Traditional Acute Care Research Articles

ASHP Foundation's forecast report feels more relevant than ever this year

ASHP Foundation's forecast report feels more relevant than ever this year

Home hospital as a disposition for older adults from the emergency department: Benefits and opportunities.

The $1 trillion industry of acute hospital care in the United States is shifting from inside the walls of the hospital to patient homes. To tackle the limitations of current hospital care in the United States, on November 25, 2020, the Center for Medicare & Medicaid Services announced that the acute hospital care at home waiver would reimburse for “home hospital” services. A “home hospital” is the home‐based provision of acute services usually associated with the traditional inpatient hospital setting. Prior work suggests that home hospital care can reduce costs, maintain quality and safety, and improve patient experiences for select acutely ill adults who require hospital‐level care. However, most emergency physicians are unfamiliar with the evidence of benefits demonstrated by home hospital services, especially for older adults. Therefore, the lead author solicited narrative inputs on this topic from selected experts in emergency medicine and home hospital services with clinical experience, publications, and funding on home hospital care. Then we sought to identify information most relevant to the practice of emergency medicine. We outline the proven and potential benefits of home hospital services specific to older adults compared to traditional acute care hospitalization with a focus on the emergency department.

Implications and Experiences in Postacute Care-Rehabilitation, Long-Term Acute Care, and Skilled Nursing.

Postacute care is a term used to describe a group of health care providers, caring for patients outside of traditional acute care. The populations served and measures of outcomes are similar, but the services provided may vary by type of setting and individual provider. Managing through the coronavirus disease-2019 (COVID-19) pandemic has been both a challenge and an opportunity to demonstrate the vital role of postacute providers in the health care continuum. National media outlets have highlighted emergency departments, critical care areas, and start-up COVID units in acute care hospitals treating critically ill patients battling COVID-19. Stories of nursing homes in crisis over the rapid spread of COVID-19 have saddened readers of newspapers and social media alike. Postacute providers have experienced the pandemic alongside the acute care hospitals in ways that have highlighted the flexibility of postacute care, challenged leaders to lead with intensity, and demonstrated their importance in the continuum of care. Through a series of interviews with postacute care leaders, this article explores the response to the pandemic from the perspective of providers in postacute care settings.

Improving continuity of care of patients with respiratory disease at hospital discharge.

Continuity of care refers to the delivery of coherent, logical and timely care to an individual. It is threatened during the transition of care at hospital discharge, which can contribute to worse patient outcomes. In a traditional acute care model, the roles of hospital and community healthcare providers do not overlap and this can be a barrier to continuity of care at hospital discharge. Furthermore, the transition from inpatient to outpatient care is associated with a transition from acute to chronic disease management and, in a busy hospital, attention to this can be crowded out by the pressures of providing acute care. This model is suboptimal for the large proportion of patients admitted to hospital with acute-on-chronic respiratory disease.In a chronic care model, the healthcare system is designed to give adequate priority to care of chronic disease. Integrated care for the patient with respiratory disease fits the chronic care model and responds to the fragmentation of care in a traditional acute care model: providers integrate their respiratory services to provide continuous, holistic care tailored to individuals. This promotes greater continuity of care for individuals, and can improve patient outcomes both at hospital discharge and more widely.Educational aimsTo understand the concept of continuity of care and its effect at the transition between inpatient and outpatient care.To understand the difference between the acute and chronic models of healthcare.To understand the effect of integration of care on continuity of care for patients with respiratory disease and their health outcomes.

Preparing the future workforce to address the health needs of small rural Australian towns through non-traditional allied health student placements

Introduction: The health care needs of underserved rural and remote communities are often not addressed due to a lack of clinicians. In some rural communities’ preschool and primary school children are showing signs of mental health disorders including emotional, social and behavioural problems. These children often have lower levels of literacy compared to state levels. Short description of practice change implemented: Occupational therapy (OT) and speech pathology (SP) students from various Australian universities are placed in preschool and primary schools throughout the year. Each of the students are given a case load of up to 20 children. The students provide ongoing support and feedback to teachers and parents. The practice changes are: 1) provision of continuous early intervention and therapy 2) traditionally these children would not have had access to allied health (AH) services 3) low intensity supervision 4) student immersion into disadvantaged rural populations 5) interprofessional placement 6) placement is outside of the traditional acute care setting 7) students are encouraged to consider where changes in policy and practice are appropriate Aim and theory of change: The primary aim of the placements are for students to experience: an authentic rural placement in a primary care environment with diverse patient populations. a real-life application of knowledge in a real community context, that cannot be replicated in a hospital or university setting. a student led, continuous, interprofessional, low intensity supervised placement. The diffusion of innovation theory is applied. Targeted population and stakeholders: Schools in small rural towns with a higher rate than the state average of Indigenous people, families experiencing poverty, and higher rates of trauma and domestic violence. Stakeholder are clinical supervisors, teachers, parents and principles. Timeline: The program has been in place for 18 months across 12 schools. Highlights (innovation, Impact and outcomes): The innovation aspects are 1) Continuous service provision 2) meeting rural healthcare needs 3) low intensity supervision 4) rural community immersion 6) non-traditional settings 7) students implementing policy and practice changes These non-traditional placements lead to students reporting: increased autonomy and confidence to work unsupported in a rural environment increased social accountability and a positive attitude towards working with disadvantaged rural populations feeling workforce ready Sustainability: The model delivers allied health services to rural communities. The stakeholders have expressed a commitment for the program to continue as they recognise improved health outcomes. Transferability: The model could be rolled out to other small rural towns and applied in other disciplines and services. The model is already applied in residential aged care demonstrating the transferability of the model. Conclusions: Students get to experience a real-life application of knowledge in a real community context, that cannot be replicated in a hospital or university setting. Discussions: Low intensity supervision. Workforce readiness. At-risk populations’ needs. Lessons learned These placements can provide an opportunity to increase students’ capability to work in rural settings and provide a solution to addressing: the lack of AH services in small rural communities and a low supply of rural AH clinicians.

Preparing the future workforce to address the health needs of rural communities – Excellence in Multidisciplinary Education

Introduction : A weekly multidisciplinary program provides regular structured opportunities for students from a wide range of health disciplines and universities across Australia to learn about, from and with each other, and to understand the strengths and limitations of various health disciplines with a focus on primary health care settings. The program prepares students to respond to rural health needs, through enhanced understanding of rural primary health care models and team approaches to the management of chronic conditions. Short description of practice change implemented : Health students from various Australian universities are placed in rural community settings throughout the year. The students attend a weekly multidisciplinary program. The practice changes are: Students gain an awareness of 1 additional support services for people living in rural areas e.g. non-government and not for profit organisations, how they work and the services they provide. 2 gaps in services and barriers to accessing health services in rural areas 3 multidisciplinary collaboration, networking and development of professional partnerships 4 the importance of allied health professionals supporting the health and wellbeing of Australians living in rural communities 5 share resources and ideas, learn about each other’s roles and problem solve as a group 6 practical examples of a team approach to the management of chronic conditions Aim and theory of change : The primary aim of the program are for students to experience: Well supported rural experiential learning experiences which positively influence student perceptions of rural practice Innovation and critical thinking, and develop students’ confidence and leadership skills Targeted population and stakeholders : Health students from a number of disciplines and universities. Stakeholders are universities, community services and organisations Timeline : The program has been in place for 18 months Highlights innovation, Impact and outcomes : The innovation aspects are 1 Real authentic multidisciplinary learning 2 community based 3 regular structured program 4 range of disciplines This program leads to students reporting : increased confidence to work with other disciplines and services in a rural environment increased understanding of the role of other disciplines and services outside of the traditional acute care settings Sustainability : The universities have expressed a commitment for the program to continue as they recognise the value of having their students participate. Transferability : The model could be rolled out across other institutions Conclusions : Students get to experience a real-life application of multidisciplinary training in a real community context, that cannot be replicated in a hospital or university setting. Discussions : Integrated care. Workforce readiness. Ability to work interprofessionally, interdisciplinary and intersectoral. Lessons learned : These program can provide an opportunity to increase students’ capability to work in rural settings and provide a solution to addressing: the lack of understanding of each other’s roles and how they work together the lack of understanding of how community services work together in rural communities

An Assessment of the Safety of an Orthopedic Specialty Hospital: A 5-Year Experience.

One of the goals of orthopedic specialty hospitals is to provide safe and efficient care to medically optimized patients. The authors' orthopedic specialty hospital is a physician-owned, 24-bed facility that accommodates a multispecialty orthopedic practice in the areas of spine, hip and knee arthroplasty, shoulder and elbow, sports, foot and ankle, and hand surgery. The purpose of this study was to examine the first 5 years of an institutional experience with an orthopedic specialty hospital and to determine if any procedures were at increased risk of postoperative transfer. When higher-level emergency treatment was required, patients were appropriately and expeditiously transferred and treated at an acute care facility. Length of stay compared favorably with that in traditional acute care hospitals. The specialty hospital may be an appropriate model for delivery of care to medically screened patients in the United States. [Orthopedics. 2017; 40(4):223-229.].

Neighbourhood as community: A qualitative descriptive study of nursing students' experiences of community health nursing

PurposeExplore the use of a neighbourhood practice placement with nursing students to gain insight into how the experience influenced their learning and how the reconceptualization of community can be a model for students' professional development. BackgroundThe integration of community health nursing competencies in undergraduate nursing education is a critical element of student development. Neighbourhood placements have been found to support development of such competencies by exposing students to issues such as culture, social justice, partnership, and community development. Design and sampleA qualitative design was used with a sample of 48 Year 3 baccalaureate nursing students enrolled in a community health nursing practice course. MethodsStudents submitted reflective reviews where they responded to questions and subsequently participated in focus groups. Meaning making of narrative data took place using the descriptive qualitative analysis approach. FindingsStudents became more self-directed learners and developed team process skills. Some found it challenging to adapt to a role outside of the traditional acute care context. ConclusionNursing practice in a neighbourhood context requires students to be innovative and creative in problem-solving and relationship building. The placement also requires neighbourhood liaison persons who are adept at helping students bridge the theory-practice gap.

What’s Your Value? Acute Care Wants to Know

What’s Your Value? Acute Care Wants to Know

A Safe Electric Medical Bed for an Acute Inpatient Behavioral Health Care Setting

The purpose of this article is to describe the process of developing a safe electric bed for a traditional acute care adult behavioral health inpatient unit. Many articles and studies exist related to creating a safe environment on acute care psychiatric units, but very few address the use of electric hospital beds. The process of adapting a traditional electric bed for inpatient use by the nursing management team of the Behavioral Health Service at the University of Iowa Hospitals and Clinics is described, including specific safety features in the prototype bed. Policy changes during implementation and safety data after 12 months of bed use on the units are also presented. Results indicate that traditional electric hospital beds can be safely adapted for use on traditional acute care psychiatric units.

Operational and quality outcomes of a mobile acute care for the elderly service

The traditional acute care for the elderly (ACE) unit has demonstrated improved functional outcomes without increased costs or changes in length of stay (LOS). It is, however, limited in scope to patients cared for on a fixed geographical unit. To compare operational and quality outcomes for patients cared for on a mobile ACE (MACE) service to those cared for on a unit-based ACE service and matched controls on other general medical services. Retrospective cohort study with propensity-score matching. An urban academic medical center. A total of 8094 hospitalized adults >64 years old admitted to an ACE, MACE, and general medical services from July 2006 to June 2009. An interdisciplinary MACE service com- posed of a geriatrician-hospitalist, fellow, nurse coordinator, and social worker. LOS, total cost, 7- and 30-day readmission rates, and in-hospital mortality. Mean LOS and total cost were significantly lower for patients in the MACE service compared with the ACE unit service (5.8 vs 7.9 days, P < 0.001, and $10,315 vs $13,187, P = 0.002) and compared with propensity-score matched controls during the second year of operation (5.6 vs 7.2 days, P < 0.001, and $10,693 vs $15,636, P < 0.001). In-hospital mortality and 7- and 30-day readmission rates were similar in all groups. A mobile ACE service may result in reduced LOS and lower costs with no change in in-hospital mortality or 7- or 30-day readmission rates when compared with standard medical service and a traditional unit-based ACE service.

Comparison of Functional Outcomes Associated with Hospital at Home Care and Traditional Acute Hospital Care

To compare differences in the functional outcomes experienced by patients cared for in Hospital at Home (HaH) and traditional acute hospital care. Survey questionnaire of participants in a prospective nonrandomized clinical trial. Three Medicare managed care health systems and a Veterans Affairs Medical Center. Two hundred fourteen community-dwelling elderly patients who required acute hospital admission for community-acquired pneumonia, exacerbations of chronic heart failure or chronic obstructive pulmonary disease, or cellulitis, 84 of whom were treated in HaH and 130 in an acute care hospital. Treatment in a HaH care model that substitutes for care provided in the traditional acute care hospital. Change in activity of daily living (ADL) and instrumental activity of daily living (IADL) scores from 1 month before admission to 2 weeks post admission to HaH or acute hospital and the proportion of groups that experienced improvement, no change, or decline in ADL and IADL scores. Patients treated in HaH experienced modest improvements in performance scores, whereas those treated in the acute care hospital declined (ADL, 0.39 vs -0.60, P=.10, range -12.0 to 7.0; IADL 0.74 vs -0.70, P=.007, range -5.0 to 10.0); a greater proportion of HaH patients improved in function and smaller proportions declined or had no change in ADLs (44% vs 25%, P=.10) or IADLs (46% vs 17%, P=.04). HaH care is associated with modestly better improvements in IADL status and trends toward more improvement in ADL status than traditional acute hospital care.

Relying on machines to do the breathing

For most of us breathing is a taken for granted part of everyday life. For some people however, assistance with breathing is a fundamental part of life. Mechanical ventilation has been the cornerstone of the critical care services, however it is now a therapy that is used more broadly than with those people who are critically ill. Mechanical ventilation began during the poliomyelitis epidemics of the mid-20th century. In the past, people who were ventilator dependent for part or all of the day were those who were unable to wean from a ventilator following acute respiratory failure (e.g. post-poliomyelitis). Some of us may remember the cumbersome negative-pressure ‘iron lung’ ventilators that were used. As modern health care evolves we are seeing sophisticated health care being provided outside the traditional acute care environments. Now we have available small portable ventilators and face and nose masks that enable non-invasive, intermittent positive-pressure ventilation, making mechanical ventilation at home a practical possibility for many people. Mechanical ventilation is now used widely beyond the critical care units as advances in health technology and research in recent decades have resulted in improved survival rates for people who have experienced acute and chronic illness. In this issue of JAN, Ballangrud et al. (2009) report the findings of their small qualitative study on the experiences of people using home mechanical ventilation. This article contributes to our developing understandings of the experience of being dependent on medical technology and the use of that technology in the home environment. Often this therapy occurs out of public gaze so understanding the experiences of people who use home mechanical ventilation is important. The commencement of home mechanical ventilation for people often requires a complex coordination of logistic, financial, technical and human issues. The actor Christopher Reeve depended on home ventilation following a riding accident that left him paralysed from the neck down. For many years he continued to lead an active life, directing movies and speaking at various functions and being an advocate for people with spinal cord injury. He revealed publicly and on many occasions that a quality of life was possible when supported by a ventilator. The aim of home mechanical ventilation today is to promote comfort, aid recovery from surgery and other medical conditions, prolong life for people with certain neuromuscular diseases, and, in cases such as Reeve’s, allow people to live at home and often lead quality lives. Revealed in Ballangrud et al.’s (2009) paper, as nurses we have much to learn from these people and their families. The determination of what constitutes quality of life is as determined by the person experiencing it. Ethical concerns regarding the prolonging of life in people with severe physical limitations are challenging and are best addressed on an individual basis.

Commentary on Chan MF, Yee ASW, Leung ELY &amp; Day MC (2006) The effectiveness of a diabetes nurse clinic in treating older patients with type 2 diabetes for their glycaemic control. Journal of Clinical Nursing 15, 770–781

Commentary on Chan MF, Yee ASW, Leung ELY &amp; Day MC (2006) The effectiveness of a diabetes nurse clinic in treating older patients with type 2 diabetes for their glycaemic control. <i>Journal of Clinical Nursing</i> 15, 770–781

Current Issues in Home Mechanical Ventilation

As modern health care continues to evolve, we expect and are seeing that more sophisticated medical care will be provided outside the traditional acute care environments. Advances in home medical technology, economic pressures, health-care consumerism, and societal changes are all factors playing a role in this evolution. Medically fragile and technology-dependent individuals who were once limited to care in acute and subacute institutional settings are now frequently cared for at home, most often by their immediate family members. Mechanical ventilation has found its way into the patient's home such that physicians and other providers must be prepared for the challenges associated with managing the conditions of complex, ventilator-dependent individuals outside of the walls, controls, and safety of the institutional setting. With little published science and recognized standards of practice, there are fewer rules to guide clinicians through this process. Experience has shown, however, that successful home management of ventilator-dependent individuals can be traced to a smooth and collaborative discharge from the hospital to home. Reimbursement and coverage issues must also be well understood to avoid the aggravation of denials and challenges for necessary equipment and assistance. Once home, a streamlined, patient-centered process supported by effective communication between all care providers can result in a safe and appropriate long-term home ventilation success story.

Addressing Domestic Violence Through Maternal–Child Health Home Visiting: What We Do and Do Not Know

Domestic violence (DV) has been described as a public health epidemic. Health care providers of all disciplines encounter victims of DV in every practice setting. However, the vast majority of DV health care research has focused on care provided to victims in traditional acute care and clinic settings. Few investigators have conducted studies with community health nurses (CHNs) who visit DV victims in their homes. CHNs, providing preventive maternal–child health (MCH) care through home visits with families, have been described by some as key providers in DV prevention. However, there is a dearth of knowledge about the actual practice and related outcomes of these nurses when working with families experiencing DV. The purpose of this article is to provide a baseline view of the current state of knowledge on which nurses may begin building future research that leads to evidence-based practice. The article describes the potential role of home-visiting MCH nurses in DV prevention and intervention, provides a critical review of the existing research, identifies primary gaps in scientific knowledge, proposes future research priorities, and makes recommendations for practice.

Architecture for health - 2050: an international perspective

The planning and design of environments for healthcare is complex and at times contradictory. Research and critical discourse have been fragmented and have not provided the degree of support required by the architectural profession. This dilemma is compounded by the enormous capital investment countries around the globe expend annually to promote the health status of their citizens. To help rectify this situation, landmark international developments in the relationship between architecture and health are outlined within a dualistic conceptual framework that is part historical and part futurist. Prognostications for the year 2050 are offered on issues concerning the rise of alternative care settings to the traditional acute care hospital. This portion of the discussion examines the rising importance of home- and community-based care, the functions of nature as a therapeutic modality, patient empowerment, the critical need for socially equitable and sustainable environments for healthcare, and the need for new paradigms in the planning and design of therapeutically supportive care and treatment settings. Two developments in particular, functional deconstruction and residentialism, are described in some detail as is the critical role of interdisciplinary approaches in meeting the global research and practice challenges which lie ahead in this century.

Staffing requirements for infection control programs in US health care facilities: Delphi project

Background: The guideline for staffing infection control programs of 1 infection control professional (ICP) for every 250 occupied acute care beds has been used in many health care facilities in the United States since 1985. Since that time, the health care system, patient populations, and expectations about the work of infection prevention and control programs have changed substantially. Methods: The Delphi method was used; data were obtained from a group of ICPs through a series of 10 surveys. Through this iterative process, participant responses were progressively synthesized and areas of agreement and disagreement identified. These surveys were conducted by electronic and paper mail to identify the personal ICP characteristics and structural variables associated with performance of activities required for contemporary infection prevention and control programs in a variety of health care settings. Results: Delphi panel members (n = 32) from 20 states and who represented acute care, long-term care, and community care settings reported tasks in addition to those identified in earlier task analyses as well as expanded responsibilities. Competing responsibilities and lack of adequate resources were the most frequently cited reasons for nonperformance of essential infection control tasks. A ratio of 0.8 to 1.0 ICP for every 100 occupied acute care beds was suggested as adequate staffing by the Delphi panel. Conclusions: Infection control responsibilities have expanded beyond the traditional acute care setting. Recommendations for staffing must not only consider the number of occupied beds (average daily census) but also include the scope of the program, the complexity of the health care facility or system, the characteristics of the patient population, and the unique or urgent needs of the facility and community. (Am J Infect Control 2002;30:321-33.)

The Acute and Long-term Care Interface: Integrating the Continuum

Acute and long-term care traditionally have been distinctly different health care services, separated by reimbursement mechanisms, types and numbers of providers, and overall approach to the management of chronic illness. Considerable effort has been made of late, primarily due to financial incentives, to integrate these two levels of care into a "seamless" continuum. Barriers to such an integration process must first be identified. Physician and other health care providers will need to develop the tools and resources necessary to manage frail, chronically ill patients in settings other than the traditional acute care hospital, as well as to develop information systems that allow communication to flow easily between all levels of care. As subacute or transitional care becomes a central piece of a health care delivery system, those tools become critical to the provision of quality, integrated care.

Financial Implications and Recommendations for Care of Ventilator-Dependent Patients

Patients who require prolonged mechanical ventilation consume a disproportionately large share of healthcare resources and represent a significant financial burden for traditional acute care institutions. When these patients are evaluated as a population, trends that may facilitate medical and financial management emerge. This report examines the demographics, cost/reimbursement, and current management of patients who require prolonged mechanical ventilation. Recommendations for potential reduction of costs, revenue producing alternatives, or both in delivering healthcare to this aggregate are also explored.