. Personal diaries were used to collect data. Data were analysed using descriptive thematic analysis. The implications of the five emerging themes and the 10-step approach used are discussed in the context of understanding care erosion and ways to effect organisational change. A novel approach to addressing care deficits, which provides a promising bottom-up approach, initiated by health care policy makers is suggested for use in other health care settings when concerns about care arise. It is anticipated this approach will prove useful for nurse managers, particularly in relation to finding positive solutions to addressing problems that surround potential failing standards of care in hospitals.