Patients In Acute Care Facilities Research Articles

Patient experiences and needs in cancer care– results from a nationwide cross-sectional study in Germany

BackgroundPatient-centredness has become a central quality indicator for oncology care. Elements include shared decision-making, patient navigation and integration of psychosocial care, which impact patient-reported and clinical outcomes. Despite efforts to promote patient-centred care in Germany in recent decades, implementation remains fragmented. Further, research on patient experiences with cancer care and its determinants is limited. Therefore, this study examines which patient- and facility-specific factors are associated with patient-centred quality care delivery.MethodsA cross-sectional study was conducted among 1,121 cancer patients in acute treatment, rehabilitation, and aftercare for different cancer entities across Germany. A participatory developed questionnaire was used. Outcome measures were the quality of physician-patient interaction and provision of psychosocial care during acute care. Predictors comprised patient-specific characteristics and treatment facility-specific factors. Multiple linear regression and multivariate binary logistic regression analyses were performed. In addition, a content analysis of open-ended comments on the patients’ overall cancer care needs was applied.ResultsMultiple linear regression analysis showed recent diagnosis (β=−0.12, p = < 0.001), being male (β=−0.11, p = 0.003), and having a preference for passive decision-making (β=−0.10, p = 0.001) to be significantly associated with higher interaction quality, but not age, education and health insurance type. An overall low impact of patient characteristics on interaction quality was revealed (adj. R2 = 0.03). Binary logistic regression analysis demonstrated the availability of central contact persons (OR = 3.10, p < 0.001) followed by recent diagnosis (p < 0.001), having breast cancer (p < 0.001) and being female (OR = 1.68, p < 0.05) to significantly predict offering psycho-oncological counselling to patients in acute care facilities. The availability of peer support visiting services (OR = 7.17, p < 0.001) and central contact persons (OR = 1.87, p < 0.001) in the care facility, breast cancer diagnosis (p < 0.001) and a higher level of education (p < 0.05) significantly increased the odds of patients receiving information about peer support in the treatment facility. Despite relatively satisfactory quality of physician-patient interactions in cancer care (M = 3.5 (± 1.1)), many patients expressed that better patient-centred communication and coordinated, comprehensive cancer care are needed.ConclusionThe findings reflect effective developments and improvements in cancer care and suggest that patients’ social characteristics are less decisive for delivering patient-centred quality care than systemic factors surrounding the care facilities. They can serve to inform oncology care in Germany.

A 6-Year Review of Carbapenemase-Producing Organisms in Alberta, Canada

Background: This review describes the epidemiology of carbapenemase-producing organisms (CPO) in both the community and hospitalized populations in the province of Alberta. Methods: Newly identified CPO-positive individuals from April 1, 2013, to March 31, 2018, were retrospectively reviewed from 3 data sources, which shared a common provincial CPO case definition: (1) positive CPO results from the Provincial Laboratory for Public Health, which provides all referral and confirmatory CPO testing, (2) CPO cases reported to Alberta Health, and (3) CPO surveillance from Alberta Health Services Infection Prevention and Control (IPC). The 3 data sources were collated, and initial CPO cases were classified according to their likely location of acquisition: hospital-acquired, hospital-identified, on admission, and community-identified. Risk factors and adverse outcomes were obtained from linkage to administrative data. Results: In total, 171 unique individuals were newly identified with a first-time CPO case. Also, 15% (25 of 171) were hospital-acquired (HA), 21% (36 of 171) were hospital-identified (HI), 33% (57 of 171) were on admission, and 31% (53 of 171) were community identified. Overall, 9% (5 of 171) resided in long-term care facilities. Of all patients in acute-care facilities, 30% (35 of 118) had infections and 70% were colonized. Overall, 38% (65 of 171) had an acute-care admission in the 1 year prior to CPO identification; 59% (63 of 106) of those who did not have a previous admission had received healthcare outside Alberta. A large proportion of on-admission cases (81%, 46 of 57) and community-identified (66%, 33 of 53) cases did not have any acute-care admissions in Alberta in the previous year. Overall, 10% (14 of 171) had ICU admissions in Alberta within 30 days of CPO identification, and 5% (8 of 171) died within 30 days. The most common carbapenemase gene identified was NDM-1 (53%, 90 of 171). Conclusions: These findings highlight the robust nature of Alberta’s provincial CPO surveillance network. We reviewed 3 different databases (laboratory, health ministry, IPC) to obtain comprehensive data to better understand the epidemiology of CPO in both the community and hospital settings. More than half of the individuals with CPO were initially identified in the community or on admission. Most had received healthcare outside Alberta, and no acute-care admissions occurred in Alberta in the previous year. It is important to be aware of the growing reservoir of CPO outside the hospital setting because it could impact future screening and management practices.Funding: NoneDisclosures: None

Incontinence-Associated Dermatitis, Characteristics and Relationship to Pressure Injury: A Multisite Epidemiologic Analysis.

PURPOSE:The purpose of this study was to measure the prevalence of incontinence-associated dermatitis (IAD) among incontinent persons in the acute care setting, characteristics of IAD in this group, and associations among IAD, urinary, fecal, and dual incontinence, immobility, and pressure injury in the sacral area.DESIGN:Descriptive and correlational analysis of data from a large database of IAD, and pressure injuries of sacral area and heels.SUBJECTS AND SETTING:The sample comprised 5342 adult patients in acute care facilities in 36 states representing all regions of the United States. Facilities used a variety of products for prevention of IAD and sacral area pressure injuries.METHODS:Data were collected for use in a national quality improvement study evaluating current practices related to the prevention of IAD and pressure injuries affecting the sacral area and heels. Data were exported to a spreadsheet, and triple checked for accuracy before being imported to a statistical analysis software program. Descriptive statistics were used to describe prevalence rates for incontinence, types of incontinence, IAD, characteristics of IAD, and pressure injuries. Multivariate logistic regression analysis was conducted on the end point of facility-acquired sacral/buttock pressure injury and the risk factors of immobility and type of incontinence.RESULTS:More than one-third of patients (n = 2492 of 5342 patients; 46.6%) were incontinent of urine, stool, or both. The overall prevalence rate of IAD was 21.3% (1140/5342); the prevalence of IAD among patients with incontinence was 45.7% (1140/2492). Slightly more than half of the IAD was categorized as mild (596/1140, 52.3%), 27.9% (318/1140) was categorized as moderate, and 9.2% (105/1140) was deemed severe. In addition, 14.8% (169/1140) of patients with IAD also had a fungal rash. The prevalence of pressure injury in the sacral area among individuals with incontinence was 17.1% (427/2492), and the prevalence of full-thickness pressure injury in this population was 3.8% (95/2492). Multivariate analysis revealed that both presence of IAD (odds ratio [OR], 4.56; 95% confidence interval [CI], 3.68-5.65) and immobility (OR, 3.56; 95% CI, 2.73-4.63) was associated with a significantly increased likelihood of developing a sacral pressure injury. Multivariate analysis also revealed that presence of IAD (OR, 2.65; 95% CI, 1.74-4.03) and immobility (OR, 6.05; 95% CI, 3.14-11.64) was associated with a significantly increased likelihood of developing full-thickness sacral pressure injury.CONCLUSION:Our study findings are consistent with prior research, supporting a clinically relevant association between IAD and pressure injury of the sacral area. This risk persists even after controlling for presence of immobility, suggesting that IAD functions as an independent risk factor for pressure injury occurrence.

Using heel protectors for the prevention of hospital-acquired pressure ulcers.

Pressure ulcers are a frequent, but often preventable, occurrence among patients in acute care facilities, and the heel is one of the anatomical locations most commonly affected. Multiple clinical guidelines recommend the use of robust assessments to identify at-risk patients and the application of heel protection devices to reduce the likelihood of developing heel pressure ulcers. A quality improvement initiative involving robust skin-assessment practices, staff education, and the use of heel protection devices was analysed retrospectively to evaluate the efficacy of current practice interventions. These analyses revealed that the incidence of heel pressure ulcers was inversely correlated with the number of heel protectors used at two large acute NHS teaching hospitals in inner London, and that the consistent and early use of heel protectors improved patient outcomes and reduced costs of care.

Preventing Ventilator-Associated Pneumonia : A Nursing - Intervention Bundle

Among critically ill patients in acute-care facilities, pneumonia is one of the most common hospital acquired infections. Ventilator Associated Pneumonia (VAP) is the most common nosocomial infection in intensive care units (ICU), and represents 31% of all ICU acquired infections. As VAP is linked with higher morbidity, mortality and costs, preventing ventilated patients from developing VAP is an important patient safety objective. The autonomous nursing-intervention bundle interrupted transmission of microorganisms to the lower respiratory tract. This bundle matches interventions with the two processes known to cause VAP. Bundling the interventions significantly contributed to reducing VAP in critically ill patients, indicating that applying consistent interventions can reduce risk and improve patient outcomes. The concept of matching interventions to the cause of a specific problem can be generalized to address other healthcare challenges. Once interventions are matched to the cause of the problem, nursing interventions can be bundled and evidence can be incorporated into nursing practice and policy.The literature includes extensive discussion of VAP diagnosis and treatment, along with interventions attributed to reducing its incidence. This article describes a “bundle” of autonomous nursing interventions that can help prevent both of the etiologic processes above and improve patient outcomes

Venous thromboembolism risk and prophylaxis in the acute hospital care setting: report from the ENDORSE study in Egypt

BackgroundVenous thromboembolism (VTE) is a leading cause of hospital-related deaths worldwide. However, the proportion of patients at risk of VTE who receive appropriate prophylaxis in Egypt is unknown. The ENDORSE study in Egypt is part of a global initiative to uncover the incidence of high-risk surgical and medical patients and determine what proportion of these patients receive appropriate VTE prophylaxis.MethodsTen Egyptian hospitals participated in this observational study, enrolling all surgical and medical patients that met the study criteria. This resulted in a cohort of 1,008 patients in acute care facilities who underwent a retrospective chart review. Each patient’s VTE risk status and the presence or absence of appropriate prophylactic care was assessed according to the American College of Chest Physicians (ACCP) guidelines 2004.ResultsOf the 1,008 patients enrolled, 395 (39.2%) were found to be at high-risk for VTE. Overall, 227 surgical patients were at high-risk, although only 80 (35.2%) received ACCP-recommended prophylaxis. Similarly, 55/268 (32.75%) of high-risk medical patients received appropriate VTE prophylaxis. Low molecular weight heparin was the most commonly used anticoagulant, while mechanical prophylactic use was quite low (1.5%) in high-risk patients.ConclusionsIn Egypt, more than one-third of all patients hospitalized for surgery or acute medical conditions are at high risk for developing VTE. However, only a small fraction of these patients receive appropriate VTE prophylaxis. Corrective measures are necessary for preventing VTE morbidity and mortality in these high risk patients.

Update on Tissue-Engineered Biological Dressings

Tissue-engineered biological dressings offer promise in the treatment of burns, chronic ulcers, donor site and other surgical wounds, and a variety of blistering and desquamating dermatologic conditions. For example, the prevalence of diabetic foot ulcers ranges from 4.4% to 10.5% of diabetics, resulting in 82,000 lower extremity amputations annually; venous leg ulcers affect 0.18% to 1.35% of the population; and pressure ulcers are found in 5.0% to 8.8% of institutionalized patients and 14.8% of patients in acute care facilities. Despite the large number of potential beneficiaries, cellular tissue-engineered products have suffered setbacks in recent years and have garnered considerably lower market share than commercial promoters anticipated. The mechanism of action of these products is not universally agreed upon, but delivery of growth factors and extracellular matrix components to the wound is thought to be important; graft "take" is not usually considered to occur. These "engineered" products do not specifically match a treatment modality to an underlying pathology. Clinical effect is often modest, and sometimes not justi- fiable from a cost-benefit perspective. Nevertheless, clinical reports in the literature of uses of tissueengineered biological dressings continue to mount, indicating that these products are finding niche applications where clinical utility is high and the cost can be defended. Despite commercial setbacks, the first-approved products, Dermagraft, Apligraf, and Cultured Epidermal Autograft (Epicel) are still being marketed, and new ones, such as OrCel, continue to be developed. The major indications for these products are summarized and a brief review of the available clinical literature is offered.

A randomized, placebo-controlled trial of parenteral hydration in terminally ill cancer patients

8004 Background: Most cancer patients develop decreased oral intake and dehydration before death. Parenteral hydration is provided to almost no patients in hospices and almost all patients in acute care facilities. Methods: 51 Patients with clinical evidence of mild to moderate dehydration and oral intake of less than 1000 ml per day were randomized to receive parenteral hydration with 1000 ml normal saline (SC or IV) versus placebo (100 ml normal saline SC or IV) over 4 hours on days 1 and 2. Patients were evaluated for target symptoms (hallucinations, myoclonus, fatigue and sedation), and global well being at baseline and on day 2 of the study using 0 to 10 numerical scales. Overall benefit of the treatment was assessed by the patient and the investigator using 1 to 7 scales. Results: 49 patients were evaluable (96%): 27 patients randomized to parenteral hydration had improvement in 53/73 (73%) evaluable target symptoms versus 33/67 (49%) in 22 patients who received placebo (p=0.005). 15/18 (83%) and 15/18 (83%) patients had improved myoclonus and sedation after hydration versus 8/17 (47%) and 5/15 (33%) after placebo (p=0.03 and p=0.005, respectively). There were no significant differences of improvement in hallucinations and fatigue. Patients assessed hydration as effective in 17/27 (63%) cases and placebo effective in 9/22 (41%) cases (p=0.78). Investigators found hydration was effective in 20/27 (74%) cases and placebo in 12/22 (54%) cases (p=0.15). The mean of pain and swelling at the injection site in subcutaneous hydration (n=20) and subcutaneous placebo (n=17) were 2.1 (+/-2.95) versus 1.75 (+/-2.55) (p=0.1), and 0.82 (+/-1.13) versus 1.41 (=/-1.66) (p=0.64), respectively. Conclusions: Parenteral hydration improved symptoms in terminally ill cancer patients with decreased fluid intake. Hydration was well tolerated and placebo effect were observed. Studies with longer follow-up are required. No significant financial relationships to disclose.

RISK FACTORS FOR NOSOCOMIAL PNEUMONIA: Focus on Prophylaxis

Despite an increased understanding of the pathogenesis of NP and advances in diagnosis and treatment, the risk, cost, morbidity, and mortality of NP remain unacceptably high. This article has identified strategic areas for primary and secondary prophylaxis that are simple and cost-effective. Realizing that the pathogenesis of NP requires bacterial colonization and the subsequent entry of these bacteria into the lower respiratory tree helps highlight the role of cross-infection and the importance of standard infection control procedures. Similarly the role of sedation and devices as risk factors can be reduced by minimizing the duration and intensity of sedation and length of exposure to invasive devices. Additional low-cost interventions that have been shown to be effective in preventing NP are the positioning of patients in a semirecumbent position and the appropriate use of enteral feeding, antibiotics, and selected medical devices. Prophylaxis of NP and VAP is carried out best by a multidisciplinary management team comprised of physicians (critical care, pulmonary medicine, infectious diseases, and primary care), critical care and infection control nurses, and respiratory therapists, even though this approach may result in decreased professional autonomy and freedom. This group should review the current guidelines, pathways, and standards for short-term and long-term prophylaxis of NP and VAP, then integrate them into and monitor their use for routine patient care. The risk factors and prophylaxis strategies for NP discussed in this article apply primarily to patients in acute care facilities, but also are relevant to alternative health care settings as well as the care of ill patients in ambulatory settings. The routine use of effective team policies for prophylaxis needs to be monitored by the Joint Commission for the Accreditation of Health Care or other agencies. Research to delineate the most effective and feasible strategies for prophylaxis NP has been compromised by insufficient funding and lack of adequate, randomized multicenter studies to enable generalizability of results. Effective strategies for prophylaxis have not been disseminated widely or implemented in hospitals. Successful short-term and long-term strategies for prophylaxis must be evaluated and implemented by a team of physicians, nurses, and respiratory therapists. More than 100 years ago, Sir William Osler warned health care providers, "Remember how much you don't know." The authors would add that clinicians have acquired significant knowledge about risk factors and prophylaxis of NP in the 1980s and 1990s, but prophylaxis as a theory rather than an action. If the tree has not been planted, the time is now.

Practice guideline for evaluation of fever and infection in long-term care facilities.

The elderly population (i.e., persons aged > or = 65 years) in the United States is rapidly expanding and will nearly double in number over the next 30 years. It is estimated that >40% of persons aged > or = 65 years will require care in a long-term care facility (LTCF), such as a skilled nursing facility (SNF), at some point during their lifetime. For the most part, residents of LTCFs are very old and have age-related immunologic changes, chronic cognitive and/or physical impairments, and diseases that alter host resistance; therefore, they are highly susceptible to infections and their complications. The diagnosis of infections in residents of LTCFs is often difficult because LTCFs differ from acute-care facilities in their goals of care, staffing ratios, types of primary care providers, availability of laboratory tests, and criteria for infections. Consequently, guidelines and standards of practice used for diagnosis of infections in patients in acute-care facilities may not be applicable nor appropriate for residents in LTCFs. Moreover, the clinical manifestations of diseases and infections are often subtle, atypical, or nonexistent in the very old. Fever may be low or absent in LTCF residents with infection. The initial evaluation of an LTCF resident suspected of an infection may not be done by a physician. Although nurses commonly perform initial assessments for infection in residents of LTCFs, further studies are needed to determine the appropriateness and validity of this practice. Provided there are no directives (advance or current by resident or caregiver) limiting diagnostic or therapeutic interventions, all residents of LTCFs with suspected symptomatic infection should have appropriate diagnostic laboratory studies done promptly, and the findings should be discussed with the primary care clinician (see Recommendations). The most common infections among LTCF residents are urinary tract infections, respiratory infections, skin or soft tissue infections, and gastroenteritis. Decisions concerning possible transfer of an LTCF resident to an acute-care facility are best expressed through an advance directive or, when not available, through transfer policies developed by the LTCF. In general, LTCF residents have been transferred to an acute-care facility when any of the following conditions exist: (1) the resident is clinically unstable and the resident or family goals indicate aggressive interventions should be initiated, (2) critical diagnostic tests are not available in the LTCF, (3) necessary therapy or the mode of administration of therapy (frequency or monitoring) are beyond the capacity of the LTCF, (4) comfort measures cannot be assured in the LTCF, and (5) specific infection-control measures are not available in the LTCF.

Practice Guideline for Evaluation of Fever and Infection in Long-Term Care Facilities

The elderly population (ie, persons aged 65 years) in the United States is rapidly expanding and will nearly double in number over the next 30 years. It is estimated that 40% of persons aged 65 years will require care in a long-term care facility (LTCF), such as a skilled nursing facility (SNF), at some point during their lifetime. For the most part, residents of LTCFs are very old and have age-related immunologic changes, chronic cognitive and/or physical impairments, and diseases that alter host resistance; therefore, they are highly susceptible to infections and their complications. The diagnosis of infections in residents of LTCFs is often difficult because LTCFs differ from acute-care facilities in their goals of care, staffing ratios, types of primary care providers, availability of laboratory tests, and criteria for infections. Consequently, guidelines and standards of practice used for diagnosis of infections in patients in acute-care facilities may not be applicable nor appropriate for residents in LTCFs. Moreover, the clinical manifestations of diseases and infections are often subtle, atypical, or nonexistent in the very old. Fever may be low or absent in LTCF residents with infection. The initial evaluation of an LTCF resident suspected of an infection may not be done by a physician. Although nurses commonly perform initial assessments for infection in residents of LTCFs, further studies are needed to determine the appropriateness and validity of this practice. Provided there are no directives (advance or current by resident or caregiver) limiting diagnostic or therapeutic interventions, all residents of LTCFs with suspected symptomatic infection should have appropriate diagnostic laboratory studies done promptly, and the findings should be discussed with the primary care clinician (see Recommendations). The most common infections among LTCF residents are urinary tract infections, respiratory infections, skin or soft tissue infections, and gastroenteritis. Decisions concerning possible transfer of an LTCF resident to an acute-care facility are best expressed through an advance directive or, when not available, through transfer policies developed by the LTCF. In general, LTCF residents have been transferred to an acute-care facility when any of the following conditions exist: (1) the resident is clinically unstable and the resident or family goals indicate aggressive interventions should be initiated, (2) critical diagnostic tests are not available in the LTCF, (3) necessary therapy or the mode of administration of therapy (frequency or monitoring) are beyond the capacity of the LTCF, (4) comfort measures cannot be assured in the LTCF, and (5) specific infectioncontrol measures are not available in the LTCF.

Long-Term Care Patients in Acute Care Facilities: Determining Discharge Arrangements

This research examined 201 hospitalized patients who underwent preadmission screening for Medicaid-reimbursed long-term care. Results suggest that these patients have substantial problems in health andfunctioning and may lack needed informal supports. Availability of community living space is consistently associated with authorization decisions for institutional versus community care and skilled versus intermediate institutional care, as well as expected length of stay in an institutional setting. We discuss implications for further research, nursing practice, and discharge planning strategies for long-term care patients in acute carefacilities.

Clinical Assessment of Cardiac Patients in Acute Care Facilities

Clinical assessment of the patient with an acute cardiac problem demands the totality of the nurse’s knowledge, skills, and special cardiac divination in sifting and sorting out pertinent data so that short- and long-term nursing care goals evolve as a natural consequence of the assessment. The patient’s clinical manifestations are the obvious clues by which nursing actions are innervated. The obscure or covert dangers are the predators that watchful observation can detect and prevent from developing into overt problems complicating an already acute illness. Cues to heart rate and rhythm, determination of the character of arterial and venous pulses, skin appearance and distribution of cyanosis, typical patient facies, and the art of listening and hearing the patient are the fundamentals of sophisticated clinical assessment accomplished by the “dramatic technology” of our own senses.