Small Community Hospital Research Articles

Speed and accuracy of text-messaging emergency department electrocardiograms from a small community hospital to a provincial referral center

Background Currently, transmission of electrocardiograms (EKGs) from a small emergency department (ED) to specialists at referral hospitals can be a time-consuming and laborious process. We investigate whether text messaging by use of short message service (SMS) of EKGs from a small hospital to consultants at a large hospital is rapid and accurate. Methods This study involved a one-month prospective evaluation of consecutive EKGs recorded in a small community ED. Investigators obtained de-identified photographs of each EKG via a mobile phone camera. Each EKG picture, along with a brief patient clinical history, was sent via SMS to on-call emergency physicians located at a large referral care site. All images were evaluated solely on a mobile phone. The primary outcome was the proportion of SMS that were received within two minutes of being sent. As a secondary outcome, the intra-rater evaluation of the initial EKG and the SMS EKG image were compared on 13 standardized features. The tertiary outcome was cost of text messaging. Results A total of 298 patients (14.6%) had 409 EKGs performed and a total of 926 SMS were sent. 921 SMS (99.5%, 95% confidence interval (CI) 98.7–99.8%) arrived within two minutes with a median transmission time of nine seconds (interquartile range (IQR) 3–32 s). Between the gold standard original EKG, and the interpretation of the texted image, six out of 409 (1.5%, 95% CI 0.6–3.3%) had any differences recorded, across all 13 categories. Overall, the study cost 4.1 cents per texted image. Conclusions Systematic text messaging of ED EKGs from a small community hospital to a referral center is a rapid, accurate, portable, and inexpensive method of data transfer. This may be a safe and effective strategy to communicate vital patient information.

The Challenge to Interpret Antimicrobial Susceptibility at a Small Community Hospital

Objective: We aimed to determine the prevailing resistance rates at a local community hospital for a select group of gram-positive and gram-negative microorganisms for the period 2008-2012. Methods: Aerobic and facultative anaerobic culture isolates representing blood, urine and wounds specimens from all wards were tested at the Microbiology Laboratory, using the MicroScan AutoScan4, to determine antimicrobial susceptibility at the local community hospital. Results: the findings allude to the prevalence of resistance at the institution for the period under review. Conclusion: Resistance trends are speculative at best without the inclusion of molecular characterization of resistance and consumption data. Pharmacists should play a greater role in the determination of resistance by providing the microbiologist with consumption or utilization data, such as the daily defined dose. The inclusion of the daily defined dose in the estimation of resistance would allow clinicians to determine if selective pressure may have contributed to the prevailing resistance rates.

Provider Commitment Is Key for High Vaginal Birth After Cesarean Delivery Rate in a Community Hospital [274

INTRODUCTION: As a community hospital committed to vaginal birth after cesarean delivery (VBAC), we reviewed our experience from 2000 to 2013 to identify contributors to successful VBAC. Our health care providers were both midwives and physicians. METHODS: Using an electronic clinical database that served as a partial electronic medical record, we reviewed records from 2000 to 2013 for all women who had a prior cesarean delivery. We collected patient demographics, insurance, epidural use, and health care provider type. All labor trials were examined for details of labor management, indication for and dilation at cesarean delivery, and neonatal morbidities. Although we reviewed all VBACs in the final analysis, we excluded women who had had a prior vaginal birth. The analysis was then confined to women who had had one prior birth that was via cesarean section. RESULTS: A total of 1,788 women with a single prior birth that was a cesarean delivery were studied, among whom 617 had a VBAC attempt (34.5%); 431 VBAC attempts were successful (70%). Among 289 VBAC attempts among private patients (epidural rate of 73%), the success rate was 66%. For 328 MediCal public patients (epidural rate of 50%), the success rate was 73%. Neither maternal age at delivery nor maternal BMI prior to gestation influenced VBAC success rates. However, private patients were approximately 7 years older than the public patients (mean private age of 36 years old with a standard deviation of 4 years versus the mean public age of 29 years old with a standard deviation of 5 years). Private patients also had a lower pregestation BMI than the public patients (private BMI of 24 versus public BMI of 27 with a standard deviation of 5). Due to changes in county funding in 2011, a combined public and private foundation model was established and a hospitalist care model for labor and delivery was expanded. Although public patients remained primarily managed by midwives as they had been in the past, now private foundation patients had access to both the midwives and hospitalists that may be different from their prenatal doctor. All other variables remained the same, namely, in house 24/7 anesthesia and pediatrics along with in-house OB (as the hospitalist) and in-house midwife. As this collaborative model progressed from 2011 to 2013, we were able to see a reversal of decreasing VBAC rates combined with continued high VBAC success along with good maternal and neonatal safety profiles. Among private patients, the VBAC rate starting at 19% in 2010 (had been as low as 12% in 2007), ended up at a high of 33% in 2013. In addition, neonatal outcomes among VBAC attempt patients were excellent with a single uterine rupture (0.2%) and a 5-minute Apgar less than 7 rate of 0.4%, both unchanged from the earlier period. CONCLUSION: Despite calls for more VBACs, a 10% VBAC rate nationally has not budged much in the last 5 years. Within the same small community hospital (1500 births/year), among all health care provider groups, VBAC rates started high, then followed the descending national rates and then in 2011 reversed. This reversal was due to an increase in VBAC attempts and largely related to a new collaborative model in which private doctors allowed other providers to manage and deliver their patients. Those providers could be either the in-house midwife or the OB hospitalist. In addition, the VBAC success rate was uniformly high at 70%. Health care provider commitment is critical to achieving higher VBAC rates in hospitals that offer VBAC. In this setting, VBAC was quite safe.

Non-attendance in musculoskeletal outpatients: the good, the bad and the ugly

Background: Non-attendance, i.e. the failure of patients to keep scheduled outpatient appointments, is well recognised. In England, of the 100.5 million outpatient appointments made between April 2013 and March 2014, 7.0 million (6.9%) were reportedly not attended. National non-attendance rates for physical therapy are unknown. Non-attendance is claimed to increase health costs, lower productivity and disrupt patient flow, resulting in poor access to health care, longer waiting lists, delays in diagnosis and treatment, sub-optimal care and poor clinical outcomes. However, the empirical evidence for these claims is limited. Understanding the causal chain to determine whether non-attendance is a voluntary behaviour, or whether there are underlying health system characteristics beyond the patient's control, is essential in designing interventions to reduce non-attendance rates. Purpose: To identify why patients fail to complete physical therapy care episodes, using mixed methods, in multiple musculoskeletal outpatient settings. Methods: An observational, longitudinal study was undertaken in one primary care musculoskeletal service, with 15 patients, purposively sampled and referred with low back pain. All physical therapy appointments were observed and audio-recorded. The clinicians and patients were interviewed about their physical therapy assessments and treatments, and a thematic analysis was undertaken, using a framework approach. In addition, two postal surveys were undertaken, in physical therapy departments in a large teaching hospital and a small community hospital, using retrospective sampling. Patients who had attended the department at least once in the last 12 months and failed to complete their care were sent a 25-item checklist about the reasons for not finishing their physical therapy, with space for free text. Results: In the observational study 8/15 patients did not complete their care. The interviews (in patients’ homes) revealed rich data about their decision to not attend, with some mismatches evident between patients’ and clinicians’ perceptions, in the multiple factors identified. In the teaching hospital, 12/50 (24%) of the questionnaires were returned, with a mean of 1 factor cited for not attending (range 0–5). The top 3 reasons reported for non-attendance were: ‘my condition improved’ (17%); ‘no improvement with physiotherapy’ (17%); and ‘advised not to attend by another health care professional’ (17%). There were 25 mailed and 5 telephone responses to the 77 questionnaires in the community hospital (39%), with a mean of 2.1 factors cited for not attending (range 1–6). The top 3 reasons for non-attendance were: ‘no improvement with physiotherapy’ (27%); ‘my condition improved’ (23%); and ‘other health issues took priority (23%). Conclusion(s): The factors influencing non-attendance in three musculoskeletal outpatient services included voluntary behaviours by the patient, behaviours exhibited by other patients, service constraints, environmental factors and resolution of symptoms. A mixed methods approach to understand the reasons for non-attendance enabled depth of data through the qualitative interviews and breadth through the surveys. Systematic collection of non-attendance data is recommended using mixed methods, to identify the contributing factors from the patients’ perspective. Implications: Identifying local reasons for non-attendance, directly from patients, could help in designing and implementing initiatives to reduce non-attendance in physical therapy services and enhance efficiency.

Influence of AIDET in the improving quality metrics in a small community hospital - before and after analysis

Background: As the US healthcare system is becoming a more outcomes based system, increasing emphasis is being paidto improving all aspects of health care delivery. Interpersonal and communication skills, an ACGME (Accreditation Councilfor Graduate Medical Education) core competency in resident education, play a fundamental role in this effort. This aspectof healthcare delivery is also part of Medicare hospital reviews. In our hospital, the administration has introduced AIDET (Acknowledge, Introduce, Duration, Explanation, and Thank you) as a communication strategy which promises to improveexchange of information between healthcare professionals as well as with patients and their families. Objective: Determine if theAIDET strategy used in our facility has improved patient satisfaction.Methods: This study was done using pretest post test experimental design. Patient satisfaction was measured using scores fromthe HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) quarterly reports from the 3rd quarter of2010 to the 2nd quarter of 2013. Pre and post AIDET implementation results were statistically analysed using a paired t-test.Results are reported as a p-value with < .05 being statistically significant.Results: There were a total of 1,811 patient responses sampled from the 3rd quarter of 2010 to the 2nd quarter of 2013. Asignificant change < .05 was seen in the way Nurses Explain, Doctors Explain and Nurses listen in the pre and post AIDETimplementation comparison. The change in percentage of patients that believed doctors and nurses explained things to them in away they could understand showed a p-value of .02. The trend in percentage of patients that perceived that nurses always listenedcarefully to them showed a p-value of .02 as well. On the other hand, the data evaluating how doctors listened carefully to themdid not reach statistical significance with a p-value of .08. The remaining categories of “Told About Medication” and “Help afterDischarge” were both found not have changed significantly either.Conclusions: The implementation of AIDET education may have had a significant impact on provider-patient communication inour facility, especially in the patient’s perception of explaining things in a way they could understand. On the other hand, in theresponses to the question of whether or not doctors listened carefully to them, there was some improvement over time, howeverthis did not achieve statistical significance.

An Infectious Diseases Physician-Led Antimicrobial Stewardship Program at a Small Community Hospital Associated With Improved Susceptibility Patterns and Cost-Savings After the First Year.

The importance of antimicrobial stewardship is increasingly recognized, yet data from community hospitals are limited. Despite an initially low acceptance rate, an Infectious Diseases physician-led program at a 70-bed rural hospital was associated with a 42% decrease in anti-infective expenditures and susceptibility improvement in Pseudomonas aeruginosa over 3 years.

‘An abundance of caution’ and Ebola in the US Healthcare System: What is the new normal?

Roosevelt General Hospital (RGH) is a small (24 bed) community hospital based in Portales, New Mexico, USA. RGH serves several towns and communities along the New Mexico/Texas border to include the enlisted and officer population of Cannon US Air Force Base as well as the civilian support and families for air force personnel. The area is also home to multiple retired and discharged military personnel who continue working in various roles as civilian contractors. As the care for the first US diagnosed patient with Ebola played out in neighbouring Texas (October 2014), a patient presented to the RGH clinic with a fever of unknown origin. Initially, there was a misunderstanding between the clinician and the patient regarding a recent international travel history. During the assessment, an ensuing discussion revealed that the patient had been in or near the area where the current West African Ebola outbreak is ongoing approximately 10 days before the onset of his fever. While it was later determined that the patient was not infected with Ebola, the fact that a potentially infected patient had entered the hospital and had been in close contact with visitors and clinicians alike was disturbing to staff and administration. The continued operation of this hospital was and remains critical to the communities served. This story focuses on a local effort to manage a local concern relying on recent and historical emergency planning and preparedness efforts.

The professional role of massage therapists in patient care in Canadian urban hospitals--a mixed methods study.

BackgroundMassage therapy (MT) is becoming established as a recognized health care profession in Canada. It has been integrated as a core service in settings such as health spas, private integrative health centers, and there is indication that MT is starting to be integrated into hospitals. Research in the area of hospital-based MT has primarily focused on the efficacy, effectiveness, and increasingly, the safety of MT. However, little is known about the professional role of massage therapists in the hospital setting. The purpose of this study was to conduct an in-depth exploration and description of massage therapists’ professional role in patient care in the context of Canadian urban hospitals.MethodsA sequential mixed methods study design was used. For the quantitative phase, a survey was sent to urban hospitals where MT services were organized by hospitals and provided by licensed massage therapists to patients to a) provide a contextual description of the hospitals and b) identify a sampling frame for the qualitative phase. The subsequent qualitative phase entailed semi structured interviews with a purposively diverse sample of participants massage therapists from the surveyed sites to explore their role perceptions. The quantitative and qualitative approaches were integrated during data collection and analysis.ResultsOf the hospitals that responded, sixteen urban hospitals across Canada (5%) provided MT to patients by licensed therapists. The majority of hospitals were located in Ontario and ranged from specialized small community hospitals to large multi-site hospitals. Based on interviews with 25 participants, six components of the massage therapists’ professional role emerged: health care provider, team member, program support, educator, promoter of the profession, and researcher.ConclusionsWhile hospital-based MT in Canada is not a new phenomenon, MT is not yet an established health care profession in such settings. However, there is significant potential for the inclusion of the massage therapists’ role in Canadian hospitals that should be evidence based for effective implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/s12906-015-0536-4) contains supplementary material, which is available to authorized users.

Achievement of Processes of Care for Patients with Type 2 Diabetes in General Medical Clinics and Specialist Diabetes Clinics in Thailand

Background: The process of care used for type 2 are common clinical performance indicators, but comparing achievement of process of care between clinic types at different hospital types has received little attention. This study compares process of care between specialist clinics (SDCs) and general medical clinics (GMCs), and how this disparity may vary across hospital types (regional, provincial, community) in Thailand. Methods: We conducted a cross-sectional study based on medical records of type 2 patients (n=26,860) collected from 595 hospitals (26 regional, 70 provincial, 499 provincial) between April 1 to June 30, 2012 across all provinces in Thailand. Generalized linear mixed models were used to investigate the association between clinic type and processes of care. Processes of care outcomes included the of diabetes where F is foot examination, A is HbA1c examination, C is low density lipoprotein cholesterol (LDL-C) examination, and E is eye examination. Aggregate measure including All FACE (yes/no), whether all four clinical examinations were achieved, and Any FACE (yes/no), whether any were achieved, were also examined. Results: SDCs were often better at large hospitals, and only for LDL-C exam were SDCs not superior in this setting. For regional hospitals, SDCs exhibited higher achievement of All FACE (OR regional=1.68, 95%CI: 1.26-2.24). For provincial hospitals, SDCs were associated with higher odds of achieving All FACE and Any FACE (OR=2.14, 95%CI: 1.50-3.06; OR=1.76, 95%CI: 1.05-2.97, respectively). For community hospitals, no difference in achievement of All FACE and Any FACE could be demonstrated between clinics types. Conclusions: SDCs perform better in process of care (singular or aggregated) than GMCs at regional and provincial hospitals, for all process of care indicators, and were never inferior. However, smaller community hospital- GMCs perform care no worse than their SDCs counterparts.

Evaluation of Viewpoints of Health Care Professionals on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas Based on Practice Environment.

We sought to evaluate whether health care professionals' viewpoints differed on the role of ethics committees and hospitals in the resolution of clinical ethical dilemmas based on practice location. We conducted a survey study from December 21, 2013 to March 15, 2014 of health care professionals at six hospitals (one tertiary care academic medical center, three large community hospitals and two small community hospitals). The survey consisted of eight clinical ethics cases followed by statements on whether there was a role for the ethics committee or hospital in their resolution, what that role might be and case specific queries. Respondents used a 5-point Likert scale to express their degree of agreement with the premises posed. We used the ANOVA test to evaluate whether respondent views significantly varied based on practice location. 240 health care professionals (108-tertiary care center, 92-large community hospitals, 40-small community hospitals) completed the survey (response rate: 63.6 %). Only three individual queries of 32 showed any significant response variations across practice locations. Overall, viewpoints did not vary across practice locations within question categories on whether the ethics committee or hospital had a role in case resolution, what that role might be and case specific queries. In this multicenter survey study, the viewpoints of health care professionals on the role of ethics committees or hospitals in the resolution of clinical ethics cases varied little based on practice location.

Community health nurses' HIV health promotion and education programmes: a qualitative study.

Globally, nurses practice in many settings with people with human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), taking an increasing share of the professional burden of care and helping to reduce morbidity and mortality. International literature is sparse about Thai community nurses providing primary healthcare programmes for people with HIV. This study aimed to describe background, experiences and strategies of community nurses regarding their design and delivery of programmes for people living with HIV and AIDS in Chiang Mai Province, Thailand. This study used a qualitative mixed-methods study employing a qualitative survey and in-depth interviews. Twenty community health nurses from 18 small community hospitals completed a survey comprising demographic data and 13 open-ended questions. Four of them later engaged in in-depth interviews using the same questions. Survey, interview data and field notes were analysed using interpretive content analysis. Four themes and six sub-themes portrayed participants' rich experiences and knowledge of HIV health promotion and education; challenges of daily work, discrimination and ethical issues; success through programme diversity comprising promotion of community volunteerism, networking and relationships; and holistic connections with Thai cultural traditions and Buddhism. Findings help to recognize the diversity, uniqueness and contributions of Thai community nurses regarding culturally appropriate health promotion and education programmes for people living with HIV and AIDS. Findings inform nurses and health officials in and outside of the country to complement innovation in future HIV health promotion and education programmes. Our sample came from one province of Thailand. Findings might not be reflective of nurses elsewhere. Three decades of collective experience in providing holistic and multifaceted HIV and AIDS nursing care, education and health promotion by community health nurses have the potential to effect new and existing policies and protocols on HIV community care in Thailand, but more research is required for this.

A Woman with Dyspnea and Hemoptysis

A 55-year-old female presented to the emergency department at a small community hospital with cough, fever, dyspnea and blood-streaked sputum. A chest radiograph was ordered. She was diagnosed with pneumonia and discharged home with antibiotics. She returned three days later, afebrile, with worsening dyspnea and gross hemoptysis. She was found to have a murmur reported as chronic but had never been evaluated by echocardiography. A computed tomography chest and echocardiography were performed (Figure). She was diagnosed with a left atrial myxoma (Video). She was transferred and underwent tumor excision.

Time to appendectomy and risk of perforation in acute appendicitis.

In the traditional model of acute appendicitis, time is the major driver of disease progression; luminal obstruction leads inexorably to perforation without timely intervention. This perceived association has long guided clinical behavior related to the timing of appendectomy. To evaluate whether there is an association between time and perforation after patients present to the hospital. Using data from the Washington State Surgical Care and Outcomes Assessment Program (SCOAP), we evaluated patterns of perforation among patients (≥18 years) who underwent appendectomy from January 1, 2010, to December 31, 2011. Patients were treated at 52 diverse hospitals including urban tertiary centers, a university hospital, small community and rural hospitals, and hospitals within multi-institutional organizations. The main outcome of interest was perforation as diagnosed on final pathology reports. The main predictor of interest was elapsed time as measured between presentation to the hospital and operating room (OR) start time. The relationship between in-hospital time and perforation was adjusted for potential confounding using multivariate logistic regression. Additional predictors of interest included sex, age, number of comorbid conditions, race and/or ethnicity, insurance status, and hospital characteristics such as community type and appendectomy volume. A total of 9048 adults underwent appendectomy (15.8% perforated). Mean time from presentation to OR was the same (8.6 hours) for patients with perforated and nonperforated appendicitis. In multivariate analysis, increasing time to OR was not a predictor of perforation, either as a continuous variable (odds ratio = 1.0 [95% CI, 0.99-1.01]) or when considered as a categorical variable (patients ordered by elapsed time and divided into deciles). Factors associated with perforation were male sex, increasing age, 3 or more comorbid conditions, and lack of insurance. There was no association between perforation and in-hospital time prior to surgery among adults treated with appendectomy. These findings may reflect selection of those at higher risk of perforation for earlier intervention or the effect of antibiotics begun at diagnosis but they are also consistent with the hypothesis that perforation is most often a prehospital occurrence and/or not strictly a time-dependent phenomenon. These findings may also guide decisions regarding personnel and resource allocation when considering timing of nonelective appendectomy.

The evidence-based practice profiles of academic and clinical staff involved in pre-registration nursing students' education: A cross sectional survey of US and UK staff

Competency in evidence-based practice (EBP) is a requirement for graduate nurses. Despite a growing body of research exploring the EBP profiles of students, little research has explored the EBP profiles of nurse educators. To explore: the differences/similarities in the EBP profiles of US and UK clinical and academic faculty; the barriers nurse educators experience when teaching EBP; the impact of postgraduate education on EBP profile and; what nurse educators perceive"success"in implementing and teaching EBP to be. A cross-sectional online survey design was employed. Two Universities delivering undergraduate nursing education in the US and UK, in partnership with large hospital systems, small community hospitals, community settings, and independent sector healthorganisations. Eighty-one nurse educators working in academic and clinical contexts in the US and UK (US academic=12, US clinical=17, UK academic=9, UK clinical=43) were recruited opportunistically. Participants were emailed a weblink to an online survey, comprising demographic questions, the Evidence-Based Practice Questionnaire and open-ended questions about EBP barriers, facilitators and successes. Quantitative results indicatedthatacademic faculty scored significantly higher on knowledge and skills of EBP, than clinical faculty, but revealed no other significant differences on EBP use or attitudes, or between US and UK professionals. Participants with postgraduate training scored significantly higher on EBP knowledge/skills, but not EBP attitudes or use. Qualitative findings identified key themes relating to EBP barriers and facilitators, including: Evidence-, organisational-, and teaching-related issues. Perceptions of successes in EBP were also described. Nurse educators working in the UK and US face similar EBP barriers to teaching and implementation, but view it positively and use it frequently. Clinical staff may require extra support to maintain their EBP knowledge and skills in comparison to staff working in academic contexts.

Reasons for encounter and diagnoses of new outpatients at a small community hospital in Japan: an observational study.

PurposeAlthough many new patients are seen at small hospitals, there are few reports of new health problems from such hospitals in Japan. Therefore, we investigated the reasons for encounter (RFE) and diagnoses of new outpatients in a small hospital to provide educational resources for teaching general practice methods.MethodsThis observational study was conducted at the Department of General Internal Medicine in a small community hospital between May 6, 2010 and March 11, 2011. We classified RFEs and diagnoses according to component 1, “Symptoms/Complaints”, and component 7, “Diagnosis/Diseases”, of the International Classification of Primary Care, 2nd edition (ICPC-2). We also evaluated the differences between RFEs observed and common symptoms from the guidelines Model Core Curriculum for Medical Students and Goals of Clinical Clerkship.ResultsWe analyzed the data of 1,515 outpatients. There were 2,252 RFEs (1.49 per encounter) and 170 ICPC-2 codes. The top 30 RFE codes accounted for 80% of all RFEs and the top 55 codes accounted for 90%. There were 1,727 diagnoses and 196 ICPC-2 codes. The top 50 diagnosis codes accounted for 80% of all diagnoses, and the top 90 codes accounted for 90%. Of the 2,252 RFEs, 1,408 (62.5%) included at least one of the 36 symptoms listed in the Model Core Curriculum and 1,443 (64.1%) included at least one of the 35 symptoms in the Goals of Clinical Clerkship. On the other hand, “A91 Abnormal result investigation”, “R21 Throat symptom/complaint”, and “R07 Sneezing/nasal congestion”, which were among the top 10 RFEs, were not included in these two guidelines.ConclusionWe identified the common RFEs and diagnoses at a small hospital in Japan and revealed the inconsistencies between the RFEs observed and common symptoms listed in the guidelines. Our findings can be useful in improving the general practice medical education curricula.

Implementation and first-year results of an antimicrobial stewardship program at a community hospital.

The implementation of an antimicrobial stewardship program (ASP) at a small community hospital affiliated with an accountable care organization (ACO) is described, including a report on first-year program outcomes. With no infectious diseases (ID)-trained pharmacists on staff, a 155-bed hospital formed an ASP by restructuring its clinical pharmacy services. One full-time pharmacist led the program; nine full- or part-time pharmacists-none of whom had residency training-shared ASP responsibilities on a weekly rotation. Under a contract with a private medical group, an ID physician reviewed cases with ASP pharmacists for up to two hours each weekday. ASP interventions and tracking and reporting of outcomes were done primarily by pharmacists. Monitoring of pharmacy purchases in the first year of the program indicated an annualized 26% decrease in overall antimicrobial expenditures from prior-year spending, with a nearly 18% decrease in defined daily doses per 1000 patient-days. Total first-year direct cost savings attributed to the ASP were estimated at $145,353. Pharmacist-initiated conversions of patients from i.v. to oral antimicrobial therapy increased by 688% (p < 0.0001). Overall, the rate of ID physician acceptance of ASP-recommended interventions (mainly streamlining of therapy, limiting the duration of therapy to a specific stop date, and discontinuation of nonindicated drugs) was 74%. An ASP was implemented at a small ACO-affiliated community hospital by a team of pharmacists without specialized ID training. During the first year of the program, antimicrobial expenditures were reduced and there was a significant increase in pharmacist-initiated i.v.-to-oral conversions.

Combining resources, combining forces: regionalizing hospital library services in a large statewide health system.

After a reduction in full-time equivalents, 2 libraries in large teaching hospitals and 2 libraries in small community hospitals in a western US statewide health system saw opportunity for expansion through a regional reorganization. Despite a loss of 2/3 of the professional staff and a budgetary decrease of 27% over the previous 3 years, the libraries were able to grow business, usage, awareness, and collections through organizational innovation and improved efficiency. This paper describes the experience--including process, challenges, and lessons learned--of an organizational shift to regionalized services, collections, and staffing. Insights from this process may help similar organizations going through restructuring.

Tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer worldwide.

Multidisciplinary management tumor boards are now conducted worldwide for the management of patients with cancer. Studies evaluating their influence on decision making and patient outcome are limited; however, single-center studies have reported significant changes in diagnosis and treatment plans. A survey from Arabic countries showed widespread use and reliance on tumor boards for decision making. A recent multi-institutional survey of veteran affairs (VA) hospitals in the United States found limited association between the presence of tumor boards and care and outcomes. The Cancer Care Outcomes Research and Surveillance Consortium looked at the association between tumor board features and measures of quality of care. Results of overall survival among the patients of these physicians participating in tumor boards is ongoing, but preliminary results are outlined along with a recent ASCO survey of international members on the presence, utilization, and influence of tumor boards in this article. Tumor boards allow for implementation of clinical practice guidelines and may help capture cases for clinical trials. Efforts to improve preparations, structure, and conduct of tumor boards, research methods to monitor their performance, teamwork, and outcomes are outlined also in this article. The concept of mini-tumor boards and more efficient methods for MDM in countries with limited resources are also discussed. In suboptimal settings, such as small community hospitals, rural areas, and areas with limited resources, boundaries in diagnosis and management can be overcome, or at least improved, with tumor boards, especially with the use of video-conferencing facilities. Studies from the United Kingdom showed that special training of multidisciplinary teams (MDT) led to better team dynamics and communication, improved patient satisfaction, and improved clinical outcome. The weight of the benefits versus the time and effort spent to improve efficiency, patient care, and better time management in the United States and in the international oncology community is also reviewed in this article.

Fall risk and fall prevention strategies for frail old people: The example of a small community hospital

Fall risk and fall prevention strategies for frail old people: The example of a small community hospital

Infection control interventions in small rural hospitals with limited resources: results of a cluster-randomized feasibility trial

BackgroundThere are few reports on the feasibility of conducting successful infection control (IC) interventions in rural community hospitals.MethodsTen small rural community hospitals in Idaho and Utah were recruited to participate in a cluster-randomized trial of multidimensional IC interventions to determine their feasibility in the setting of limited resources. Five hospitals were randomized to develop individualized campaigns to promote HH, isolation compliance, and outbreak control. Five hospitals were randomized to continue with current IC practices. Regular blinded observations of hand hygiene (HH) compliance were conducted in all hospitals as the primary outcome measure. Additionally, periodic prevalence studies of patient colonization with resistant pathogens were performed. The 5-months intervention time period was compared to a 4-months baseline period, using a multi-level logistic regression model.ResultsThe intervention hospitals implemented a variety of strategies. The estimated average absolute change in “complete HH compliance” in intervention hospitals was 20.1% (range, 7.8% to 35.5%) compared to −3.1% (range −6.3% to 5.9%) in control hospitals (p = 0.001). There was an estimated average absolute change in “any HH compliance” of 28.4% (range 17.8% to 38.2%) in intervention hospitals compared to 0.7% (range −16.7 to 20.7%) in control hospitals (p = 0.010). Active surveillance culturing demonstrated an overall prevalence of MRSA carriage of 9.7%.ConclusionsA replicable intervention significantly improved hand hygiene as a primary outcome measure despite barriers of geographic distance and lack of experience with study protocols. Active surveillance culturing identified unsuspected reservoirs of MRSA colonization and further promoted IC activity.