Patients In Different Settings Research Articles

Nurse Practitioners' Experiences of Transitioning to and Working in the Pioneering Nursing Role: An Interview Study.

Nurse practitioners (NPs) play a crucial role in healthcare by providing person-centred and high-quality care. Their contributions encompass enhanced accessibility to healthcare and reduced hospital admissions and cost-effectiveness. They usually hold a master's degree in nursing, incorporating expanded clinical skills to manage patients in different settings and address both nursing and medical needs. Despite the global development of the role, its implementation varies, presenting challenges related to role clarity, regulation and acceptance by other healthcare professionals. To explore how nurses who are or have been employed as NPs describe their experiences of transitioning to and working in the NP role in Sweden. A qualitative interview study. This study explores the experiences of 15 NPs in Sweden, using a snowball sampling strategy and semi-structured interviews. The data were collected through interviews in April and May 2022 and analysed with inductive content analysis. The present study explores the experiences of NPs as they transition from experienced nurses to NPs, emphasising motivations, educational challenges, acceptance and autonomy. Transitioning into the NP role initially brought isolation that evolved into acceptance. They recognised their strength in integrating medical and nursing competencies for holistic care. Leadership was pivotal, with managerial support crucial for the successful implementation of the role. Autonomy-related challenges, such as prescription rights and dependency on physicians, underscored the need for a protected professional title and national guidelines. This study enriches the evolution of the NP role in Sweden, offering vital insights into the ongoing national-level dialogues on NP role development in Sweden. The paper's relevance extends globally by providing valuable perspectives on NPs practicalities and fostering international understanding and advancement. Standards for reporting qualitative research. Not applicable.

Patient Satisfaction and Its Socio-Demographic Correlates in a Tertiary Hospital of Nepal.

Patient satisfaction is an integral component of patient care. This concept has been already integrated in the developed nations and the topic is getting interest in developing nations. Hence attempt has been made to address the satisfaction of the patients in different settings and hospitals. The objective of this study was to assess the satisfaction and likely sociodemographic factors affecting the satisfaction among the outpatients. A cross-sectional study was conducted among 207 outpatients visiting different departments of the hospital by systematic random sampling method. The satisfaction was assessed by the abbreviated form of Patient Satisfaction Questionnaire-18 and the mean scores of seven domains were obtained. Mean satisfaction level was 3.53(0.40) out of 5. Highest level of satisfaction was in interpersonal manner domain and the lowest in accessibility and convenience domain. None of the sociodemographic variables was significantly associated with the overall satisfaction (p>0.05). Enrollment into the national health insurance, occupation and educational status of the patients were found to significantly affect one or more domains. This study showed that the overall satisfaction was fair; hence there is room for improvement for better patient satisfaction. Hospital needs to focus on easy accessibility and convenience of the healthcare facilities and resources to the patients.

Prognostic Value of PCSK9 Levels in Premenopausal Women at Risk of Breast Cancer-Evidence from a 17-Year Follow-Up Study.

The involvement of cholesterol in cancer development remains a topic of debate, and its association with breast cancer has yet to be consistently demonstrated. Considering that circulating cholesterol levels depend on several concomitant processes, we tested the liability of plasma levels of proprotein convertase subtilisin/kexin type 9 (PCSK9), one of the key regulators of cholesterol levels, as a prognostic biomarker in the context of breast neoplastic events. Within a prospective randomized breast cancer prevention trial we measured baseline plasma levels of PCSK9. A total of 235 at-risk premenopausal women were randomized and followed up for 17 years. Participants enrolled in this placebo-controlled, phase II, double-blind trial were randomly assigned to receive either tamoxifen 5 mg/d or fenretinide 200 mg/d, both agents, or placebo for 2 years. The associations with breast cancer events were evaluated through competing risk and Cox regression survival models, adjusted for randomization strata (5-year Gail risk ≥ 1.3% vs. intraepithelial neoplasia or small invasive breast cancer of favorable prognosis), age, and treatment allocation. PCSK9 associations with biomarkers linked to breast cancer risk were assessed on blood samples collected at baseline. The plasmatic PCSK9 median and interquartile range were 207 ng/mL and 170-252 ng/mL, respectively. Over a median follow-up period of 17 years and 89 breast neoplastic events, disease-free survival curves showed a hazard ratio of 1.002 (95% CI: 0.999-1.005, p = 0.22) for women with PCSK9 plasma levels ≥ 207 ng/mL compared to women with levels below 207 ng/mL. No differences between randomization strata were observed. We found a negative correlation between PCSK9 and estradiol (r = -0.305), maintained even after partial adjustment for BMI and age (r = -0.287). Cholesterol (r = 0.266), LDL-C (r = 0.207), non-HDL-C (r = 0.246), remnant cholesterol (r = 0.233), and triglycerides (r = 0.233) also correlated with PCSK9. In premenopausal women at risk of early-stage breast cancer, PCSK9 did not appear to have a role as a prognostic biomarker of breast neoplastic events. Larger studies are warranted investigating patients in different settings.

The Uncommon White Cerebellum Sign in Three Patients in Different Settings

The white cerebellum sign is a rare, unusual but striking radiological sign encountered commonly in patients with severe and often irreversible anoxic-ischemic brain injury, usually due to extra-cranial causes. It is not frequently described and its pathophysiology is still controversial. Radiologically, it is characterized by cerebellar hyperdensity, associated with diffuse cerebral hemispheres hypoattenuation. Its identification by the radiologists is imperative as it is often associated with an unfavorable prognosis and poor outcome. In this paper, we report three cases of children with full clinical and imaging workup, in whom brain computed tomography (CT) scan revealed the white cerebellum sign. We discussed the relevance of this sign as it affects diagnosis, treatment, prognosis and equally reviewed the pertinent literatures.

Feasibility, Safety, and Efficacy of Aggressive Multimodal Management of Elderly Patients with Pancreatic Ductal Adenocarcinoma.

We aimed to evaluate the safety and efficacy of NAT followed by surgical resection in patients with PDAC aged ≥75 years. Whether administration of neoadjuvant therapy (NAT) followed by surgical resection in elderly patients with pancreatic ductal adenocarcinoma (PDAC) is safe and effective is unknown. The present study is a three-part comparison of older (≥ 75 years) versus younger (< 75 years) patients in different settings throughout the continuum of PDAC care. The first analysis was a comparison of older versus younger consecutive patients with non-metastatic PDAC who were initiated on FOLFIRINOX. The second was a comparison of older vs. younger patients who underwent NAT followed by surgical resection, and the third and final analysis was a comparison of older patients who underwent either NAT followed by surgical resection vs. upfront surgical resection. Postoperative complications, overall survival (OS), and time to recurrence (TTR), were compared. Propensity-score matching (PSM) analysis was performed to adjust for potential confounders. In the first analysis, a lower proportion of older patients (n=40) were able to complete the intended neoadjuvant FOLFIRINOX (8) cycles compared to younger patients (n=214) (65.0% vs. 81.4%, P=0.021). However, older patients were just as likely to undergo surgical exploration as younger patients (77.5% vs 78.5%, P=0.89) as well as surgical resection (57.5% vs 55.6%, P=0.70). In the second analysis, PSM was conducted to compare older (n=54) vs. younger patients (n=54) who underwent NAT followed by surgical resection. There were no significant differences in postoperative complications between the matched groups. While there was a significant difference in overall survival (OS) between older and younger patients (median OS: 16.43 months vs. 30.83 months, P=0.002), importantly, there was no significant difference in time to recurrence (TTR, median: 7.65 months vs. 11.83 months, P=0.215). In the third analysis, older patients who underwent NAT followed by surgical resection (n=48) were compared with similar older patients who underwent upfront surgical resection (n=48). After PSM, there was a significant difference in OS (median OS: 15.78 months vs. 11.51 months, P=0.037) as well as TTR (median TTR: 8.81 months vs. 7.10 months, P=0.046) representing an association with improved outcomes that favored the neoadjuvant approach among older patients alone. This comprehensive three-part study showed that administration of NAT followed by surgical resection appears to be safe and effective among patients ≥ 75 years of age. An aggressive approach should be offered to older adults undergoing multimodal treatment of PDAC.

The multidimensional prognostic index (MPI) predicts long-term mortality in old type 2 diabetes mellitus patients: a 13-year follow-up study

PurposeThe Multidimensional Prognostic Index (MPI) is a tool capable of holistically frame older patients in different settings and affected by different pathologies, establishing a risk of adverse events. Among them, type 2 diabetes mellitus (T2DM), a common metabolic disease in the elderly, is responsible for complications and deaths. Few previous works have focused specifically on MPI and DM, and none have followed up the patients for more than 3 years. The aim of the present study is to analyze MPI accuracy in predicting mortality in a cohort of T2DM patients followed-up for 13 years.MethodsThe enrolled subjects were evaluated with MPI, identifying three levels of risk: MPI1 (low risk, 0.0–0.33), MPI2 (moderate risk, 0.34–0.66), and MPI3 (severe risk, 0.67–1.0), and with glycated hemoglobin, and years since T2DM diagnosis.ResultsOne hundred and seven patients met the inclusion criteria. MPI3 was excluded by further analysis since it was made up of only three patients. Overall, cognitive performances, autonomies in daily living, nutritional status, risk of pressure injuries, comorbidities, and taken drugs were better (p ≤ 0.0077) in MPI1 than MPI2; moreover, the story of T2DM was shorter (p = 0.0026). Cox model showed an overall 13-year survival of 51.9%, and survival rates were significantly smaller in MPI2 (HR: 4.71, p = 0.0007). Finally, increased age (HR: 1.15), poorer cognitive abilities (HR: 1.26), vascular (HR: 2.15), and kidney (HR: 2.17) diseases were independently associated with death.ConclusionOur results prove that MPI predicts short-, mid-, and even long-term mortality in T2DM patients, whose death seems to be related to age and cognitive status, and even more to vascular and kidney diseases.

A Systematic Review of the Measurement Properties of Face, Legs, Activity, Cry and Consolability Scale for Pediatric Pain Assessment.

We performed this systematic review to summarize the psychometric properties of Face, Legs, Activity, Cry and Consolability (FLACC) scale in pediatric patients in different settings. Two investigators independently searched PubMed, EMBASE, OVID and China National Knowledge Infrastructure (CNKI) for eligible studies through July 2021. We assessed the psychometric properties using the modified critical appraisal tool (CAT). Finally, we systematically reviewed the results of the included studies. A total of 15 studies were eventually included. The overall quality of each eligible study was low to moderate. The FLACC scale has been available in different versions and in different settings. Although eligible studies have demonstrated significant clinical benefit in assessing postoperative pain in pediatric patients aged 0 to 10 years from post-anesthetic care unit (PACU), pediatric intensive care unit (PICU) and inpatient unit, and in assessing procedural pain in pediatric patients aged 0.5 to 7 years from emergency unit, immunization center and PICU, mostly without test-retest analysis. Although the absence of a gold standard of pain assessment, the currently available data support the usefulness of the FLACC from the perspective of criterion validity. Therefore, the FLACC scale can be considered for measuring observational pain in infants and children. However, further studies are still needed to provide more robust evidence.

Informed or misinformed consent and use of modified texture diets in dysphagia

BackgroundUse of modified texture diets—thickening of liquids and modifying the texture of foods—in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners.Main textValid informed consent requires provision of accurate and balanced information, and that agreement is given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients’ communication difficulties but also poor communication—and no real attempt to obtain consent—by practitioners before people are ‘put on’ modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients’ decisions is also questionable if they are told ‘you must’, when ‘you might consider’ is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information.ConclusionResearch is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the ‘lens’ of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people’s preferences and values.

The use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência and Sociedade Brasileira de Medicina Hospitalar. Part 2 - Technical aspects.

Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

Nutrition and physical activity in cancer patients: a survey on their information sources

BackgroundMany cancer patients suffer from problems concerning nutrition and physical activity (PA) during and after their treatment. Forwarding reliable health information could help to alleviate severe symptoms. The present study aimed to examine cancer patients’ commonly used information sources on nutrition and PA.MethodsAn anonymous questionnaire was developed and distributed to German cancer patients in different settings. In total, 90 questionnaires have been completed between October 2021 and March 2022. For analysis, descriptive statistics were used and associations between information sources and patients’ lifestyle behaviour explored utilising Spearman’s Rho, Mann–Whitney U, and Pearson’s Chi Square tests.ResultsThe cancer patients received information on nutrition and PA most frequently from physicians (70.9%), family and friends (68%) and browsing the internet (61.3%). Half of the patients (51.1%) had questions concerning these topics during the time of their disease. The majority of those patients (81.8%) reported that their questions were answered. The topics were addressed primarily with outpatient oncologists (60.0%) and in rehabilitation clinics (53.3%). Just about half of the patients (55.3%) felt satisfactorily informed on nutrition and PA in their cancer disease, more so if they talked to their oncologist or family physician (Z = − 2.450, p = 0.014 and Z = − 3.425, p = 0.001 resp.).ConclusionCancer patients receive information on nutrition and PA predominantly after their initial treatment. Since they might be missing significant information to alleviate severe symptoms during their treatment, the importance of nutrition and PA should be emphasised by clinicians early on in treatment.Trial registrationTrial Registration Number (May 7, 2021): 2021-2149-Bef.

How Does Mindfulness Affect Registered Nurses Practicing in Acute Care Settings? A Study of the Lived Experiences of Nurses After Participating in a Mindfulness Program.

Psychological well-being of nurses is necessary to protect the overall care of themselves, as well as their patients. This is especially concerning given the effects of the COVID-19 pandemic. There are several research studies on mindfulness for RNs and its impact on psychological health and well-being. There is limited research on how nurses may use mindfulness during patient care. The purpose of this study was to explore the effects of mindfulness education and practice on helping RNs to develop self-care skills and to apply mindfulness in the clinical setting. This was an exploratory mixed method design including quantitative (pilot study) and qualitative methods. Upon completion of a 4-week course on mindfulness practices, focus groups were held with the seven participants who completed the program. Open-ended, semi-structured interviews were held 1 week and then 3 months post-intervention. A constant comparative method and thematic analysis were utilized to analyze the data. Four themes were identified; (1) using mindfulness to calm down one's emotional response in the clinical setting; (2) awareness; (3) loving yourself; and (4) self-care. Nurses reported increased awareness and were able to use the technique of mindfulness practice during patient care. The findings of this study validate the benefits of mindfulness for self-care. Nurses were able to utilize mindfulness while caring for patients in different settings and during difficult patient situations, including in Behavioral Health. Further research is needed longitudinally, to explore how mindfulness can be practiced and utilized to improve outcomes in patient care.

COVID-19 Patients from Hospitalization to Tracheostomy, the Experience of a High-Volume Center

Background: Making decisions and planning about tracheostomy is not clear yet. Objectives: This study aimed to report intensive care unit (ICU) admission, intubation, and tracheostomy rates among patients in different settings and compare the outcomes of surgical and Percutaneous dilational tracheostomy (PDT) techniques between COVID-19 and non-COVID patients. Methods: Patients admitted to Masih Daneshvary hospital were assessed from February 2020 to May 2021 for intubation and tracheostomy rates. Different aspects and outcomes of two methods of tracheostomy, including surgical and PDT tracheostomy, were compared. Among non-COVID patients, 15 ICU admitted patients with different etiologies of pneumonia who required mechanical ventilation and tracheostomy were randomly selected and compared to COVID-19 patients. Results: A total of 7,748 COVID-19 patients were admitted, with 12.7% admitted to ICU with an intubation rate of 5.13%. Tracheostomy was performed for a total of 36 patients (0.46%) for prolonged intubation with a trend of 0.1% to 1.45% in 16 months. Regarding the technique of tracheostomy, 24% and 33.3% of patients survived in surgical and PDT groups, respectively (P=0.44). Surgical tracheostomy and PDT were performed in 26.5% and 40% of non-COVID patients, respectively (P=0.5). The mortality rate was 72.2% and 20% in the surgical tracheostomy and PDT groups, respectively (P=0.003). Conclusion: Given the study results, both surgical and percutaneous techniques are feasible for COVID-19 patients, and the decision about the optimal timing of intubation needs more inquiry.

Thromboprophylaxis in Patients with COVID-19: Systematic Review of National and International Clinical Guidance Reports.

Venous Thromboembolism (VTE) is common among patients with severe Coronavirus Disease 2019 (COVID-19). Anticoagulation in hospitalized COVID-19 patients has been associated with survival benefit; however, the optimal thromboprophylaxis strategy has not yet been defined. To identify published guidance reports by national and international societies regarding thromboprophylaxis strategies in COVID-19 patients in different settings (outpatients, hospitalized, post-discharge). A systematic review of the literature (Pubmed/EMBASE) was conducted independently by two investigators. Among 1942 initially identified articles, 33 guidance documents were included: 20 published by national and 13 by international societies. These documents provide recommendations mainly for hospitalized (97% of reports) and post-discharge (75%) COVID-19 patients, and less so for outpatients (34%). Thrombotic and bleeding risk stratification prior to any treatment decision is the cornerstone of all suggested thromboprophylaxis strategies; 81% of the documents recommend thromboprophylaxis for all hospitalized patients with a prophylactic dosage of low molecular weight heparin irrespective of VTE risk. Intermediate or therapeutic dose intensity is recommended in high VTE risk patients by 56% and 28% of documents, respectively. Mechanical thromboprophylaxis is suggested in case of high bleeding risk or contraindication to pharmacological thromboprophylaxis (59% of documents). Extended pharmacological thromboprophylaxis is recommended for patients with high VTE risk after hospital discharge (63% of documents). For non-hospitalized outpatients, 28% of documents recommend pharmacological thromboprophylaxis for high VTE risk. The current guidance identifies thromboprophylaxis in COVID-19 patients, especially during hospitalization, as of major importance for the prevention of VTE. Recommendations are derived from limited evidence from observational studies.

Z-drugs and Falls: A Focused Review of the Literature

OBJECTIVE: To provide a focused review of the literature related to the association between exposure to Z-drugs and the risk of falls, especially in the older population.<br/> DATA SOURCES: A literature search was conducted using Medline, PsychInfo, and the Cochrane Library database for all clinical trials, case series, and case reports published in English up to May 2020. The search terms used consisted of each Z-drug, including "zolpidem," "zopiclone," "eszopiclone," and "zaleplon," matched with "falls."<br/> STUDY SELECTION: The search yielded 295 studies. After review of abstracts, content and references were reviewed, and duplicates removed, a total of 9 articles met inclusion of exposure to at least 1 Z-drug and a primary outcome of falls.<br/> DATA EXTRACTION: The American Geriatrics Society 2019 Beers Criteria Update for Potentially Inappropriate Medication Use in Older Adults recommends to avoid using nonbenzodiazepine hypnotics in this patient population because of the risk of adverse events.<br/> DATA SYNTHESIS: A majority of the literature suggests an increased risk of falls with exposure to Z-drug use, especially zolpidem. Eight trials examined falls as a primary outcome in non-elderly (n=3) and elderly (n=5) patients in different settings, mostly in an inpatient setting (nursing facility or acute care hospital).<br/> CONCLUSION: Exposure to Z-drugs, especially zolpidem, should be evaluated and counseled on continuously as these medications put patients at an increased risk for falls and other complications.

Z-drugs and Falls: A Focused Review of the Literature.

OBJECTIVE: To provide a focused review of the literature related to the association between exposure to Z-drugs and the risk of falls, especially in the older population.<br/> DATA SOURCES: A literature search was conducted using Medline, PsychInfo, and the Cochrane Library database for all clinical trials, case series, and case reports published in English up to May 2020. The search terms used consisted of each Z-drug, including "zolpidem," "zopiclone," "eszopiclone," and "zaleplon," matched with "falls."<br/> STUDY SELECTION: The search yielded 295 studies. After review of abstracts, content and references were reviewed, and duplicates removed, a total of 9 articles met inclusion of exposure to at least 1 Z-drug and a primary outcome of falls.<br/> DATA EXTRACTION: The American Geriatrics Society 2019 Beers Criteria Update for Potentially Inappropriate Medication Use in Older Adults recommends to avoid using nonbenzodiazepine hypnotics in this patient population because of the risk of adverse events.<br/> DATA SYNTHESIS: A majority of the literature suggests an increased risk of falls with exposure to Z-drug use, especially zolpidem. Eight trials examined falls as a primary outcome in non-elderly (n=3) and elderly (n=5) patients in different settings, mostly in an inpatient setting (nursing facility or acute care hospital).<br/> CONCLUSION: Exposure to Z-drugs, especially zolpidem, should be evaluated and counseled on continuously as these medications put patients at an increased risk for falls and other complications.

Improving the care of older patients during the COVID-19 pandemic.

The SARS-CoV-2 pandemic has led to a dramatic crisis of Health Care Systems worldwide, and older people have been among the most disadvantaged. Specific recommendations and reports have been released both at International and National level, regarding the diagnosis and management of COVID-19 in the elderly. However, little has been proposed for an appropriate response to older, frail and multimorbid patients in different settings of care (acute care units, long term care facilities, nursing homes and primary care) and for the management of geriatric syndromes (i.e. delirium, sarcopenia, falls). We presume that the current pandemic of will leads to substantial changes in health care systems, and we suggest some key guide principles that could inspire the provision of healthcare services to older people and their families. These principles are primarily directed to physicians and nurses working in the geriatric field but could also be useful for other specialists.

The Italian USL Toscana Centro model of a vascular hub responding to the COVID-19 emergency

BackgroundSpreading of the COVID-19 pandemic in Italy forced health facilities to drastically change their organization to face the overwhelming number of infected patients needing hospitalization. The aim of this paper is to share with all the vascular community the protocol developed by the USL (Unità Sanitaria Locale) Toscana Centro for the reorganization of the Vascular Surgery Unit during the COVID-19 emergency, hoping to help other institutions to face the emergency during the hard weeks coming. MethodsThe USL Toscana Centro is a public Italian health care institution including four districts (Empoli, Florence, Pistoia, Prato) with 13 different hospitals, serving more than 1,500,000 people in a 5000 km2 area. The USL adopted a protocol of reorganization of the Vascular Surgery Unit during the first difficult weeks of the epidemic, consisting in the creation of a Vascular Hub for urgent cases, with a profound reorganization of activities, wards, surgical operators, operating blocks, and intensive care unit (ICU) beds. ResultsAll 13 hospitals are now COVID-19 as the first days of April passed. The San Giovanni di Dio Hospital (Florence) has more than 80 COVID-19 patients in different settings (ICU, medical and surgical ward), which at the time of writing is almost one-third of the total hospital capacity (80/260 beds). It has been identified as the Surgical Hub for urgent vascular COVID-19 cases. Therefore, the elective surgical and office activities were reduced by 30% and 80%, respectively, and reserved to priority cases. A corner of the whole operating block, well separate from the remaining operating rooms, was rapidly converted into one operating room and six ICU beds dedicated to COVID patients. The COVID-19 surgical path now includes an emergency room for suspected COVID-19 patients directly connected to an elevator for the transfer of COVID patients in the COVID operating block and dedicated COVID-19 ward and ICU beds. ConclusionsRapid modification of hospital settings, a certain “flexibility” of the medical personnel, a stepwise shutdown of vascular surgical and office activity, and the necessity of a strong leadership are mandatory to cope with the tsunami of the COVID-19 outbreak.

Multiple Vulnerabilities in Medical Settings: Invisible Suffering of Doctors

While there is a substantive amount of literature on vulnerability of different kinds of patients in different settings, medical professionals are usually considered as the ones who possess power and gain a privileged position. In this paper, we aim to demonstrate that in a certain context physicians—a social group which is usually referred to as “powerful”—consider themselves vulnerable, and this positioning may influence patients in turn. This perspective highlights the complexity of interactions within medical organizations and contributes to the studies of sensitive topics and vulnerable groups. We conceptualize vulnerability of doctors and discuss what can be problematic in powerful doctors’ position. We describe some features of the post-Soviet context of Russian healthcare system and maternity care, both of which can be conceptualized as a hybrid of legacy of Soviet paternalism and new neoliberal reforms, managerialism and marketization. Empirical research is based on the ethnographic evidence from the study of a Russian perinatal center. In this article, we explore specific “existential” and “moral” vulnerabilities of medical professionals who routinely have to cope with multiple challenges, such as complicated clinical tasks, rigid control of different state bodies and emotional responses of suffering patients. We argue that there is a bond between the vulnerability of doctors and that of patients, whose position becomes more problematic as professionals become more vulnerable. At the end, we discuss methodological and theoretical implications of our research.

Patient Safety Climate: A Study of Southern California Healthcare Organizations.

Human error remains the most important factor in unnecessary deaths and suffering in U.S. hospitals. Human error results from healthcare providers' attitudes and behaviors toward patients in different settings. Therefore, taking periodic snapshots of the attitudes and behaviors prevalent in an organization and manifested in its patient safety climate (PSC) is essential.We developed and tested a short survey instrument intended as an organization-level measure of PSC with good psychometric properties that can be used in hospitals, clinics, or other healthcare provider settings. Analysis of data from 61 Southern California healthcare organizations resulted in a PSC model with four distinct, reliable factors: (1) Assistance From Others and the Organization, (2) Leadership Messages of Support in Policy and Behavior, (3) Resources and Work Environment, and (4) Error Reporting Behavior. A PSC score, ranging from 0 to 100, was generated for each organization.For a subsample of hospitals in our study, preliminary results indicate a predictive quality of the model. The higher the PSC score, the lower the number of violations detected by the Centers for Medicare & Medicaid Services in complaint inspections, and the fewer the safety problems reported by The Leapfrog Group.Given the association between PSC and health outcomes, we urge healthcare leaders to use various means, such as our survey, to monitor the degree to which their organizations maintain a climate that fosters patient safety and use such data to pinpoint areas for improvement.

Differential Family Experience of Palliative Sedation Therapy in Specialized Palliative or Critical Care Units

ContextNo study has examined the varying family experience of palliative sedation therapy (PST) for terminally ill patients in different settings. ObjectivesTo examine and compare family concerns about PST use and its effect on the grief suffered by terminally ill patients' families in palliative care units (PCUs) or intensive care units (ICUs). MethodsA total of 154 family members of such patients were recruited in Taiwan, of whom 143 completed the study, with 81 from the PCU and 62 from the ICU. Data were collected on their concerns regarding PST during recruitment. Grief levels were assessed at three days and one month after the patient's death with the Texas Revised Inventory of Grief. ResultsFamilies' major concern about sedated patients in the PCU was that “there might be other ways to relieve symptoms” (90.2%), whereas families of ICU sedated patients gave the highest ratings to “feeling they still had something more to do” (93.55%), and “the patient's sleeping condition was not dignified” (93.55%). Family members recruited from the ICU tended to experience more grief than those from the PCU (P = 0.005 at Day 3 and < 0.001 at Month 1). PST use predicted higher levels of grief in family members recruited from the PCU (P < 0.001 at Day 3 and Month 1). ConclusionFamily experiences with the use of PST in terminally ill patients varied in different settings. Supportive care should address family concerns about PST use, and regular attention should be paid to the grief of individuals at higher risk.