Unit Closures Research Articles

Exploration of the Effects of Rural Obstetric Unit Closures on Birth Outcomes in North Carolina.

Closures of rural labor and delivery (L/D) units have prompted national and state-based efforts to assess the impact on birth outcomes. This study explores local effects of L/D closures in rural areas of North Carolina (NC). This is a retrospective cohort study of birth outcomes of 4,065 women in 5 rural areas of NC with L/D unit closures between 2013 and 2017. Outcomes were abstracted from birth certificate data from the NC Vital Statistics Reporting System. Localized outcomes 1 year prior to L/D unit closure were compared with outcomes 1 and 2 years post closure, including: (1) birth location and demographics, (2) change in travel patterns for birth, and (3) birth outcomes, including rates of labor induction, cesarean deliveries, maternal morbidity, and neonatal outcomes. Before closures, 25%-56% of deliveries occurred outside county of residence. Commercially insured and college-educated women were more likely to deliver out-of-area. Closures increased travel distance to delivery hospital an average of 7-27 miles. In 2 areas, cesarean delivery rates decreased despite an increase in labor inductions. There was also variability between areas in prenatal care adequacy and breastfeeding. We found that L/D unit closures in rural NC disproportionately affected women on Medicaid. The impact showed area-specific variability, highlighting effects potentially masked by statewide or national analyses. Implications for future L/D closures would be eased by regional coordination and planning to mitigate negative effects, and state and national policies should address the excess burden placed on vulnerable populations.

Impact of obstetric unit closures, travel time and distance to obstetric services on maternal and neonatal outcomes in high-income countries: a systematic review

ObjectivesTo systematically review (1) The effect of obstetric unit (OU) closures on maternal and neonatal outcomes and (2) The association between travel distance/time to an OU and maternal and neonatal...

Prevention of respiratory outbreaks in the rehabilitation setting

BackgroundRespiratory viral (RV) outbreaks in rehabilitation facilities can jeopardise patient safety, interfere with patient rehabilitation goals and cause unit closures that impede patient flow in referring facilities.ProblemDespite education about infection...

Impact of Structural Changes on Energy Efficiency of Finnish Pulp and Paper Industry

A key challenge in prevention of global warming is how to increase energy efficiency, to be able to deal with increased fossil CO2 emissions from rising energy usage. Increasing energy efficiency will decrease energy usage and is in a key role in emission mitigation. The focus is the pulp and paper industry, which is energy-intensive. Development of industrial energy efficiency has been studied before but the role of industrial transformation is still mostly unknown. The knowledge must be improved, to be able to predict future developments in the most effective way. In this research, impact of various production unit closures and start-ups on energy efficiency of the Finnish pulp and paper industry were studied utilizing statistical analysis. Results indicate that about 20% of the Finnish pulp and paper industry energy efficiency improvement between 2011 and 2017 is caused by the major structural changes. The rest, 80% of the progress, was mainly due to improved technology and more optimal operational modes. Additional findings suggest that modern mill start-ups have a significantly greater potential to reduce energy consumption than old mill closures.

687: Rural obstetrical unit closures and preterm delivery rates at a regional perinatal center in georgia

To determine if rural obstetrical unit closures within our perinatal region from 2012-2015 impacted rates of preterm delivery at Augusta University Medical Center, which functions as the designated regional perinatal center. A retrospective chart review was conducted within the Department of Obstetrics and Gynecology at Augusta University Medical Center in Augusta, Georgia. The National Institute of Health’s (NIH) Informatics for Integrating Biology and the Bedside (I2B2) software was used to identify charts corresponding to patients seen at our institution for obstetrical services between the period of January 1, 2010-December 31, 2011 to January 1, 2015-December 31, 2016. Clinical outcomes between the January 1, 2010-December 31, 2011 cohort and January 1, 2015-December 31, 2016 cohort were compared. The I2B2 software was able to extrapolate 2562 charts corresponding to the 2010-2011 period and 3534 charts corresponding to the 2015-2016 period for a total of 6096 charts. 1501 charts from the 2010-2011 period were found to be appropriate for study inclusion. This amounted to 74.60% (1501/2012) of our total hospital deliveries during that period. 2071 charts from the 2015-2016 period were found to be appropriate for study inclusion. This amounted to 71.17% (2071/2910) of our total hospital deliveries during that period. Gestational age at time of delivery were categorized as: early preterm (< 34.0 weeks), late preterm (34.0-36.6 weeks), early term (37.0-38.6 weeks), full term (39.0-40.6 weeks), late term (41.0- 41.6 weeks), and post-term (> 42.0 weeks). As seen in table 1, rates of early and late preterm deliveries remained relatively unchanged at 8.00% to 7.79% and 10.27% to 10.21%, respectively. The rate of early term deliveries decreased from 33.20% to 27.59%. The rate of full term deliveries increased from 46.0% to 50.7%. The rate of late and post term deliveries remained relatively constant. The differences of proportions among gestational age categories for years 2010-11 and 2015-2106 were found to be statistically significant (p=0.0038). The rate of preterm delivery at Augusta University Medical Center does not appear to have been impacted by rural obstetrical unit closures in the 2012-2015 time period.

How the cap limit for food-crop-based biofuels may affect France’s stakeholders by 2030? A range-based multi-actor multi-criteria analysis

From 2012 to 2016, the long-term signal in the biofuel market changed almost once per year, leading to a drastic decrease in investments and contributing to multiple production unit closures in France and around Europe. The European Commission proposed a new renewable energy directive that includes a 3.8% cap limit on the contribution of food-crop biofuels by 2030. Given the role of biofuels in green growth, the bioeconomy, and renewable energy incorporation targets, how will this measure affect the stakeholders by 2030? Will it lead to, contribute to, or hamper their sustainability criteria? This paper aims to contribute to this debate by studying the case of France. To this end, our methodology—the range-based multi-actor multi-criteria analysis—aims to (1) explicitly consider the stakeholder groups and their sustainability criteria; (2) evaluate and compare how the cap limit will affect these sustainability criteria whether or not advanced biofuels are deployed by 2030; (3) capture the uncertainty of the context evolution and biofuel capacity to fulfil the stakeholders’ sustainability criteria by means of a Monte Carlo. The results suggest that the cap limit is a double-edged sword for the stakeholders and their sustainability criteria. Shifting towards advanced biofuels while limiting the food-crop biofuels is the better alternative for most of the stakeholders. Nevertheless, given biofuel policy instability and the lost confidence of investors, such a shift may not occur by 2030. In such a case, this paper demonstrates that the cap limit may highly and negatively affect the stakeholders and their sustainability targets, whereas fostering French food-crop biofuel production at its full capacity level constitutes a better alternative. As no alternative is suited to all actors simultaneously, this paper also studies the strengths and weaknesses of these alternatives from each stakeholder groups’ perspective.

Access To Obstetric Services In Rural Counties Still Declining, With 9Percent Losing Services, 2004-14.

Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9percent of rural counties experienced the loss of all hospital obstetric services in the period 2004-14. In addition, another 45percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. Counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.

The Milieu Manager: A Nursing Staffing Strategy to Reduce Observer Use in the Acute Psychiatric Inpatient Setting.

Rising acuity levels in inpatient settings have led to growing reliance on observers and increased the cost of care. Minimizing use of observers, maintaining quality and safety of care, and improving bed access, without increasing cost. Nursing staff on two inpatient psychiatric units at an academic medical center pilot-tested the use of a "milieu manager" to address rising patient acuity and growing reliance on observers. Nursing cost, occupancy, discharge volume, unit closures, observer expense, and incremental nursing costs were tracked. Staff satisfaction and reported patient behavioral/safety events were assessed. The pilot initiatives ran for 8 months. Unit/bed closures fell to zero on both units. Occupancy, patient days, and discharges increased. Incremental nursing cost was offset by reduction in observer expense and by revenue from increases in occupancy and patient days. Staff work satisfaction improved and measures of patient safety were unchanged. The intervention was effective in reducing observation expense and improved occupancy and patient days while maintaining patient safety, representing a cost-effective and safe approach for management of acuity on inpatient psychiatric units.

Why Are Obstetric Units in Rural Hospitals Closing Their Doors?

To understand hospital- and county-level factors for rural obstetric unit closures, using mixed methods. Hospital discharge data from Healthcare Cost and Utilization Project's Statewide Inpatient Databases, American Hospital Association Annual Survey, and Area Resource File for 2010, as well as 2013-2014 telephone interviews of all 306 rural hospitals in nine states with at least 10 births in 2010. Via interview, we ascertained obstetric unit status, reasons for closures, and postclosure community capacity for prenatal care. Multivariate logistic regression and qualitative analysis were used to identify factors associated with unit closures between 2010 and 2014. Exactly 7.2 percent of rural hospitals in the study closed their obstetric units. These units were smaller in size, more likely to be privately owned, and located in communities with lower family income, fewer obstetricians, and fewer family physicians. Prenatal care was still available in 17 of 19 communities, but local women would need to travel an average of 29 additional miles to access intrapartum care. Rural obstetric unit closures are more common in smaller hospitals and communities with a limited obstetric workforce. Concerns about continuity of rural maternity care arise for women with local prenatal care but distant intrapartum care.

Babies born before arrival to hospital and maternity unit closures in Queensland and Australia.

Evidence suggests the closure of maternity units is associated with an increase in babies born before arrival (BBA). To explore the association between the number of maternity units in Australia and Queensland by birthing numbers, BBA rate and geographic remoteness of the health district where the mother lives. A retrospective study utilised routinely collected perinatal data (1992-2011). Pearson correlation tested the relationship between BBA rate and number of maternity units. Linear regression examined this association over time. During 1992-2011, the absolute numbers (N=22,814) of women having a BBA each year in Australia increased by 47% (N=836-1233); and 206% (n=140-429) in Queensland. This coincided with a 41% reduction in maternity units in Australia (N=623-368=18 per year) and a 28% reduction in Queensland (n=129-93). BBA rates increased significantly across Australia, r=0.837, n=20 years, p<0.001 and Queensland, r=0.917, n=20 years, p<0.001 and this was negatively correlated with the number of maternity units in Australia, r=-0.804, n=19 years, p<0.001 and Queensland, r=-0.906, n=19 years, p<0.001. The closure of maternity units over a 20-year period across Australia and Queensland is significantly associated with increased BBA rates. The distribution is not limited to rural and remote areas. Given the high risk of adverse maternal and neonatal outcomes associated with BBA, it is time to revisit the closure of units.

Lessons for providers and hospitals from Philadelphia's obstetric services closures and consolidations, 1997-2012.

The Affordable Care Act is triggering an increase in hospital consolidation and mergers. How other hospitals respond to these disruptions in supply could influence patient outcomes. We examined the experience of Philadelphia County, Pennsylvania (coterminous with the city of Philadelphia), where thirteen of nineteen hospital obstetric units closed between 1997 and 2012. Between October 2011 and January 2012 we interviewed twenty-three key informants from eleven hospitals (six urban and five suburban) whose obstetric units remained open, to understand how the large number of closures affected their operations. Informants reported having confronted numerous challenges as a result of the obstetric unit closures, including sharp surges in delivery volume and an increase in the proportion of patients with public insurance or no insurance. Informants reported adopting a number of strategies, such as innovative staffing models, to cope with the added demand brought about by the closure of nearby obstetric units. Informants emphasized that interhospital communication could mitigate closures' stresses on the health care system. Our study supports the need for policy makers to anticipate reductions in supply and monitor patient outcomes.

Perinatal health inequalities and accessibility of maternity services in a rural French region: Closing maternity units in Burgundy

Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.

Co-circulation of multiple genotypes of human rhinovirus during a large outbreak of respiratory illness in a veterans’ long-term care home

BackgroundHuman rhinoviruses (HRVs) are a well-recognized cause of long-term care home (LTCH) outbreaks of respiratory illness. However, there are limited data on the molecular epidemiology of the HRV types involved. ObjectivesTo determine whether a large respiratory outbreak in a LTCH was caused by a single type of HRV, and to describe the clinical impact of the outbreak. Study designNasopharyngeal swabs were collected from residents with one or more of the following: fever, cough, rhinitis, or congestion. Specimens were interrogated by multiplex PCR using the ResPlex II assay. Samples positive for HRV were then submitted for genotyping by partial sequence analysis of the 5′ untranslated (UTR) and viral protein (VP) 1 capsid regions. ResultsOf 71 screened, 56 residents were positive for a HRV during an outbreak that lasted 5.5 weeks; 27 healthcare workers also had respiratory symptoms. Three residents were transferred to hospital and 2 died. Seven units in two wings of the LTCH were affected, resulting in 3152.5 resident unit closure days. Three different HRV genotypes were identified, although HRV-A1 dominated. ConclusionsThis large outbreak of HRVs among residents and healthcare workers in a LTCH was associated with substantial resident and staff morbidity as well as significant unit closures. Multiple types of HRV were implicated but an HRV-A1 type dominated, warranting further investigation into viral determinants for virulence and transmission.

Infection control in United Kingdom neonatal units: variance in practice and the need for an evidence base

Infection prevention is a cornerstone of good neonatal care. There are, however, few research data to support infection control approaches in this population. Through a structured telephone interview we surveyed all neonatal units in the United Kingdom to identify infection control issues, practices and policies. Eighty seven percent of the 198 neonatal units participated. Twenty one units (12.2%) had closed with infection control issues in the last year; 14.1% had current infection control concerns; 81.5% of units decolonised MRSA positive infants, but over 15 regimens were used. Wide variations in hygiene measures were identified; 22.1% of units used theatre scrubs for all staff, 7.6% used aprons and 5.8% required gloves to be worn when entering clinical areas. Only 54% required hand washing and alcohol gel before entry to a patient care area; 11.6% required only the use of alcohol gel. Although infection control issues are resulting in neonatal unit closures and risks to patients, there are considerable variations in hygiene and screening practices. There is little data to support the safety or efficacy of decolonisation in neonatal populations, but this is widely practised. Research needs to be carried out to evaluate the effectiveness of screening practices and decolonisation in order that a consistent evidence-based approach can be applied.

Preventing Multidrug-Resistant Gram-Negative Organisms in Surgical Patients

Multidrug-resistant gram-positive infections have consumed the attention of health care organizations as well as the media, but recently multidrug-resistant gram-negative organisms (MDR-GNOs) have become more and more prevalent. Limited treatment options are available for MDR-GNO infections; thus, prevention is key. Patients who are at high risk for developing infections must be identified, and specialized prevention interventions must be developed for their care. Surgical patients are one subset of patients at high risk for developing MDR-GNOs. Advanced practice nurses must support nurses and other health care personnel in preventing MDR-GNO infections. Education should include active surveillance, contact precautions, cohorting patients and staff members, unit closures, reinforced hand hygiene practices, and environmental cleaning tailored to the care of surgical patients in regard to their preoperative, intraoperative, and postoperative care.

The impact of obstetric unit closures on maternal and infant pregnancy outcomes.

To define the association between large-scale obstetric unit closures and relative changes in maternal and neonatal outcomes. Birth and death certificates were linked to maternal and neonatal hospital discharge records for all births between January 1, 1995 and June 30, 2005 in Philadelphia, which experienced the closure of 9 of 19 obstetric units between 1997 and 2005, and five surrounding counties and eight urban counties that did not experience a similar reduction in obstetric units. A before-and-after study design with an untreated control group compared changes in perinatal outcomes in Philadelphia to five surrounding control counties and eight urban control counties after controlling for case mix differences and secular trends (N = 3,140,782). Relative to the preclosure years, the difference in neonatal mortality (odds ratio (OR) 1.49, 95 percent CI 1.12-2.00) and all perinatal mortality (OR 1.53, 95 percent CI 1.14-2.04) increased for Philadelphia residents compared with both control groups between 1997 and 1999. After 2000, there was no statistically significant change in any outcome in Philadelphia county compared with the preclosure epoch. Obstetric unit closures were initially associated with adverse changes in perinatal outcomes, but these outcomes ameliorated over time.

Choice in maternity care: associations with unit supply, geographic accessibility and user characteristics

BackgroundDespite national policies to promote user choice for health services in many European countries, current trends in maternity unit closures create a context in which user choice may be reduced, not expanded. Little attention has been paid to the potential impact of closures on pregnant women’s choice of maternity unit. We study here how pregnant women’s choices interact with the distance they must travel to give birth, individual socioeconomic characteristics and the supply of maternity units in France in 2003.ResultsOverall, about one-third of women chose their maternity units based on proximity. This proportion increased steeply as supply was constrained. Greater distances between the first and second closest maternity unit were strongly associated with increasing preferences for proximity; when these distances were ≥ 30 km, over 85% of women selected the closest unit (revealed preference) and over 70% reported that proximity was the reason for their choice (expressed preference). Women living at a short distance to the closest maternity unit appeared to be more sensitive to increases in distance between their first and second closest available maternity units. The preference for proximity, expressed and revealed, was related to demographic and social characteristics: women from households in the manual worker class chose a maternity unit based on its proximity more often and also went to the nearest unit when compared with women from professional and managerial households. These sociodemographic associations held true after adjusting for supply factors, maternal age and socioeconomic status.ConclusionsChoice seems to be arbitrated in both absolute and relative terms. Taking changes in supply into consideration and how these affect choice is an important element for assessing the real impact of maternity unit closures on pregnant women’s experiences. An indicator measuring the proportion of women for whom the distance between the first and second maternity unit is greater than 30 km can provide a simple measure of choice to complement indicators of geographic accessibility in evaluations of the impact of maternity unit closures.

Out-of-hospital births and the supply of maternity units in France

Maternity unit closures in France have increased distances that women travel to deliver in hospital. We studied how the supply of maternity units influences the rate of out-of-hospital births using birth certificate data. In 2005–6, 4.3 per 1000 births were out-of-hospital. Rates were more than double for women living 30km or more from their nearest unit and were even higher for women of high parity. These associations persisted in multilevel analyses adjusting for other maternal characteristics. Long distances to maternity units should be a concern to health planners because of the maternal and infant health risks.

Australian Aboriginal kinship: a means to enhance maternal well-being.

The relocation of women from their rural communities to birth in a centralised hospital is becoming increasingly common as maternity units close in rural areas of Australia. The significance for Aboriginal women when they are denied the support of kin around the time of birth but have that support re-established postnatally is explored. This paper gathered data from multiple sources including in-depth interviews with three Aboriginal mothers and one partner; observational field notes; and during debriefing, the knowledge and experience of an Aboriginal midwife. Thematic analysis was utilised to both explore and critique the collected data. Aboriginal women are particularly disadvantaged by maternity unit closures in rural areas of the south eastern Australian state of New South Wales (NSW). However, contrary to the expectation that this would result in postnatal mental health problems, the support the Aboriginal participants in this study received from kin may have had a mediating effect which enhanced their well-being and possibly prevented mental ill health. Recommendations relate to strategies and policies that have the potential to increase community governance and feelings of cultural safety for Aboriginal childbearing women living in rural areas. While the practice of forcing Aboriginal women to relocate around the time of birth has a negative impact on perinatal health outcomes, kinship support may be a mediating factor.

Outbreaks of nosocomial infections: lessons learned and perspectives

The review summarizes the results of selected outbreak reports and systematic analyses of nosocomial outbreaks from 2007 and focuses on different aspects of hospital epidemiology and infection control. A single outbreak report is likely be influenced by the local setting. In contrast, a systematic analysis of a large number of similar outbreaks draws a much better picture of the real conditions on the pathogen's reservoirs, on modes of transmission, and on appropriate infection control measures to prevent the spread of the microorganism. Isolation, unit closures, sick leave, cleaning, and diagnostic/therapeutic measures may lead to enormous costs during an outbreak. Thus, cost calculations of outbreaks should be performed to justify future expenses for infection control. Mathematic modeling is a fairly new approach to estimate the risk of pathogen transmission in outbreak settings. Examples are shown to differentiate between epidemic and sporadic infections and to evaluate the influence of infection control interventions. Outbreak reports may add some very important information to the understanding of transmission and infection control. There is a need for a more structured publication of nosocomial outbreaks to ensure that no key data are lacking in the article.