Hospital Team Research Articles

Evaluation of simvastatin and CYP3A4-inhibitor interactions in an inpatient population

Abstract Introduction The maximum recommended dose for simvastatin in conjunction with the CYP3A4 inhibitors amiodarone, amlodipine, diltiazem, or verapamil is 20 mg/day.1 Studies have reported on the extent of potentially harmful simvastatin interactions which can increase the risk of myopathy.2 A project in a local primary care setting had identified that 42 (14%) of 305 patients prescribed simvastatin and one of these CYP3A4 inhibitors were receiving the unlicensed dose of simvastatin 40mg. We wanted to investigate if there were similar concerns for hospital inpatients. Aim The aim of this evaluation was to ascertain whether patients were prescribed simvastatin 40mg with one of the named interacting drugs during their hospital admission and whether any action was taken for patients on such a combination. Methods A search was undertaken of patients prescribed simvastatin 40mg with amiodarone, amlodipine, diltiazem, or verapamil using the electronic prescribing system (EPS) (Careflow Medicines Management) between January to October 2022. Relevant data were extracted from the EPS and discharge summaries were searched for any additional information, in particular for any notes made by the prescriber or pharmacy team that they had recognised and acted on this combination. Data were collated and analysed using Microsoft Excel. As this project falls under the definition of a service evaluation, according to UK NHS Research Ethics Committees, formal ethical approval was not required. This project was registered on the hospital’s clinical audit database. Results Fifty-six patients (mean age 78, range 59-94, 50% female) were prescribed a combination of interest during their admission. A further 13 who died in hospital were excluded. Thirty (54%) patients were admitted on this combination. Simvastatin 40mg appeared with amlodipine in 77% (n=43) of instances, diltiazem in 11% (n=6), amiodarone in 11% (n=6), and verapamil in 1% (n=1). Thirty-one (55%) of 56 patients were discharged on this combination, and 6 had no discharge information. Of the 19 (34%) not discharged on the combination, six were due to proactive pharmacy intervention, whilst remaining instances were due to other clinical reasons. Discussion/Conclusion We observed a possible lack of knowledge of these potentially hazardous interactions with some inpatients commenced on the combination, and just over half of the cohort discharged on such a combination. Such in-hospital prescribing of interacting drugs and lack of pharmacy team clinical check could be due to unawareness of the MHRA alert. Though our EPS has the functionality of triggering alerts to notify prescribers of interactions, only level 4 warnings are flagged and the interactions we examined, as a level 3 warning, remain suppressed and not easily visible to the prescriber. Our results will be shared with hospital and primary care pharmacy teams, as this is an area of prescribing that the Care Quality Commission may review when inspecting general practices.3 This evaluation will be repeated. Recognised limitations of this single centre, retrospective study include: we did not look at interactions between simvastatin and other medicines, nor interactions with other statins; we did not investigate whether these patients were suffering from muscle-related adverse events.

To addend or not to addend? Exploring medical student and resident perceptions of the use of student notes for billing purposes

Background: Clinical documentation is an essential skill for which medical students are often not prepared. Changes in documentation rules for medical students allow the utilization of student notes for official billing purposes, which requires investigation for possible educational intervention. Potential benefits to medical learners and impacts on feasibility and workflow must be explored. Methods: Pediatric clerkship students were randomly assigned to one of two inpatient hospitalist teams: control group students wrote daily notes that were not addended or used for billing; study group students’ notes were used for billing after being addended by resident and faculty members. At the end of the clerkship, residents and medical students completed surveys and focus groups. Results: In surveys, residents from both groups reported similar satisfaction with medical student documentation. Study group students spent more time reviewing notes, found the feedback from residents beneficial, and felt their experience with documentation was more valuable than control group students. Focus group themes included: educational value for learners, increased student engagement, possible negative impact on workflow, inherent feedback in reviewing edits, the importance of clear communication, and minimal effects on patient care. Conclusions: Our results highlight the potential educational benefits of using student notes as official documentation and provide evidence that this practice may not negatively impact resident learners.

Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units.

Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.

Evaluation of the effectiveness regarding the participation of pharmacists in perioperative blood glucose management via the iGMS: a pilot RCT

BackgroundExcellent blood glucose management is a key guarantee for successful progress of surgery. However, the impact of clinical pharmacists on blood glucose management of perioperative patients needs to be further investigated. To investigate the effectiveness regarding the participation of pharmacists in blood glucose management via the informatized glucose management system (iGMS) on perioperative patients with type 2 diabetes mellitus (T2DM).MethodsThe working mode of clinical pharmacists participating in blood glucose management of perioperative patients with diabetes was constructed. A total of 300 patients with T2DM who underwent elective surgery were recruited and divided into a clinical pharmacist management group (intervention group) of 150 patients (94 men and 56 women; mean age: 44.38 ± 14.03 years) and a control group of 150 patients (101 men and 49 women; mean age: 47.85 ± 12.26 years) between September 2019 to April 2020. The outcomes of perioperative blood glucose management, and healthcare indicators such as preoperative waiting time, total hospitalization time, postoperative infection rate and other indicators were analyzed statistically between the two groups.ResultIn the blood glucose management team of the whole hospital, the physicians, clinical pharmacists and nurses of blood glucose management in endocrinology department were the core members, and were responsible for perioperative blood glucose management of the participants in the intervention group. All subjects had lower blood glucose after 3 days of management compared to the time of admission, and blood glucose was significantly lower in the intervention group compared to the control group (P < 0.05). As compared with the control group, subjects in intervention group demonstrated significant differences in outcome measures. The relevant parameters included preoperative blood glucose compliance rate (60.67% vs. 35.33%, P<0.05), preoperative waiting time [(5.27 ± 3.34) vs. (7.45 ± 4.38), P<0.05], length of hospitalization [(11.11 ± 4.56) vs. (14.87 ± 5.39), P<0.05], incidence of hypoglycemia (8.67% vs. 18.00%, P<0.05), incidence of hyperglycemia (32.00% vs. 62.67%, P<0.05) and postoperative infection rate (18.00% vs. 24.67%, P > 0.05).ConclusionThe involvement of clinical pharmacists in blood glucose management utilizing the iGMS can control the blood glucose level of patients with T2DM in the perioperative period more stably and effectively, thereby leading to an improvement in the quality of healthcare.

Palliative care for cardiovascular patients: description of motives for referral and actual care provided

Abstract Background Palliative care (PC) for cardiovascular patients remains suboptimal, whereby only a small proportion of patients are referred to specialist palliative care, and often too late in the disease course. We investigated the reasons that prompted cardiologists to request an intervention from the PC team, and we describe the actions implemented by the PC in response to referrals from the cardiology department. Methods This retrospective study included all patients with cardiovascular disease who were referred to the mobile palliative care team of a large University Hospital in France between 2010 and 2020. All data were extracted from the medical hospital files. For all patients referred to PC during the study period, we recorded the original motive for requesting assistance, as cited in request sent from cardiology to PC. We also recorded the types of services provided by PC, the date of the first and last consultation of the patient with PC, and the number of PC consultations per patient. Results From a total of 142 cardiology patients for whom PC assistance was requested, 136 (95.8%) died, while 6 (4.2%) are still alive. In 42 patients (29.6%), there was a generic request for intervention without indicating any particular domain where specific assistance was needed. In other cases, a motive for referral to the PC mobile team was provided by cardiologists, with ethical dilemmas (35 patients; 24.6%), symptom management (23 patients; 16.2%), and discussion about where the patient could live (11 patients; 7.7%), as the most common motives (see Figure 1). In response to these referrals, the PC team provided assistance with ethical dilemmas in 69 patients (48.6%), symptom management in 28 patients (19.7%), discussion about where the patient could live in 15 patients (10.6%), 2 or more of these issues in 16 patients (11.3%), and other issues in 14 patients (9.8%) (e.g. reorientation to oncology or family support). The majority of patients had 1 (n=90, 63.4%) or 2 PC consultations (n=27, 19%), while 10 patients (7%) had 3, 9 patients (6.4%) had 4, and 6 (4.2%) had 5 or more PC consultations. Among those who died, the median number of days between the first and the last PC consultation was 0 (quartile 1=0, quartile 3=3). Conclusion This study shows that cardiologists do not necessarily have a specific motive in mind when referring patients to PC. Because many more patients received assistance with ethical dilemmas than was requested, this indicates that cardiologists may not be aware of the ethical issues at stake in the care of cardiology patients, or that they only refer patients to PC when they have no other solution or do not know what else to do for the patient. There is clearly a need to raise awareness among cardiologists about ethical issues and about the services that the PC team can provide.

Abstract 17246: Using Alerts vs Automated Tools to Better Document CHADS2-VASc Scores in Patients Hospitalized With Atrial Fibrillation

Introduction: Atrial fibrillation (Afib) is the most common cardiac arrhythmia in the United States and a significant burden on our healthcare system. Currently as many as six million people in the United States carry a diagnosis of Afib, with that number likely increasing as our population ages and our methods of detection improve. Accurate diagnosis and risk stratification are imperative as these patients may have stroke rates as high as 20% annually. Comprehensive documentation of the CHADS2-VASc score can better determine the need for Anticoagulation for patients hospitalized with Afib Hypothesis: What is the rate of recording of CHADS2-VASc scores in patients admitted to House Staff and Hospitalist teams and what interventions would lead to better data gathering: a best practice alert or an automated diagnosis tool in the Electronic Medical Record (EMR). Methods: At The University of Chicago Medical Center, attendings on the cardiology service and hospitalists documented CHADS2-VASc without intervention. Then the response rate was measured after implementing a best practice alert, or soft stop dialog box in the EMR. Later for Hospital Medicine teams, an auto diagnosis tool, a hard stop auto-generated in the note, was added to the EMR. Results: Over the course of three years (January 2018 to December 2021) CHADS2-VASc score was charted an average of 1% of the time for hospitalists and 7% of the time for House Staff Cardiology. After implementing the EMR Best practice alert (January 2022 to January 2023 for House Staff and January 2022 to November 2022 for Hospitalists) these rates increased to 19% (p &lt;0.0001) for the hospitalist team and 54% for the House Staff Cardiology team (p&lt;0.00001). With the Auto diagnosis tool (November 2022 to January 2023) the rate increased from 19% to 56% (p &lt;1x10 -7 ) Conclusions: As our data shows, CHADS2-VASc scores recording rates remained low among both cardiology and medicine attendings. However, an EMR generated alert increased responses while an auto diagnosis tool increased documentation even more. This demonstrates the effectiveness of EMR tools. This improvement in adherence should also lead to better rates of prescribing Anticoagulation to patients with higher risk.

Abstract 16845: Heart Failure Hospitalist Service Line Have Decrease All Cause Readmission, Length of Stay and Cost at 3 UPMC Hospitals in Central Pennsylvania in 2022

Introduction: Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. Despite numerous evidence-based strategies in the literature aiming at reducing HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Methods: Patients with both primary diagnosis HF at UPMC Harrisburg/West Shore/Community General totaled to 1574 in 2022. Hospitalist, Cardiologist, teaching service N= 547 (36%); CHF hospitalist Team N=1027 (64%). Heart failure order set usage, length of stay, all-cause 30-day readmission rates, readmission with HF, cost per case were assessed between these two groups for 2022. Results: All-cause 30-day HF readmission rates at UPMC (Harrisburg, West Shore, Community General Hospitals) for all other providers (Hospitalist, Cardiologist, teaching service) is 32%. HF Hospitalist team at 3 UPMC hospitals had lower 30 day all cause readmission rates: 8.46%. All other providers length of stay was 7.7 days while length of stay while on HF hospitalist service was 6.3 days. Potential cost savings to UPMC hospitals greater than $2.3 million dollars since start of HF Hospitalist service line. Conclusions: HF patients rarely have a consistent provider when readmitted. To address this health care priority at a system level, UPMC Central Pennsylvania’s strategy of creating a HF hospitalist service line has shown to be a unique method to not only develop trusting relationships with our patients but also attain impressive results. The HF Hospitalist service line was created to support an environment of patient-centered care by providing continuity of care for HF admissions and HF patients admitted for non-HF medical issues. At this community-based healthcare system, HF Hospitalist outcomes include decreased 30 day all-cause readmission to an impressive 8.2%, and reduced 30 day HF readmissions 4.12%. This was done while reducing healthcare costs during the 5yrs of the HF Hospitalist service line now at 3 hospitals at UPMC.

Abstract 18199: Relationship Between Hospital Care Team Segregation Index and Cardiovascular Care for Black and White Patients

Background: High levels of hospital health care team segregation has been associated with worse outcomes for Black patients. We sought to determine whether hospital level segregation index (SI, degree of dissimilarity between composition of teams that care for Black versus White patients) was associated with care by a cardiologist, 30-day readmission, and 1-year survival for Black versus White patients with heart failure (HF). Methods: Using Optum’s de-identified Clinformatics® Data Mart Database, for commercial and Medicare plans, we examined SI among Black and White patients admitted with primary diagnosis of HF from 2010-2018. Hospitals were stratified into three SI groups based on tertiles from least to most segregated hospital teams. Generalized linear mixed-effects models were used to evaluate each outcome including effects of race, SI, race by SI as well as gender, age-adjusted Charlson Comborbidity Index, and hospital factors. For 30-day readmission and 1-year survival, we included effects of cardiology care, 2 and 3-way interactions of race, SI, and cardiology care. Results: Among 119, 272 patients, Black patients were less likely to be seen by a cardiologist compared to White patients across SI tertiles, particularly medium SI hospitals (OR 0.833, 95% CI 0.770-0.902). There was no significant difference in odds of readmission between races across hospital SI levels and whether seen by a cardiologist. For 1-year survival, the odds were significantly higher for Black patients compared to White patients across all SI levels ( Figure ). Conclusion: Black patients with commercial or Medicare insurance were less likely to be seen by a cardiologist for HF care than White patients across SI levels, particularly medium SI. Hospital SI levels did not demonstrate a consistent relationship between 30-day readmission and 1-year survival. Figure .

Ripple effects of hospital team faultlines on patient outcomes

Medical errors are rampant across healthcare settings, imposing a significant burden on patient safety. Here, we examined the ripple effects of diversity splits, or faultlines, within hospital teams on patient safety and care. Hospitals consist of hierarchical, mixed-gender, and multiracial units that are prone to conflict. Within a diverse unit, faultlines can occur when multiple attributes (e.g., gender and race) of unit members align and divide a unit into two or more homogeneous subgroups. Yet, little is known about how such faultlines influence patients. Hierarchical path modeling of data collected from 1,102 hospital employees and 4,138 patients across 38 hospital units illustrated that when strong faultlines formed through homogenous subgroups within hospital units resulted in decreased civility among staff. This incivility was related to higher rates of medical error and patient deaths. A 10% increase in unit incivility was linked to a maximum 8.87% increase in healthcare-associated infection rates and a maximum 10.59% increase in mortality rates. However, we found patients within units high on collaborative cultures for managing conflicts—that fostered mutual respect, active listening, and openness to differing opinions—experienced fewer medical errors and lower mortality rates, regardless of strong faultlines. These findings offer an evidence-based, culture-focused approach to reducing medical errors and improving the quality of patient care.

Psychological support during a pandemic: an intervention for hospital teams.

The COVID-19 pandemic placed unprecedented stress on healthcare professionals and resulted in teams being scattered by shielding, working from home and redeployment. The Recovery, Readjustment and Reintegration programme (R3P) was implemented and evaluated in an acute NHS hospital Trust with the aim of supporting those staff involved. To explore the impact of offering themed reflective sessions to staff in an acute hospital and to disseminate this learning for application in other settings and future pandemics. During the initial recovery phase of the pandemic, all Trust staff were invited to attend an R3P where themed discussions were facilitated by psychologists. Feedback was requested pre- and post-session, and a mixed-methods design was followed to gain quantitative and qualitative information. A total of 430 staff members attended an R3P between April 2021 and January 2022. A significant majority found attendance helpful and agreed that it had provided them with the opportunity to reflect on their own and their teams' experience of pandemic working and led them to feel more supported by their organization. Finding meaning in experiences through facilitated reflective discussion can help limit the negative psychological impact of working in an acute hospital during a pandemic. Staff are likely to benefit from such opportunities in any future pandemic recovery phase.

Optimizing Acute Sickle Cell Care at Community Health Partners Medical Center

CONCLUSION Sickle cell disease (SCD) is an inherited disease affecting more than 100,000 Black and Hispanic patients in the US. An adult with SCD has an average life expectancy of 54 years compared to 76 years in a typical US adult. This poor survival rate can be attributed to disease and race-related biases, a lack of standardized procedures and dedicated care providers, and delayed or insufficient pain management in the acute care setting. Delays and disparities in care, particularly pain management in acute care setting, have been identified as one of the key deficiencies leading to a decreased quality of care and patient reported outcomes. This SCD quality improvement project seeks to improve the quality and timeliness of acute sickle cell vaso-occlusive care by utilizing an ED pain pathway, SCD-specific inpatient order sets, and educating providers on care-related biases for patients seeking acute care at Community Health Partners Medical Center (CHP). The primary objective is to improve efficacy, timeliness and patient-centered care in order to optimize health outcomes for patients with SCD seeking acute care at CHP. This is a collaborative effort between ED, Hospitalist and Pain Management teams. By identifying areas of strength and areas for improvement, we can work towards delivering more efficient, effective, and patient-centered care, ultimately leading to better health outcomes for patients with SCD disease in need of emergency services. Using the Epic EMR, a metric dashboard was created for SCD patients to measure time from arrival to ED order placement, time from arrival to medication administration, number of inpatient admissions, and length of stay. We focused on crucial time metrics and patient outcomes to gauge the department's efficiency and quality of care for SCD Vaso-occlusive pain crisis. Our intervention included delivering an educational presentation to the ED providers regarding appropriate recognition and treatment of SCD pain episodes, and by creating ED and inpatient SCD-specific order sets. The baseline data was evaluated from 3/1/2021-2/28/2022, and metrics were followed for one year after implementation of the intervention from 3/1/22-2/28/23. After implementation, the average time from arrival to ED order placement improved from 94.9 minutes to 69.4 minutes, a difference of 25.5 minutes or 27%. The average time from arrival to medication administration improved from 158.5 minutes to 135.3 minutes, a difference of 23.2 minutes or 14.6%. The average length of stay increased from 5.7 days to 8.4 days, an increase of 2.7 days or 32.2%. By providing education and SCD-specific order sets, we were able to significantly decrease the total amount of time to medication administration for SCD patients experiencing acute pain crises. While our methods were aimed at ED providers to simplify the input of orders, it did not address the time for nursing to obtain and administer the medication; future improvements could be made towards educating nursing staff to help administer medications sooner. One complicating factor is that these metrics were evaluated during the COVID pandemic, which was responsible for an overall increase in patient admissions and length of stay during this time period. These additional burdens have strained the ability of providers and nurses to provide timely care to SCD patients, though this will hopefully continue to improve as the pandemic recedes. Additionally, the proportion of ED patients who were admitted for further management decreased marginally from 25/39(61%) to 36/63(57%) though the overall number of patients seeking care in our acute care setting has increased. This increase in the number of patients utilizing our acute care may be partly due to an expanding Sickle Cell program at our facility. This analysis shows that by providing appropriate education and using a standardized order set and pathway, we observed a significant decrease in time to order placement to facilitate a faster administration of medications. While the results indicate positive changes in the acute setting, there are opportunities for continued improvement, particularly in reducing the time from order placement to medication administration to ensure more efficient, effective, and patient-centered care.

Pediatric Vascular Surgery: A Review of Cases from a Dedicated Pediatric Vascular Surgery Clinic

The experience in pediatric vascular diseases is limited in the United Kingdom and worldwide due to their rarity and variations in practice. We looked at types of cases presenting to a dedicated pediatric vascular clinic. Medical records of children seen in a dedicated pediatric vascular clinic at a tertiary referral service between 2016 and 2022 were reviewed. These patients were either seen for the first time in that clinic or had their appointments as a follow-up after inpatient review or intervention while being under the care of pediatric teams in local hospitals. Fifty-five patients (34 males) were seen aged between 4months and 17years (mean 9.5years). Common presentations were limb length discrepancy secondary to iatrogenic arterial occlusion, follow-up after bypass for trauma, lower limb swelling or discoloration, and varicose veins. Operative procedures included lower limb bypass, angioplasty, ligation of aneurysms, and varicose vein surgery. Pediatric vascular conditions are uncommon and therefore most vascular surgeons and trainees will have little exposure to such cases. Intervention is needed for arterial injury secondary to penetrating or iatrogenic trauma. A national registry is required for these rare cases to gain prospective data that can help build up more evidence for educational purposes and to establish guidelines.

Correlation of Sedation Depth During Critical Care Transport and Hospitalization.

Purpose: We aim to assess the impact of the exposure to deep versus light sedation by a critical care transport agency during prehospital and interhospital transport on hospital sedation levels, medication exposure, and outcomes of mechanically ventilated patients. Materials and Methods: Retrospective cohort review of mechanically ventilated adult critical care transport patients from January 1, 2019, to March 11, 2020, who arrived at an academic medical center. The primary outcome was the correlation of deep sedation during transport with deep sedation within the first 48 h of hospitalization (defined as Richmond Agitation Sedation Scale [RASS] -3 to -5). The secondary outcomes were duration of mechanical ventilation, hospital length of stay, intensive care unit (ICU) length of stay, inpatient mortality, delirium within 48 h, and coma within 48 h. Results: One hundred and ninety-eight patients were included, of whom 183 (92.4%) were deeply sedated during transport which persisted through the first 48 h of hospital care. Deep sedation during transport was not correlated with deep sedation in the hospital within the first 48 h (OR 2.41; 95% CI, 0.48-12.02). There was no correlation with hospital length of stay, ICU length of stay, duration of mechanical ventilation, or hospital mortality. Deep sedation during transport was not correlated with delirium or coma within the first 48 h of hospitalization. There was a negligible correlation between final transport RASS and initial hospital RASS which did not differ based on the lapsed time from handoff (<1 h corr. coeff. 0.23; ≥1 h corr. coeff. 0.25). Conclusions: Deep sedation was observed during critical care transport in this cohort and was not correlated with deep sedation during the first 48 h of hospitalization. The transition of care between the transport team and the hospital team may be an opportunity to disrupt therapeutic momentum and re-evaluate sedation decisions.

Understanding the connection between hospital goals and patient and family engagement: A scoping review.

The person-centered care movement has influenced hospitals to make patient and family engagement (PE) an explicit commitment in their strategic plans. This is often reflected in mission, vision, and value (MVV) statements, which are organizational artifacts intended to influence the attitudes, beliefs, and actions of hospital teams and employees because of their saliency in organizational documents and communications. Previous research has found that organizational goals for PE, like those articulated in MVV statements, can lead to effective and meaningful PE. However, a deeper understanding of how and under which circumstances MVV statements encourage and promote PE practices is needed. A scoping review was conducted to understand the connection between hospital PE goals (such as MVV statements) and PE processes and practices. The research question was: what is known about how hospital MVV statements relate to PE processes and activities? Following Arksey and O'Malley's scoping review approach, 27 articles were identified as relevant to the research question. These articles revealed five strategies that help realize hospital PE goals: communicating organizational goals; aligning documents that convey organizational goals; aligning organizational processes to support PE; providing employees with resources and support; and motivating and empowering employees to integrate PE into their work. We discuss the implications of misalignment between hospital goals and practices, which reduce team and individual motivation toward hospital PE goals.

A EU-Africa partnership to co-design a training intervention to scale-up access to surgery in Africa

Abstract Background The EU Global Health Strategy recognises that a skilled workforce is critical to advance universal health coverage. In response, our consortium brought together researchers, academics and clinicians from Ireland, the UK, the Netherlands, Malawi, Zambia and Tanzania to co-design a surgical workforce training and supervision intervention for district hospital teams aimed at scaling-up access to essential surgery in rural East Africa. Participatory action research (PAR) informed intervention design, incorporating the needs of frontline surgical providers and tailoring the training to meet identified gaps. This is the first study of this type in global surgery. Methods PAR workshops were held in Malawi, Zambia and Tanzania in 2017-2019 with key stakeholder groups: local authorities, professional associations, hospital managers and multi-disciplinary representatives of surgical teams from 67 district and referral hospitals. Through semi-structured discussions, qualitative data were collected on participants’ perceptions and experiences of barriers to safe and timely surgical and anaesthesia care, challenges in referral systems, and district surgical teams’ training and supervision needs. Data were compared for themes across sites and cadres. Results District surgical providers reported: a lack of in-service training, lack of access to mentoring and a demand for feedback on referrals. Participants prioritised training needs that could be addressed through regular in-service training and supervision visits from referrals to district hospitals to be delivered over the intervention period. Participants used findings in an action-planning cycle to develop country- and site-specific training plans for each research site. Conclusions Our approach to surgical capacity building, utilising both European and African expertise, has resulted in a demand-driven in-service training and supervision programme, now included in the participating countries’ national health strategies. Key messages • The inclusive, participatory approach to surgical system strengthening employed by our study enabled the co-design of a locally relevant, contextualised intervention. • Our study generated lessons on how to rebalance power dynamics in European-African health partnerships.

Home initiation of apomorphine infusion: lessons from the COVID-19 pandemic and implications for current clinical practice

Starting Parkinson’s disease (PD) patients on subcutaneous apomorphine (APO) infusion is generally undertaken on a hospital day-case basis. During the COVID-19 pandemic, day-case facilities were unavailable. To avoid delays in treatment, a new procedure was developed for initiation of APO therapy in the patient’s home. A home initiation protocol was developed and followed for each patient in this analysis. The hospital team worked in collaboration with APO nurses provided by the manufacturer of APO therapies to implement initiation and undertake follow-up. In this analysis, 27 PD patients were initiated onto APO infusion and 21 (77.8%) achieved a therapeutic response. Home initiation of APO infusion can be undertaken successfully and has benefits for both patients and healthcare teams. This protocol will now continue as a standard of care at our centre.

Better medical care quality in weekday daytime schedule with gastrointestinal hospitalists than conventional care teams

ABSTRACT Objectives This study sought to uncover whether having a gastrointestinal (GI) hospitalist available during weekday daytime hours results in higher-quality medical care compared to care provided by a team of residents. Methods Our hospitalist GI team consisted of two gastroenterologists working weekday daytime hours and two physician assistants. The team of conventional care headed by thirteen professors, comprised twelve residents and eight physician assistants. We conducted a retrospective cohort study in South Korea between March 2 and 9 December 2020. The hospitalist team treated 528 patients, while the conventional care team treated 2,335. We assessed the medical parameters of length of stay (LOS), rates of in-hospital mortality, transfer to the intensive care unit, and readmission rate within 30 days. Furthermore, we gathered feedback from nurses working with both teams. Results The study found that there was no significant difference in LOS between infections (P = 0.422) and other GI diseases like bleeding (P = 0.226). There was no significant difference in the rates of in-hospital mortality (P = 0.865) and transfer to the intensive care unit (P = 0.486) between the two teams. However, the hospitalist team had notably lower readmission rates than the conventional care team (P = 0.002) as well as a lower unscheduled readmission rate (P = 0.046). Furthermore, the survey results indicated that nurses who worked with the hospitalist team had significantly better responses than those who worked with the conventional care team (P < 0.001). Conclusions This study indicates that having GI hospitalists work weekday daytime hours improves patient care, and treatment and reduces readmission rates.

Planning and implementing practice changes in Ontario maternal-newborn hospital units: a secondary qualitative analysis

BackgroundMoving evidence into practice is complex, and pregnant and birthing people and their infants do not always receive care that aligns with the best available evidence. Implementation science can inform how to effectively move evidence into practice. While there are a growing number of examples of implementation science being studied in maternal-newborn care settings, it remains unknown how real-world teams of healthcare providers and leaders approach the overall implementation process when making practice changes. The purpose of this study was to describe maternal-newborn hospital teams’ approaches to implementing practice changes. We aimed to identify what implementation steps teams take (or not) and identify strengths and potential areas for improvement based on best practices in implementation science.MethodsWe conducted a supplementary qualitative secondary analysis of 22 interviews completed in 2014–2015 with maternal-newborn nursing leaders in Ontario, Canada. We used directed content analysis to code the data to seven steps in an implementation framework (Implementation Roadmap): identify the problem and potential best practice; assemble local evidence; select and customize best practice; discover barriers and drivers; tailor implementation strategies; field-test, plan evaluation, prepare to launch; launch, evaluate, and sustain. Frequency counts are presented for each step.ResultsParticipants reported completing a median of 4.5 of 7 Implementation Roadmap steps (range = 3–7), with the most common being identifying a practice problem. Other steps were described less frequently (e.g., selecting and adapting evidence, field-testing, outcome evaluation) or discussed frequently but not optimally (e.g., barriers assessment). Participants provided examples of how they engaged point-of-care staff throughout the implementation process, but provided fewer examples of engaging pregnant and birthing people and their families. Some participants stated they used a formal framework or process to guide their implementation process, with the most common being quality improvement approaches and tools.ConclusionsWe identified variability across the 22 hospitals in the implementation steps taken. While we observed many strengths, we also identified areas where further support may be needed. Future work is needed to create opportunities and resources to support maternal-newborn healthcare providers and leaders to apply principles and tools from implementation science to their practice change initiatives.

ASPECTS OF THE DEVELOPMENT OF THE PROGRAM OF PALLIATIVE ASSISTANCE FOR CHILDREN OF THE KHARKIV REGION THROUTH THE CHALLENGES OF THE MILITARY CONFLICT

In the context of armed confl ict, palliative care, pain management, and care for the dying and bereaved require increasedand urgent attention. The devastating humanitarian crisis in Ukraine makes these issues even more critical. In 2021, a projectworking group was created in the Kharkiv region to prepare the program for the implementation of palliative care for childrenin the Kharkiv region. The main reasons for the imperfect development of pediatric palliative care in Kharkiv region were somepoints such as: lack of a systematic vision of the organization of pediatric palliative care services; acute shortage of qualifi edmedical personnel, lack of educational programs and opportunities to study best practices in this fi eld; lack of relations betweenprimary and secondary (tertiary) links of medical care and coordination; lack of formulations of children’s drugs for painrelief and fear of prescribing opioid analgesics; an imperfect system of informing medical workers about the rights of childrenas patients; lack of interdisciplinary cooperation in the fi eld of providing pediatric palliative care (education, social services,clergy, lawyers, economists); lack of joint programs between health, social and education departments in the fi eld of pediatricpalliative care; lack of a state policy in the fi eld of pediatric palliative care; lack of a system for fi nancing pediatric palliativecare measures and monitoring their eff ectiveness. Before the war, the approximate number of children in need of palliative carein the Kharkiv region was 9,000 - 10,000, plus an estimated 21,000 - 25,000 family members. As of January 1, 2022, there were426,000 children under the supervision of health care institutions in the region. 216,900 children lived in the city of Kharkiv,209,700 in the rural areas. In the pre-war period there were 9,372 children with disabilities in the Kharkiv region. The structureof the causes of disability was as follows: congenital malformations - 25.5% (2389 children), diseases of the endocrine system- 16.4% (1537 children), diseases of the nervous system - 16.0% (1497 children), mental and behavioral disorders 13.8% (1295children), ear diseases - 9.2% (862 children). The authors’ vision is: to start policy development and creation of an eff ectivesystem of pediatric palliative care in accordance with the needs and international standards; creation of an eff ective system oftraining of medical and social workers in pediatric palliative care protocols and standards; development of coordinated pediatric palliative care at the place of residence/stay of the child; mobile teams; hospital beds and hospital teams; wide public awareness and involvement of public organizations in the provision of pediatric palliative care; attraction of budgetary and extra-budgetary funds for fi nancing pediatric palliative care. Authors also speculate that other important steps need to be implemented to regional program of pediatric palliative care and integrated with international recommendations and organizations.

An Interdisciplinary Videoconference to Improve Transitions of Care and Reduce Readmission, Cost, and Post-Acute Length of Stay in a Teaching and Community Hospital

ObjectivesCoordination of care across health care settings is needed to ensure safe patient transfers. We examined the effects of the ECHO-Care Transitions program (ECHO-CT) on readmissions, skilled nursing facility (SNF) length of stay (LOS), and costs. DesignThis is a prospective cohort study evaluating the ECHO-CT program. The intervention consisted of weekly 90-minute teleconferences between hospital and SNF-based teams to discuss the care of recently discharged patients. Setting and ParticipantsThe intervention occurred at one small community hospital and 7 affiliated SNFs and 1 large teaching hospital and 11 associated SNFs between March 23, 2019, and February 25, 2021. A total of 882 patients received the intervention. MethodsWe selected 13 hospitals and 172 SNFs as controls. Specific hospital-SNF pairings within the intervention and control groups are referred to as hospital-SNF dyads. Using Medicare claims data for more than 10,000 patients with transfers between these hospital-SNF dyads, we performed multivariable regression to evaluate differences in 30-day rehospitalization rates, SNF lengths of stay, and SNF costs between patients discharged to intervention and control hospital-SNF dyads. We split the post period into pre-COVID and COVID periods and ran models separately for the small community and large teaching hospitals. ResultsThere was no significant difference-in-differences among intervention compared to control facilities during either post-acute care period for any of the outcomes. Conclusions and ImplicationsAlthough video-communication of care plans between hospitalists and post-acute care clinicians makes good clinical sense, our analysis was unable to detect significant reductions in rehospitalizations, SNF lengths of stay, or SNF Medicare costs. Disruption of the usual processes of care by the COVID pandemic may have played a role in the null findings.