Priority Of Patients Research Articles

Modest Impact of Liver Transplantation on Hepatocellular Carcinoma Mortality in the United States, Findings from The Transplant Cancer Match (TCM) Study

Abstract Liver transplantation is considered the most curative treatment for patients with localized hepatocellular carcinoma (HCC). Recent organ allocation policies have reduced the priority of patients with HCC for liver transplantation, which might affect overall liver transplantation usage and HCC-specific mortality among patients with HCC. Therefore, studies on the impact of liver transplantation on population-level HCC-specific mortality rates are necessary and essential. Mahale and colleagues used comprehensive, linked population databases on both HCC cancer cases and liver transplantation recipients and applied incidence-based mortality (IBM) analysis to evaluate the overall impact of liver transplantation on HCC mortality in the United States. Although liver transplantation rates continue to rise in the United States, the authors showed that liver transplantation has had modest impact over time on HCC-specific mortality at the population level (liver transplantation was associated with a 0.5% reduction in the annual rate of increase in the IBM rate vs. nontransplant). Considering these findings, HCC screening and surveillance for early detection should be a priority, meanwhile, increased availability of liver transplantation for patients with HCC and other HCC curative-intent treatment modalities are also necessary to improve HCC survival. Moreover, HCC risk factors, viral hepatitis and nonalcoholic fatty liver disease prevention and treatment should also be incorporated in future HCC mortality research. See related article by Mahale et al., p. 513

Criminal law characteristics of medical sorting (triage): COVID-19 and shortage of resources

The subject of this research is the legal norms that regulate the procedure of determining priority of patients (triage) in the Russian Federation, as well as the grounds for bringing to criminal responsibility of the representatives of medical profession for causing death during this process. The object of this research is the social relations arising in terms of prioritizing  treatment  of patients under the circumstances of severe shortage of medical resources, namely in case of mass infection. Analysis is conducted on the established by Chapter 8 of the Criminal Code of the Russian Federation conditions that exclude criminal nature of the act. The conclusion is made that on their inapplicability in similar circumstances. The author examines the nature of the process of medical sorting  – allocation of patients according to certain characteristics and order of their treatment, regulatory norms, as well as analyzes  the trends in the context of COVID-19 pandemic. Due to the fact that the Russian criminal law science does not feature special research dedicated to triage, the article provides a brief overview of the works of foreign legal scholars along with similar positions of national scholars, as well as determines the circumstances that affect the criminal nature of patient's death that takes place in the conditions of severe shortage of resources. The novelty lies in the cross-sectional study of the norms of Russian criminal law and the corresponding norms of medical law, based on which the author develops solution to the problem that did not previously receive due coverage in the Russian science. The author answers the question regarding criminal responsibility for the death of one of the two patients when it is not feasible to provide simultaneous medical treatment to both. It also The article also describes potential amendments to the sectoral medical legislation for the purpose of consolidation of legal status of medical professionals, protect their rights from unsubstantiated criminal prosecution,  protect rights of the patients, and maintain ethical well-being of medical profession.

Impaired skeletal muscle mitochondrial bioenergetics and physical performance in chronic kidney disease.

The maintenance of functional independence is the top priority of patients with chronic kidney disease (CKD). Defects in mitochondrial energetics may compromise physical performance and independence. We investigated associations of the presence and severity of kidney disease with in vivo muscle energetics and the association of muscle energetics with physical performance. We performed measures of in vivo leg and hand muscle mitochondrial capacity (ATPmax) and resting ATP turnover (ATPflux) using 31phosphorus magnetic resonance spectroscopy and oxygen uptake (O2 uptake) by optical spectroscopy in 77 people (53 participants with CKD and 24 controls). We measured physical performance using the 6-minute walk test. Participants with CKD had a median estimated glomerular filtration rate (eGFR) of 33 ml/min per 1.73 m2. Participants with CKD had a -0.19 mM/s lower leg ATPmax compared with controls but no difference in hand ATPmax. Resting O2 uptake was higher in CKD compared with controls, despite no difference in ATPflux. ATPmax correlated with eGFR and serum bicarbonate among participants with GFR <60. ATPmax of the hand and leg correlated with 6-minute walking distance. The presence and severity of CKD associate with muscle mitochondrial capacity. Dysfunction of muscle mitochondrial energetics may contribute to reduced physical performance in CKD.

Development of an energy management education program (“the PEP program”) for adults with end-stage renal disease

Introduction Fatigue is a highly common symptom of end-stage renal disease, interferes with occupational engagement, and is a top research priority of patients. The objective of this project was to develop an energy management education program that would meet the needs of people with end-stage renal disease and to conduct a preliminary evaluation of the acceptability and usability of the program. Methods We used the World Health Organization’s health education planning framework to guide the intervention development process. We systematically assessed the needs of people with end-stage renal disease related to energy management education, and transformed them into program objectives. Based on these findings, we designed a program that would (a) improve occupational engagement in people with end-stage renal disease; (b) be feasible; and (c) build on existing energy management education and health education literature. Finally, we conducted qualitative interviews about the program with four key informants and conducted usability testing with five target end-users. Findings: The Personal Energy Planning program combines an established problem-solving approach with three brief web modules on energy management. Preliminary testing suggested the program was acceptable to stakeholders and was usable by the target population. Conclusions Future research should explore the effects of the program on fatigue and occupational engagement in people with end-stage renal disease.

Value of Duke Treadmill Score in Setting Priority of Patients for Coronary Angiography

Background: exercise treadmill test remains a good test in identification of coronary artery disease(CAD). The Duke Treadmill Score (DTS), shown to predict CAD better than ST segment deviation alone. Aim of the work: To determine the potential of DTS in setting priority of patients for coronary angiography. Patients and methods: This was a prospective study that was done from July 2017 to October 2018 and included 150 patients referred to Damannhour Teaching Hospital for evaluation of chest pain. Patients underwent: history, clinical examination, ECGs, Echocardiography, Treadmill exercise ECG with calculation of DTS then coronary angiography that was correlated with DTS and other variables. Results: There were 59 patients(39.3%)with high DTS and 91patients (60.7%) with intermediate DTS. For the intermediate Duke's risk group the result of coronary angiography distributed on normal (26.4%), single vessel disease (33%), two vessel disease (22%), and three vessels disease or left main disease (18.7%). For high Duke's risk group the result of coronary angiography showed mainly three vessels disease or left main disease (54.2%), two vessels disease (27.1%), single vessel disease (6.8%) and normal vessel (11.9%), The P value was<0.001.Adding patient's risk factors to intermediate DTS group were statistically significant in the diagnosis of CAD ,the P value was<0.001. Conclusion: The DTS is a good predictor for CAD. Intermediate risk DTS group exercise test results should be managed individually according to clinical data.

Triage live lecture versus triage video podcast in pre-hospital students' education.

IntroductionTriage is the process of determining the priority of patients’ treatments based on the severity of their conditions. The aim of the present study was to survey the effect of triage video podcasting on the knowledge and performance of pre-hospital students.MethodsSixty pre-hospital students were randomly divided into two groups of a 30-subject control group and a 30-subject intervention group. A pre-test was administered among all students. Afterwards, for the first group, triage education was offered through lectures using PowerPoint, while for the second group, audio and video podcasts tailored for this training program were employed. Right after the training as well as one month later, post-tests were run for both groups, and the results were analysed using an independent t-test and covariance.ResultsNo significant difference was observed between the effects of both types of education on knowledge and performance, either immediately, or one month after training.DiscussionWe suggest that video podcasts are ready to replace traditional teaching methods in triage.

Evaluation of elderly care dynamics in an emergency care unit.

understand elderly care dynamics of an emergency care unit. this is a case study evaluation, using a qualitative approach and the theoretical-methodological reference of a fourth generation evaluation. Data collection was conducted between February and September 2017, through 460 hours of participant observation, interviews with 33 social actors among health professionals, elderly people and their relatives of an emergency care unit located in a municipality in the northwest of Paraná, as well as negotiation meetings with participants. the evaluation showed the elderly care dynamics is mainly influenced by nursing actions that articulate care practices based on priority, frailty, autonomy, independence and family context of the elderly patients. an evaluation of how the emergency care unit operates helps improve elderly care in urgent and emergency services.

Associação entre sinais vitais e Sistema Manchester de Triagem: estudo observacional retrospectivo

Aim: To evaluate the association between vital signs collected at the patient's entrance to the emergency department and the risk levels of the Manchester Triage System (MTS). Method: This is a retrospective observational study; whose sample was 154,714 patients. The exposure factor was the vital signs data, and the primary endpoint was the level of risk of MTS. Statistical, descriptive and inferential analyzes were conducted. Results: The most evaluated vital data was pain intensity; blood pressure was the least evaluated. Changes in heart rate to more or less of physiological patterns have increased the clinical priority of patients. Discussion: The higher the level of severity of MTS, the greater the variability of the mean of the vital signs evaluated. Conclusion: More severe patients tend to present greater variation in terms of vital signs on admission to the emergency department.

Reliability analysis of the Manchester Triage System: inter-observer and intra-observer agreement.

ABSTRACTObjective:To analyze the reliability of the Manchester Triage System to determine the priority of patients in emergency services. Method:This is a reliability study with a sample of 361 nurses. The data were collected in three stages and the questionnaires were applied using the electronic software. The agreement was measured by the evaluation of clinical cases. The outcomes evaluated were agreement with the gold standard and intra-observer in the indication of the flowchart, discriminator, and level of risk. Data were submitted to univariate and bivariate analyses. The agreement was measured by the Kappa index. Results:The external and internal reliability of the protocol ranged from moderate to substantial (Kappa: 0.55-0.78). The time of professional experience as a nurse, in emergency services and in the classification of risk were associated with external and internal reliability. The correct choice of the discriminator influenced the correct indication of the risk level (R² = 0.77, p <0.0001) more than the correct choice of the flowchart (R² = 0.16, p <0.0001). Conclusion:The reliability of the Manchester Triage System ranged from moderate to substantial and it was influenced by the clinical experience of the nurse. The protocol is safe for defining clinical priorities using different classification flowcharts.

Invoking the "expectant" triage category: Can we make the paradigm shift?

Medical triage is the process of determining the priority of patients' treatments based on the severity of their condition. Triage provides the healthcare provider the ability to identify the most urgent cases first, with the goal of maximizing each individual patient's outcome. When resources are challenged, such as in a disaster, the healthcare provider's goal becomes to maximize overall population survival. In this context, the triage process must identify patients who require resources urgently, as well as those who have the best chance of survival. The revised triage process must include an "expectant management" category, to identify patients for whom further resuscitation is delayed, as they have a poor chance of survival and require significant resources. The paradigm shift that is required in these circumstances can be challenging for pediatric healthcare providers. Many may find themselves unable to change the decision-making process that would favor overall survival and best outcome for the most members of a population, while potentially not addressing the most sick or injured because they have low chances of survival. We hypothesized that participating in a multiprofessional ethics-based educational session regarding making difficult triage decisions may improve participants' perceived ability to use the "expectant" triage category in a disaster setting. Participants took part in an ethics-based educational session and completed a pre- and postsurvey. Results demonstrated a significant change in the participants' self-perceived comfort level using the disaster triage tools and improved their confidence to use the expectant triage category in a disaster setting.

Allocation of antiretroviral drugs to HIV-infected patients in Togo: perspectives of people living with HIV and healthcare providers

AimTo explore the way people living with HIV and healthcare providers in Togo judge the priority of HIV-infected patients regarding the allocation of antiretroviral drugs.MethodFrom June to September 2015, 200...

A GRASP algorithm for the elective surgeries scheduling problem in a Chilean public hospital

The high capital expenditures in surgery units fosters to hospital to look for methods to optimize the use of their resources. This article presents a GRASP algorithm to determine a good schedule for elective surgeries considering the context of a Chilean public hospital, with the objectives of maximize the priority of patients and minimize the use of overtime in the operating room. To evaluate the quality of the solution, the results are compared with a mathematical model in small instances, finding the optimum in half of the instances. For larger instances, the unscheduled patients are a 22.6% and the overtime used is a 72.8%, on average, providing a good approximation to the optimal schedule.

(574) - Risk Factors of Waiting List Mortality for Patients Awaiting Heart Transplant

Waiting list mortality for patients awaiting heart transplant has significantly improved in the recent era and appears to be associated with increasing use mechanical circulatory support (MCS). With proposed changes to the heart organ allocation system, we assessed the risk factors associated with waiting list mortality at 180 days to identify high risk patients that need to be prioritized for transplant in this era of MCS support. United Network of Organ Sharing (UNOS) database for thoracic organ transplant was requested and available dataset was queried to identify patients with age >/=18 years who were listed for heart transplant from 1999 to 2013. Patients who received heart transplant within 180 days of listing and received MCS after 180 days of listing were excluded from final analysis. Patients taken off the waitlist due to improvement or worsening were excluded. A logistic regression model was created to assess the risk factors associated with 180 days mortality on waiting list. There were 33,837 patients of which 7371 patients were included in the final dataset after applying inclusion and exclusion criteria. A total of 1111 (15%) patients died and 6260 (85%) were still waiting for a donor heart at 180 days after listing. The logistic regression model (area under ROC=84%) showed that higher age, mean pulmonary artery pressure, creatinine and lower albumin as well as initial listing status 1A, initial need for ventilator and inotropic support, blood group AB (vs. O) were significant predictors of 6 month waitlist mortality. Use of continuous flow MCS and rhythm control device in particular was protective against the 6 month waitlist mortality (Table 1). A logistic regression model can be very useful in predicting waitlist mortality of patients listed for heart transplant and objectively determine priority of patients for organ allocation. From this analysis, patients that are not candidates for continuous flow MCS support should have the highest priority for donor heart allocation.

A Two-Stage Stochastic Programming for Nurse Scheduling in Razavi Hospital

Background: One of most important operations research problems is Nurse Scheduling Problem (NSP) that tries to find an optimal way to assign nurses to shifts with a set of hard constraints. Most of the researches are dealing with this problem in deterministic environment with constant parameters. While In the real world applications of NSP, the stochastic nature of some parameters like number of arriving patients, stay periods, etc. are some sources of uncertainties that need to be controlled to provide a qualified schedule. Objectives: In this article we propose our model in an uncertain environment in Department of Heart Surgery in Razavi Hospital. Materials and Methods: The demand and stay period of patients are stochastic whose the distribution is determined from historical data. Finally, the demand of nurses in each shift in planning horizon is calculated regarding the priority (vitality) of patients. Results: The stochastic optimization is adapted for our problem and the Sample Average Approximation (SAA) method is used to obtain a optimal schedule with respect to minimizing the regular and over time assignment costs. The results have been analyzed and show the validity of our model. Conclusions: In this model the demand and stay period of patients are stochastic whose the distribution is determined from historical data. We also consider the priority (vitality) of patients in our model.

Scheduling prioritized patients in emergency department laboratories

This research focuses on scheduling patients in emergency department laboratories according to the priority of patients’ treatments, determined by the triage factor. The objective is to minimize the total waiting time of patients in the emergency department laboratories with emphasis on patients with severe conditions. The problem is formulated as a flexible open shop scheduling problem and a mixed integer linear programming model is proposed. A genetic algorithm (GA) is developed for solving the problem. Then, the response surface methodology is applied for tuning the GA parameters. The algorithm is tested on a set of real data from an emergency department. Simulation results show that the proposed algorithm can significantly improve the efficiency of the emergency department by reducing the total waiting time of prioritized patients.

MELD: Which Patients Fall Through the Cracks?

In 2002, the use of the MELD scoring system was adopted as the primary means of determining the priority of patients listed for liver transplantation. Implementation of the MELD system has changed the face of organ allocation for livers and as a result, overall waitlist times along with pre- and post-transplant mortality for patients with significant liver disease have declined. Although the MELD accurately predicts mortality in most patients with end stage liver disease, it may not adequately risk stratify some patients who have a high risk of morbidity and mortality not reflected in the score. Automatic exception points are granted for a subset of conditions if candidates meet agreed upon criteria. However, even within this framework, there are some at risk patients who will be missed. Herein we review conditions associated with increased mortality and morbidity that are not reflected in the MELD score and reflect on the issues which arise when considering allocation of organs to these patients.

English

Access to publicly funded bariatric surgery is limited, potential candidates face lengthy waits, and no universally accepted prioritization criteria exist. We examined patients' perspectives regarding prioritization for surgery. We surveyed consecutively recruited patients awaiting bariatric surgery about 9 hypothetical scenarios describing patients waiting for surgery. Respondents were asked to rank the priority of these hypothetical patients on the wait list relative to their own. Scenarios examined variations in age, clinical severity, functional impairment, social dependence and socioeconomic status. Willingness to pay for faster access was assessed using a 5-point ordinal scale and analyzed using multivariable logistic regression. The 99 respondents had mean age of 44.7 ± 9.9 years, 76% were women, and the mean body mass index was 47.3 ± SD 7.6. The mean wait for surgery was 34.4 ± 9.4 months. Respondents assigned similar priority to hypothetical patients with characteristics identical to theirs (p = 0.22) and higher priority (greater urgency) to those exhibiting greater clinical severity (p < 0.001) and functional impairment (p = 0.003). Lower priority was assigned to patients at the extremes of age (p = 0.006), on social assistance (p < 0.001) and of high socioeconomic status (p < 0.001). Most (85%) respondents disagreed with payment to expedite access, although participants earning more than $80 000/year were less likely to disagree. Most patients waiting for bariatric surgery consider greater clinical severity and functional impairments related to obesity to be important prioritization indicators and disagreed with paying for faster access. These findings may help inform future efforts to develop acceptable prioritization strategies for publicly funded bariatric surgery.

Improving Children Emergency Care Satisfaction through Standardized Approach of Pediatric Triage

Triage is the process of determining the priority of emergency patients' treatments based on the severity of their condition. Pediatric triage assessment is a rapid, focused evaluation to gather pertinent subjective and objective data to determine the severity of illness. This can be achieved through standardized triage approach. Patient satisfaction is considered an important indicator of the quality of care from the perspective of the consumer. Satisfied patients are more likely to comply with treatment, take an active role in their own care. The study aims to improve children emergency care satisfaction through standardized approach of pediatric triage. This is a quasi-experimental study design, which was carried out at Pediatric Emergency Department at Al-Menshawy General Hospital, Tanta City. Purposive sample of one hundred children were involved in the study. They were divided into two groups' fifty children in each one. Data was collected from the period of June to the end of September 2013. Two tools were used to collect data, the first tool was a questionnaire sheet used to collect socio-demographic data. The second tool was a Consumer Emergency Satisfaction Scale (CECSS). The results of this study revealed that, 60% of the triage group was satisfied by emergency visit compared to 26% of the non-triage group. There was a statistical significant difference regarding total nursing care and total education between the triage and non-triage group. It is recommended to apply triage nursing care at all Emergency Departments.

The consultants’ role in the referring process with general practitioners: partners or adjudicators? a qualitative study

BackgroundWithin the health system, communication between the different levels of care is essential for the patients’ clinical pathways and medical treatment. This includes the referral process: how and why patients are sent from the primary care level to specialist health services. We wanted to identify and describe hospital consultants’ reflections on and attitudes to the referral process and cooperation with general practitioners (GPs).MethodsA qualitative study of semi-structured interviews with 13 hospital consultants representing eight different specialties, analyzed using systematic text condensation. Interviews conducted from February 2011 to October 2012.ResultsThe consultants reported a considerable workload assessing referrals from GPs and prioritizing patients for specialist services. National guidelines were used as well as individual standards and guidelines. Good referrals could make the prioritization process easier. The specialists expressed a deep concern about securing a fair priority of patients and a willingness to give reasonable advice back to the referring GP when rejecting a referral. Better communication, such as a telephone call to confer with a hospital specialist before referral, was wanted.ConclusionsBetter communication and cooperation between hospital consultants and GPs could make the referral process more balanced, and the participants more like partners.

Information needs among patients with chronic obstructive pulmonary disease at their first hospital admission: priorities and correlates

To better understand chronic obstructive pulmonary disease patients' informational needs and associated factors using the Predisposing, Reinforcing and Enabling Causes in Educational Diagnosis and Evaluation model. Despite the increase in the incidence of chronic obstructive pulmonary disease, little research has been carried out on the information needs from a patient perspective. A cross-sectional, correlational design was used. A convenience sample of 107 subjects was recruited from four Taiwanese hospitals. Multiple regression analyses were conducted to identify the total informational needs and related factors. Major findings were that (1) patients' top informational need was daily care, and (2) variables associated with the total information needs were younger age, greater health internal locus of control, less dyspnoea severity and greater social support. Patients' perceived chronic obstructive pulmonary disease informational needs are not congruent with the information received from healthcare professionals. Healthcare professionals need to be sensitive to the fact that treatment-related information was not the top priority of patients with chronic obstructive pulmonary disease. Healthcare professionals also need to target the special subpopulation of chronic obstructive pulmonary disease patients with greater total informational need to maximise educational impact.