Regional Acute Care Research Articles

Medication Administration Interruptions in a Rural Hospital and Evaluation of a Red Light Intervention

Purpose: This study was conducted to determine the prevalence and types of interruptions nurses experience during the peak medication administration period (weekdays 7:00 AM-9:00 AM) at a rural regional hospital and to evaluate the effectiveness of a red light intervention to reduce interruptions. Sample: Participants were a convenience sample of registered nurses who agreed to be observed administering medications. The same nurses were observed during both phases of the study. Methods: This study employed a prospective exploratory design. The same observation procedures were used during both phases of the study. During each 2-hour observation period, each participating nurse was accompanied by two observers who recorded all interruptions. During the intervention, a small flashing red light was attached to the medication administration computer. When turned on it served as a signal to avoid interruptions. Educational flyers were distributed to staff, physicians, patients, and visitors to inform them about the meaning of the light. Findings: Average interruptions per 2-hour medication administration period dropped from an average of 7.2 during baseline to 3.0 during the red light intervention. The top two source of interruptions during both phases were other personnel and not having needed medical supplies/equipment, though the rankings were reversed. The relative prevalence of interruptions caused by other personnel declined from 27.6% (baseline) to 21.8% (intervention). Conclusions: The major categories of interruptions at this rural regional acute care hospital were similar to those identified in studies in urban settings. The red light intervention effectively reduced the average number of interruptions per 2-hour period and reduced the incidence of interruptions caused by other personnel. The prevalence of interruptions due to missing supplies/equipment remained high and should be addressed by implementing procedures to ensure that carts are appropriately stocked. DOI: http://dx.doi.org/10.14574/ojrnhc.v15i2.327 Keywords: Medication administration, Interruptions, Rural

Impact of a Dedicated Noninvasive Ventilation Team on Intubation and Mortality Rates in Severe COPD Exacerbations.

Compared with usual care, noninvasive ventilation (NIV) lowers the risk of intubation and death for subjects with respiratory failure secondary to COPD exacerbations, but whether administration of NIV by a specialized, dedicated team improves its efficiency remains uncertain. Our aim was to test whether a dedicated team of respiratory therapists applying all acute NIV treatments would reduce the risk of intubation or death for subjects with COPD admitted for respiratory failure. We carried out a retrospective study comparing subjects with COPD admitted to the ICU before (2001-2003) and after (2010-2012) the creation of a dedicated NIV team in a regional acute care hospital. The primary outcome was the risk of intubation or death. The secondary outcomes were the individual components of the primary outcome and ICU/hospital stay. A total of 126 subjects were included: 53 in the first cohort and 73 in the second. There was no significant difference in the demographic characteristics and severity of respiratory failure. Fifteen subjects (28.3%) died or had to undergo tracheal intubation in the first cohort, and only 10 subjects (13.7%) in the second cohort (odds ratio 0.40, 95% CI 0.16-0.99, P = .04). In-hospital mortality (15.1% vs 4.1%, P = .03) and median stay (ICU: 3.1 vs 1.9 d, P = .04; hospital: 11.5 vs 9.6 d, P = .04) were significantly lower in the second cohort, and a trend for a lower intubation risk was observed (20.8% vs 11% P = .13). The delivery of NIV by a dedicated team was associated with a lower risk of death or intubation in subjects with respiratory failure secondary to COPD exacerbations. Therefore, the implementation of a team administering all NIV treatments on a 24-h basis should be considered in institutions admitting subjects with COPD exacerbations.

Patterns of palliative care consultation among elderly cancer patients.

e17557 Background: Although the role of palliative care (PC) has expanded over the past several decades, its evolution has not been characterized at the population-based level. Methods: This study defined the patterns of PC delivery using a retrospective cohort of advanced cancer patients within the SEER-Medicare linked database. We identified 83,022 patients with metastatic breast, prostate, lung, and colorectal cancer. We studied trends between 2000-2009 and determined patient-level and regional-level predictors of PC delivery. Results: PC consultation rates increased from 3.0% in 2000 to 12.9% in 2009, with the majority of consultations occurring in the last 4 weeks of life (77%) in the inpatient setting. The rates of PC delivery were highest in the West (7.6%) and lowest in the South (3.2%). The likelihood of PC consultation increased with decreasing numbers of regional acute care hospital beds per capita. PC consultation increased with increasing numbers of regional physicians. PC utilization decreas...

Abstract W MP77: Effects of Emergency Medical Services Stroke Center Routing on Sites of Care and Enrollment in a Prehospital Research Study: The FAST-MAG Experience

Background: Emergency Medical Services (EMS) routing of acute stroke patients to designated stroke centers has the potential to increase the proportion of patients receiving care at facilities meeting national standards and to augment recruitment rates for prehospital stroke research. Methods: We analyzed a prehospital stroke treatment trial dataset to determine the number of patients cared for at certified primary stroke centers (PSC), prehospital care time intervals, and trial enrollment rates prior to and following implementation of a Los Angeles County-wide regional acute stroke care system in November 2009, with preferential routing of likely acute stroke patients, within 2 hours of symptom onset, to designated centers PSC certification. Analyses were performed in the overall study (1/2005 to 12/2012) as well as the period encompassing the year before and after implementation. Results: There were 863 subjects enrolled in LA County before and 764 after EMS routing and proportion transported to PSC increased substantially, from 10% prior to 91% following implementation (P<0.001). Routing was associated with a slight decrease in total time from paramedic on-scene to ED arrival, 34.5 minutes (SD 9.1) vs. 33.5 (SD 10.3), p=0.045. When comparing the year before to the year after implementation, enrollment increased by 18.6%, (215 at 44 hospitals vs. 255 at 27 hospitals), and proportion transported to PSC increased from 17% to 88%. During the study, the number of PSCs increased from 1 in 2005 to 28 in 2012, including from 7 to 17 in the year before to the year after EMS routing policy adoption. Conclusions: The establishment of a regionalized EMS system of acute stroke care dramatically increased the proportion of acute stroke patients cared for at Primary Stroke Centers, from 1 in 10 to more than 9 in 10, with no increase in prehospital care times, and enhanced recruitment of patients into an ongoing prehospital stroke trial.

Foundation's Pledge of Securities in Support of Hospital's Bond Issue Ruled Program‐Related Investment

A tax‐exempt hospital organization is in the process of building a regional acute care hospital. This will enable the exempt organization to consolidate the inpatient services of two current facilities, which are inadequate to meet the growing health care demands of its community. This hospital will offer comprehensive inpatient and outpatient services.

Impact of a regional acute care surgery model on patient access and outcomes

The consolidation of acute care surgery (ACS) services at 3 of 6 hospitals in a Canadian health region sought to alleviate a relative shortage of surgeons able to take emergency call. We examined how this affected patient access and outcomes. Using the generalized linear model and statistical process control, we analyzed ACS-related episodes that occurred between 39 months prior to and 17 months after the model's implementation (n = 14,713). Time to surgery increased after the consolidation. Wait times increased primarily for patients presenting at nonreferral hospitals who were likely to require transfer to a referral hospital. Although ACS teams enabled referral hospitals to handle a much higher volume of patients without increasing within-hospital wait times, overall system wait times were lengthened by the growing frequency of patient transfers. Wait times for inpatient admission were difficult to interpret because there was a trend toward admitting patients directly to the ACS service, bypassing the emergency department (ED). For patients who did go through the ED, wait times for inpatient admission increased after the consolidation; however, this trend was cancelled out by the apparently zero waits of patients who bypassed the ED. Regionalization showed no impact on length of stay, readmissions, mortality or complications. Consolidation enabled the region to ensure adequate surgical coverage without harming patients. The need to transfer patients who presented at nonreferral hospitals led to longer waits.

Attending surgeon burnout and satisfaction with the establishment of a regional acute care surgical service

Establishment of the Acute Care Surgical Service (ACSS) has dramatically changed the management of acute, nontrauma surgical patients in Winnipeg, Manitoba. Its formation was partially driven by increasing strain on surgeons and surgical services. We sought to determine surgeon level of burnout and satisfaction with the ACSS. All Winnipeg ACSS surgeons were mailed surveys. Burnout was established using the Maslach Burnout Inventory Human Services Survey. Satisfaction was ascertained with a series of questions. We attained a response rate of 76%. Most surgeons were married men with children. A burnout level of 61% was determined. Although most surgeons felt the ACSS was a positive change in their careers, they felt that operating room accessibility and teaching opportunities were lacking. Although a high level of burnout exists among ACSS surgeons, most are satisfied with its establishment. Factors such as operating room accessibility and teaching opportunities must be addressed.

Use of an Electronic Surveillance System to Further Refine MDRO Isolation Categorization

Based on review by the Pharmacy and Therapeutics Committee and Infectious Disease, the laboratory standards for defining multidrug resistant (MDR) Gram negative rods were revised at a large regional acute care health system serving a three state area. Previous to this, MDR Gram negative rods were defined as ‘any isolate demonstrating resistance to both gentamicin and tobramycin.’ The revised MDR Gram negative rod definition, put into place September 2011, was ‘any isolate demonstrating resistance to the third-generation cephalosporins AND piperacillin-tazobactam.’ Hospital policy requires all patients with a history of MDR Gram negative rods to be placed into isolation precautions.

Application and Performance of Two Stroke Outcome Prediction Models in a Chinese Population

To apply and examine the performance of 2 acute stroke outcome prediction models, the Six Simple Variable Model (SSV model) and the One-Year Mortality Model (OYM model), in patients in China who had either a cerebral infarction or a cerebral hemorrhage. An observational study that used both retrospective and prospective study methods. A regional acute care facility in China. Two hundred and forty-eight consecutive patients who had an acute stroke who were admitted to the hospital between October 2007 and March 2009. Not applicable. Survival and daily activity independence 6 months after a stroke and 1-year mortality. The study sample had a mean age of 68.6 years (standard deviation, 11.1); 52.8% of the subjects were men, 66.5% had a cerebral infarction, and 33.5% had a cerebral hemorrhage. In the cohort, 107 patients (43.1%) achieved daily activity independence at 6-month follow-up, and 52 patients (21.0%) had died within 1 year. The area under the receiver operating characteristic curve (ROC) was 0.966 (0.935-0.998) for patients who had a cerebral infarction and 0.859 (0.766-0.952) for patients who had a cerebral hemorrhage in the prediction of 6-month survival and daily activity independence with use of the SSV model. The area under the ROC curve was 0.894 (0.846-0.965) for patients who had a cerebral infarction and 0.937 (0.904-0.988) for patients who had a cerebral hemorrhage in the prediction of 1-year mortality when the OYM model was used. Both the SSV and OYM prognostic models can be used for function and mortality outcome prediction for patients in China who have had a stroke. Variation existed in the precision of prediction between patients who had a cerebral infarction and those who had a cerebral hemorrhage. Other potential factors influencing functional recovery and mortality after stroke must be considered in outcome prediction.

Evaluation of a Regional Acute Care Surgery Service by Residents in General Surgery

Acute care surgery (ACS) services dedicated to care of acute general surgery patients have been established in many tertiary centers across Canada. Little is known about the impact of this trend on postgraduate education. In this study we aimed to evaluate ACS through a cross-sectional survey of general surgery residents in Winnipeg, Manitoba. General surgery residents at the University of Manitoba were asked to complete an anonymous survey. Basic demographic data were obtained. The educational value of ACS was assessed using 10 statements derived from the CanMEDS framework for training physicians. Resident burnout was measured using the Maslach Burnout Inventory, on emotional exhaustion, depersonalization, and personal accomplishment. The response rate was 70% (14/20). ACS was evaluated positively based on the CanMEDS roles by the following proportions of responders: surgical skills (79%), clinical knowledge (100%), communicator (100%), collaborator (100%), manager (86%), health advocate (100%), scholar (64%), and professional (93%). Fifty percent of responders had a high score on emotional exhaustion, 43% on depersonalization, and 0% on low sense of personal accomplishment. The overall burnout was 64%. ACS provides a comprehensive clinical experience based on the CanMEDS competencies. Despite an increased sense of personal accomplishment, residents experienced a high incidence of burnout, as demonstrated by high scores on emotional exhaustion and depersonalization of patients.

Applying Toyota Production System Techniques for Medication Delivery: Improving Hospital Safety and Efficiency

The inpatient medication delivery system used at a large regional acute care hospital in the Midwest had become antiquated and inefficient. The existing 24-hr medication cart-fill exchange process with delivery to the patients' bedside did not always provide ordered medications to the nursing units when they were needed. In 2007 the principles of the Toyota Production System (TPS) were applied to the system. Project objectives were to improve medication safety and reduce the time needed for nurses to retrieve patient medications. A multidisciplinary team was formed that included representatives from nursing, pharmacy, informatics, quality, and various operational support departments. Team members were educated and trained in the tools and techniques of TPS, and then designed and implemented a new pull system benchmarking the TPS Ideal State model. The newly installed process, providing just-in-time medication availability, has measurably improved delivery processes as well as patient safety and satisfaction. Other positive outcomes have included improved nursing satisfaction, reduced nursing wait time for delivered medications, and improved efficiency in the pharmacy. After a successful pilot on two nursing units, the system is being extended to the rest of the hospital.

Triaging to a Regional Acute Care Surgery Center: Distance Is Critical

In acute care surgery, predicting mortality is important to determine appropriate patient transfer to a regional emergency general surgery (EGS) center. We hypothesized that distance to a referral center and severity of illness (SOI) would be predictors of death. We performed a retrospective analysis of a prospectively collected EGS registry from 2004 to 2008. The study population consisted of all patients discharged from the EGS service with an available home zip code in the registry. Study data included age, gender, length of stay (LOS), intensive care unit (ICU) LOS, distance between our facility and patient home zip code, and need for operative management. Systemic inflammatory response syndrome/sepsis/shock, peritonitis, perforation, and acute renal failure were used as SOI indicators. Mortality at discharge was the primary outcome. Patients were stratified by survival and compared using non-parametric statistical tests. Logistic regression assessed the simultaneous contribution of age, SOI, and distance to risk of death. A total of 3,439 patients met study criteria. Females slightly outnumbered males (1,813, 52.7%) with a median age of 47 years. The overall LOS was 6.4 days±9.3 days, and 2,331 (67.8%) of the patients underwent operation. Mean distance was 41.5 miles±51.2 miles (median, 22.2). Overall mortality was 2.7%. Increasing distance, age, and presence of SOI indicators were associated with mortality in univariable analyses. In multivariable logistic regression controlling for patient age and SOI, increasing distance in miles was related to increased mortality (odds ratio, 1.005; p<0.001). This odds ratio equates to a doubling in odds of death for each 132 miles between our center and the patient's home zip code. Age, SOI, and distance from a regional referral center explain much of the variation in mortality and can be used for triage to regional EGS centers.

Senior-Friendly Emergency Department Care: An Environmental Assessment

to assess the environment of an emergency department (ED) and its impact on care of adults aged 75 and over, using a 'senior-friendly' conceptual framework that included the physical environment, social climate, hospital policies and procedures, and wider health care system. in this focused ethnography, we collected and analysed data from the ED of a regional acute care hospital located in Ontario, Canada from October 2007 to January 2008. Data collection included interviews with seniors or their proxy decision-makers, staff and key community informants; on-site observations; a staff survey; and hospital administrative data. Data sets were individually analysed and a synthesis of findings developed to formulate recommendations for policy, practice and education. staff expressed their vision of providing senior-friendly care. However, the ED was fast-paced, overcrowded, chaotic and lacked orientation and wayfinding cues, as well as appropriate equipment and furniture, all of which created barriers to providing appropriate care. Seniors' expectations often went unmet and staff expressed moral angst at recognizing unmet needs. Some hospital policies and procedures compounded these difficulties, including hallway practice, lack of off-hour access to multidisciplinary health care professionals, and the inability of patients to access food and drink. Better communication and coordination between the ED and other components of the health care system are needed. the ED is an important part of seniors' health care. Changes to policy and practices, and enhanced education must occur to better meet the complex health care needs of seniors. This assessment provides a method that can be replicated elsewhere to generate site-specific recommendations and initiate capacity development processes to enhance senior-friendly care.

Implementing bedside handover: strategies for change management

To identify factors influencing change in two hospitals that moved from taped and verbal nursing handover to bedside handover. Bedside handover is based on patient-centred care, where patients participate in communicating relevant and timely information for care planning. Patient input reduces care fragmentation, miscommunication-related adverse events, readmissions, duplication of services and enhances satisfaction and continuity of care. Analysing change management was a component of a study aimed at developing a standard operating protocol for bedside handover communication. The research was undertaken in two regional acute care hospitals in two different states of Australia. Data collection included 532 semi-structured observations in six wards in the two hospitals and 34 in-depth interviews conducted with a purposive sample of nursing staff involved in the handovers. Observation and interview data were analysed separately then combined to generate thematic analysis of factors influencing the change process in the transition to bedside handover. Themes included embedding the change as part of the big picture, the need to link the project to standardisation initiatives, providing reassurance on safety and quality, smoothing out logistical difficulties and learning to listen. We conclude that change is more likely to be successful when it is part of a broader initiative such as a quality improvement strategy. Nurses are generally supportive of quality improvement initiatives, particularly those aimed at standardising care. For successful implementation, change managers should be mindful of clinicians' attitudes, motivation and concerns and their need for reassurance when changing their practice. This is particularly important when change is dramatic, as in moving from verbal handover, conducted in the safety of the nursing office, to bedside handover where there is greater transparency and accountability for the accuracy and appropriateness of communication content and processes.

Relationships Among Intrapartum Maternal Fluid Intake, Birth Type, Neonatal Output, and Neonatal Weight Loss During the First 48 Hours After Birth

To examine predictive relationships among intrapartum maternal fluid intake, birth type, neonatal output, and neonatal weight loss during the first 48 hours after birth. Prospective descriptive design. Women's center of a 900-bed regional acute care facility with 6,700 births per year. A convenience sample of 200 mother/neonate dyads. The Optimality Index of Murphy and Fullerton guided the inclusion and exclusion criteria to ensure healthy dyads. Data collection began in the intrapartum period and concluded with maternal/neonatal discharge. Measures included maternal intrapartum fluid intake from admission to birth, daily neonatal weight, output, and feedings. Data were analyzed via descriptive statistics, tests of significance and multiple regression. Neonatal weight loss was not significantly related to intrapartum maternal fluid intake. Strong predictors of neonatal weight loss and significant weight loss within the first 48 hours were type of feeding (p=.000) and average number of wet diapers (p=.003). Variables predictive of neonatal weight loss can facilitate identification of at-risk neonates to prevent significant weight loss. Close monitoring of the number of wet diapers in the first 48 hours and accurate daily weights at birth time can lead to early detection and preventive interventions.

Validity of a Retrospective National Institutes of Health Stroke Scale Scoring Methodology in Patients With Severe Stroke

Quantifying stroke severity is essential for interpreting outcomes in stroke studies; severity impacts outcomes. Because outcome studies often enroll patients some time after stroke and there is little standardization of the history and physical examination, objective measurement of stroke severity is limited. A method for retrospectively scoring the National Institutes of Health Stroke Scale (NIHSS) based on history and physical examination has been proposed, but has yet to be validated in patients with higher NIHSS score. We evaluate the validity of this scoring method across the spectrum of the NIHSS scores. The retrospective scoring algorithm was applied to history and physical examinations documented for 58 patients with ischemic stroke presenting to any of 17 regional acute care facilities who had a NIHSS score recorded by a stroke team physician. The retrospective NIHSS score was obtained by standardized chart review. Linear regression was used to estimate scale-dependent and scale-independent bias. Limits of agreement quantify deviation of the retrospective NIHSS score from the prospective NIHSS score. Mean (SD) age at stroke was 66 (14) years; 27 (46.6%) patients were men, and 38 (65.5%) were white. The mean (SD) prospective NIHSS score was 13.6 (7.8); the mean (SD) retrospective NIHSS score was 13.7 (7.8). There were 23 (40%) prospective NIHSS scores above 15, and 13 scores (22%) above 20. The linear regression constant was 0.290 (95% confidence interval -0.107, 0.687); the slope was 0.987 (95% confidence interval 0.962, 1.013). The R(2) for the model was 0.991. Limits of agreement were -1.35 and 1.59. The retrospective NIHSS appears valid across the entire spectrum of scores.

Antibiotic Use in Non–University Regional Acute Care General Hospitals in Southwestern Germany, 2001–2002

A previous study from Germany showed high antibiotic use in university hospitals, particularly in intensive care units (ICU) and hematology-oncology services, but there has been no information about recent antibiotic use in non-university hospitals. In the present study, we collected data from 40 non-university regional general hospitals located in the southwestern part of the country, and analyzed use density in the medical and surgical services of these hospitals. Hospital pharmacy records for the calendar years 2001 and 2002 were evaluated. The number of defined daily doses (DDD, definition according to the WHO/ATC 2001 index) and prescribed daily doses (PDD) per 100 patient days (DDD/100 or PDD/100, respectively) were calculated to compare antibiotic use densities in medical and surgical services. Data for surgery included various subspecialties and gynecology. Antibiotic use in the participating hospitals increased minimally between 2001 and 2002 both in medicine as well as in surgery. Use density in internal medicine (ICU areas excluded) in the year 2002 ranged between 13.5 and 93.7 DDD/100 with a weighted mean of 49.9 DDD/100 (corresponding to 28.6 PDD/100, respectively). Values for surgery were lower with a weighted mean of 43.4 DDD/100 (corresponding to 26.1 PDD/100, range, 10 to 65.4 DDD/100), respectively. Hospital size was not a strong predictor of use density, while large differences were observed between intensive care areas and normal wards. Mean use densities in intensive care areas in 2002 were 105.6 DDD/100 (or 49.7 PDD/100) in medical intensive care units, 116.9 DDD/100 (or 61.2 PDD/100) in surgical intensive care units, and 112.7 DDD/100 (or 66.7 PDD/100) in mixed, interdisciplinary intensive care units. Betalactams made up > 50% of all PDDs, while fluoroquinolones were the second most frequently prescribed drugs (15% of all PDDs). Fluoroquinolones were usually given orally. Overall glycopeptide and aminoglycoside use was < 1 PDD/100. This recent data from a large regional nonuniversity acute care hospital sample confirms that hospital antibiotic use density largely depends on patient care areas and less on hospital size. Surprisingly low use was observed for glycopeptides and aminoglycosides. The data may be useful as a benchmark for further pharmaco-epidemiologic evaluation and focused drug use control interventions.

Silent practices: imperatives of a culture of urgency

Despite advances in both technology and the delivery of health care services, health care associated infection (HAI) continues to exact a significant cost from both the patient and the health care provider. Studies monitoring practice and investigating outbreaks of HAI indicate that many of these infections are preventable if clinicians comply with basic infection control principles. Success in improving infection control practice has, to date been poor.This study sought to identify the impact of the clinical culture of the intensive care unit (ICU) on infection control practice. A clinical ethnography was undertaken at a large regional acute care facility. Data were collected through participant observation and individual interviews.This paper reports a part of the findings, specifically an issue conceptualised as silent practices. These are constructions that reflect imperatives of the intensive care environment and how these interact with infection control practice. The findings reported here indicate that, in the ICU, environmental dynamics construct imperatives and priorities that have a negative impact on infection control practice.

Medication study supports registered nurses' competence for single checking.

In 1999, a review of medication policies and practices for The Geelong Hospital, a Victorian regional acute care hospital, was conducted under the leadership and direction of the Executive Nursing Director. The findings of the review suggested that a study be conducted to examine the safety of single-person (registered nurse division 1) checking of a designated group of medications that had previously been double-checked. The present study was conducted as a descriptive study in adult inpatient units and speciality and midwifery services of The Geelong Hospital, and included the monitoring of medication errors for the designated group of medications under a single-person checking protocol for a 7-month period. A similar number of medication errors were reported when compared with a similar time-frame in which double-person checking was standard practice. At the completion of the study, a convenience sample of 129 nurses from the participating units and services completed questionnaires. The majority of the nurses appreciated the increased autonomy the change to single-person checking of medications provided. They also identified benefits for patients, including that they were able to be more responsive to patient needs.

Adaptors and innovators: a description of staff nurses.

Ongoing research has further delineated mean scores on the Kirton Adaption-Innovation Inventory for a convenience sample of 266 staff nurses working in 13 regional acute care hospitals, thus adding to the knowledge of score descriptions in occupational groups.