Hospital Unit Research Articles

Geriatrics-Focused vs Traditional Primary Care in the Veterans Affairs Health Care System

ImportanceOlder adults often require specialized health care expertise, but the effects of geriatrics-focused models of primary care have not been fully evaluated.ObjectiveTo compare the effects of geriatrics-focused primary care vs traditional primary care for older patients in the Veterans Affairs (VA) health care system.Design, Setting, and ParticipantsIn this cohort study, geriatrics-focused primary care and traditional primary care patient dyads matched on variables associated with geriatrics-focused primary care entry and outcomes were enrolled from VA medical centers with operational geriatrics-focused primary care clinics serving 500 or more patients annually in fiscal year 2016. Across 57 eligible sites, patients 65 years or older who transferred their care to geriatrics-focused primary care within the previous 12 months (exposure period) (n = 291) and their matched traditional primary care controls (n = 277) were enrolled. Study recruitment occurred from March 22, 2018, through December 11, 2019, with patient outcomes data collection completed June 24, 2021. Data were analyzed from June 2023 to January 2024.ExposureAt least 2 geriatrics-focused primary care visits during the exposure period. Geriatrics-focused primary care involves interprofessional teams of clinicians with geriatrics expertise to provide comprehensive primary care for older veterans with complex needs.Main Outcomes and MeasuresThe primary outcome was home time (days not in a hospital unit, short-term nursing facility, inpatient rehabilitation, or an emergency visit) within 18 months of the exposure period. Secondary outcomes were completion of advance directives, assessments (falls, incontinence, and function), and medication quality (potentially inappropriate medications, Anticholinergic Drug Scale score). Patients were surveyed over 18 months about care experiences using Patient Perceptions of Integrated Care subscales, and Patient-Reported Outcomes Measurement System self-reported health and well-being measures.ResultsA total of 568 patients were enrolled (mean [SD] age, 80.5 [7.0] years; 558 [98.2%] male), including 291 in the geriatrics-focused primary care and 277 matched in the traditional primary care groups; most baseline variables were comparable between the 2 groups. Geriatrics-focused primary care was not associated with more home time (rate ratio, 0.97; 95% CI, 0.62-1.51) over 18 months. Geriatrics-focused primary care was associated with higher odds of assessment for falls (odds ratio [OR], 2.86; 95% CI, 1.62-5.04), incontinence (OR, 2.73; 95% CI, 1.69-4.42), and function (OR, 4.05; 95% CI, 2.39-6.85) at 18 months. Geriatrics-focused primary care was not associated with advance directive completion, medication quality, or self-reported health and well-being.Conclusions and RelevanceIn this cohort study, geriatrics-focused primary care did not increase time at home or other measures of self-reported health and well-being or integration of care within the first 18 months after care transition. However, increases in some process measures important for quality of care were observed, suggesting that further studies are needed to evaluate outcomes over a longer time frame.

Improving Newborn Professional Billing at a Community Hospital

INTRODUCTION In community hospital medicine programs, newborns often represent a large patient population with diverse clinical needs. Capturing the care provided through professional billing provides the foundation for division revenue; however, provider knowledge on how to optimally bill is often lacking. Our group underused Hospital Care current procedural terminology (CPT) evaluation and management (E/M) codes for newborns requiring increased monitoring, diagnostic interventions, or therapy. Our aim was to increase use of Level 2 and 3 Hospital Care CPT E/M codes for newborns from 1% to 15%. METHODS The process improvement project was conducted from October 2022 through October 2023 in the mother–baby unit of a community hospital with approximately 1800 births per year. Key drivers for underuse of Hospital Care CPT E/M codes were identified, and interventions were developed that included educational sessions, real-time guidance, and improved access to the billing codes. All newborn initial and subsequent care professional billing codes were included. We used retrospective chart review to determine whether clinical care and documentation supported the use of the codes. RESULTS The proportion of Level 2 and 3 Hospital Care CPT E/M codes increased to 17%. This increase represented a 7% increase in work relative value units and an estimated increase in revenue of $37 805 per 10 000 billing encounters. Review of select charts demonstrated appropriate documentation to support use of the codes 72% of the time. CONCLUSIONS Providing education and tools on professional billing for newborns improved appropriate billing code use and optimized revenue at 1 community hospital.

Accessibility to Primary Health Services and Quality of Life in Patients with Type 2 Diabetes Mellitus in Mountainous Greece

Type 2 diabetes mellitus (T2DM) has a negative impact on the quality of life (QoL) of patients. We evaluated the health status and quality of life (QoL) in relation to accessibility to primary health care (PHC) units among patients with T2DM in mountainous Greece. We analyzed data obtained from 340 patients with diabetes living in the region of Epirus, Greece. The diabetes-specific quality of life was assessed with the Audit of Diabetes-Dependent Quality of Life questionnaire (ADDQoL-19) and the generic health status with the 12-item Short-Form Health Survey (SF-12). Ninety-three percent of the respondents reported that diabetes had a negative impact on their QoL. Lower scores were seen in relation to “leisure activities” (−1.200 ± 1.251) and “freedom to eat” (−1.088 ± 1.058). The mean physical (PCS) and mental (MCS) component scores were 45.6 ± 8.0 and 43.9 ± 8.0, respectively. According to the linear regression analysis, health status was related to the accessibility to the nearest hospital or health care unit, exercise, blood glucose level, and HbA1c level. The QoL was related to the accessibility to the nearest hospital and diet. T2DM has a negative impact on patients’ QoL. Accessibility to PHC units and hospitals as well as the efficient management of patients with diabetes by said PHC units are imperative to control T2DM’s course and improve patients’ generic health status.

Nursing Skills in the Care of Patients With Respiratory Stomas in Hospitals With and Without Advanced Practice Tracheostomy Service.

To identify whether there are differences in knowledge regarding the management of patients with respiratory stomas among nurses working in hospitals with an advanced practice tracheostomy service compared to those without it. Descriptive, cross-sectional, comparative, analytical survey study. The study was conducted from January to March 2023 in four tertiary care hospitals, two of which have an advanced practice tracheostomy service. A self-administered questionnaire was designed, consisting of 16 questions about nurses' specialised training in caring for tracheostomy patients. The study adhered to the STROBE checklist. Statistical analyses were performed using SPSS (24.0) from IBM. Nurses in hospitals with a dedicated tracheostomy service obtained a higher mean score (7.1/10) and demonstrated greater anxiety when managing patients with stomas (p < 0.001), as well as an increased willingness to undergo specific training (p = 0.017) to reduce their lack of self-confidence. A higher level of anxiety in the management of tracheostomised patients and a greater interest in receiving specific training have been observed among nurses in hospitals with advanced practice services (APTS), despite having greater training. Therefore, institutions should commit to incorporating advanced practice nurses and continuing education in the approach to ostomies among their professionals. Implementing ongoing training programmes and specific tracheostomy services or units in hospitals would enable nurses to provide high-quality care for patients with respiratory stomas. The study adhered to the STROBE checklist. Neither patients nor the public were involved in the design or conduct of this research. Nurses participated exclusively in data collection.

Enhancing chronic care pathways with Health Lean Management: a case study in a Spanish hospital

PurposeFacing the burden of chronic diseases has become a priority for health-care systems’ economic and social sustainability. To this end, this paper aims to focus on adopting Health Lean Management (HLM), a widely used managerial approach, to improve the performance and quality of care provided in chronic care pathways. HLM addresses not only efficiency and timeliness issues but also care effectiveness and integration. Indeed, the lack of continuity and co-ordination of care constitutes a major challenge for chronic pathways. This research provides an innovative contribution, by extending the implementation of HLM to chronic pathways developed across hospital and territorial care. Indeed, HLM scope typically regards hospital units and departments; hence, analysing the interaction between different levels of care represents a novelty from an academic and practical perspective.Design/methodology/approachWith the aim of understanding how to extend the adoption of HLM towards the territory, an action research project has been developed. In particular, an improvement project focused on breast cancer care pathways has been launched in a Spanish hospital. The research investigates which HLM activities, tools and practices need to be accomplished in this kind of project, grasping insights into emerging wastes. To this end, the HLM project followed the Define, Measure, Analyse, Improve and Control (DMAIC) cycle, supporting the project team in effectively conducting a preliminary context analysis, qualitative and quantitative data collection, the current state analysis and the countermeasure proposals.FindingsThe analysis conducted on the breast cancer care pathway highlighted major criticalities in managing the diagnosis of new patients. In particular, waiting times to obtain diagnostic imaging and breast specialist consultations highly impacted the care pathway effectiveness and efficiency. Specific wastes that caused these delays have been investigated, leading to the definition of specific countermeasures that could minimise the inefficiencies: an 85% reduction of the staging process lead time was estimated.Originality/valueThe achieved results contribute to enhancing the quality of care delivered to breast cancer patients. This paper enriches the theoretical knowledge about HLM, extending its typical field of application; provides practical support to health-care providers, managers and leaders with a case demonstrating how to develop HLM projects adopting the DMAIC cycle; and finally, it has valuable social implications, addressing the global threat of chronic disease.

Scaphoid Fat Stripe Sign: Is It a Reliable Radiological Sign of Scaphoid Fracture in Children?

Objectives: The scaphoid fat pad stripe (SFS) is a radiological sign first described in 1975 as a line of relative lucency lying parallel to the lateral border of the scaphoid, with slight convexity toward it, and it is optimally demonstrated on postero-anterior and oblique views with ulnar deviation of the carpus. The obliteration or displacement of this line is commonly present in acute fractures of the scaphoid, radial styloid process, and proximal first metacarpus. The aim of this observational study is to investigate the supportive value of the fat stripe sign (SFS) in the diagnosis of scaphoid fractures in the pediatric population. Methods: This is a monocentric, retrospective study of all patients referred to the Pediatric Traumatology Unit of a tertiary hospital from the Emergency Department with clinical suspicion of scaphoid fracture without visible fracture in the initial X-ray. Radiological reports for CT and MRIs were recorded, and the initial X-rays were blindly reviewed by a pediatric orthopedic fellowship-accredited surgeon for the presence of an abnormal scaphoid fat pad stripe sign and the presence of a fracture line in the initial X-rays. Results: The results of the blind interpretation of the initial X-rays for the fat stripe sign showed 86% sensitivity and 58% specificity, with the negative predictive value reaching 92%. Conclusions: The scaphoid fat stripe sign can be used as an adjacent in the diagnosis of an occult scaphoid fracture in children or adolescents. Its high negative predictive value, if confirmed in larger studies, can be an element used to exclude scaphoid fracture and consequently avoid unnecessary immobilizations and health costs.

Evaluation of the In vitro efficacy of ceftazidime-avibactam against Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa isolates from respiratory tract cultures in intensive care units

Aims: Worldwide, an increase in multidrug resistance is observed in Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), and Pseudomonas aeruginosa (P. aeruginosa) isolates, leading to challenges in the treatment of infections caused by these pathogens. This study aims to investigate the in vitro efficacy of ceftazidime-avibactam (CZA) against isolates containing K. pneumoniae, E. coli, and P. aeruginosa strains obtained from respiratory tract samples sent from intensive care units. Methods: A retrospective analysis was conducted on 653 Enterobacterales (E. coli, K. pneumoniae) and P. aeruginosa isolates obtained from respiratory tract cultures, including sputum, tracheal aspirates, and bronchial lavage, from patients over 18 years old admitted to the intensive care units of Ordu University Training and Research Hospital between May 1, 2021, and May 1, 2024. Automated systems were used to identify the pathogens and perform antibiotic susceptibility testing. Discriptive data analysis was conducted using SPSS version 24.0. Results: A total of 653 isolates from respiratory tract samples were included in the study, consisting of 368 Enterobacteriaceae [61 E. coli (9.3%) and 307 K. pneumoniae (47%)] and 285 P. aeruginosa (43.7%). These samples were isolated from endotracheal aspirate (69.5%), sputum (27.9%), and bronchoalveolar lavage (2.6%). Among all isolates, 364 (55.7%) were found to be sensitive to carbapenems, while 289 (44.3%) were carbapenem-resistant. Of the samples, 631 (96.6%) were sensitive to CZA, while 22 (3.4%) were resistant. Although resistance to CZA was detected in 3.6% of K. pneumoniae isolates and 3.9% of P. aeruginosa isolates, no resistance was detected in E. coli. Colistin resistance was observed in 15.3% of K. pneumoniae and 5.6% of P. aeruginosa isolates, but was absent in E. coli isolates. Resistance rates to other antibiotics were as follows for E. coli, K. pneumoniae, and P. aeruginosa isolates, respectively: amikacin (3.3%, 46.6%, 8.1%), ciprofloxacin (73.8%, 73.6%, 85.9%), ceftazidime (67.2%, 77.8%, 35.8%), piperacillin-tazobactam (26.2%, 70%, 37.2%), and trimethoprim-sulfamethoxazole (52.5%, 66.4%, 0%). Conclusion: In our study, CZA was found to be the most effective antibiotic against multidrug-resistant Enterobacterales and P. aeruginosa isolates, followed by colistin.

Combined effects of reflexology massage and respiratory relaxation on pain following chest tube removal in heart surgery patients

Background and aimRemoving the chest tube in cardiac patients after surgery is one of the worst experiences of hospitalization in the intensive care units. Various pharmacological and non-pharmacological methods are available to control pain in these patients. This study aimed to investigate the combined effect of reflexology massage and respiratory relaxation on pain following chest tube removal in cardiac surgery patients of Shahid Beheshti Hospital in Shiraz, Iran, in 2023.MethodsThis was a double-blind randomized clinical trial performed on 140 patients who underwent heart surgery and had a chest tube in Shiraz, Iran. The samples were randomly divided into four groups: 1- control group, 2- respiratory relaxation group, 3- foot reflex massage group, and 4- a combination of respiratory relaxation and reflexology massage. To collect data, two demographic questionnaires, and a visual analog scale were used.ResultsThe participants of the four groups were not meaningfully different in terms of age, BMI, duration of surgical operation, gender, job, education, place of residency, number of chest tubes, history of operation (P = 0.99, 0.31, 0.06, 0.81, 0.97, 0.96, 0.17, 0.10, 0.89 respectively). The mean scores of pain intensity during chest tube removal, and 15 min after chest tube removal were not statistically different among the four groups of study (P = 0.15, 0.54 respectively); However, just after chest tube removal, the mean scores of pain intensity differed meaningfully among four groups (P = 0.008).ConclusionThe results showed that reflexology massage and respiratory relaxation both reduce pain immediately after chest tube removal in heart surgery patients. Also, the combination of these two techniques was more effective in reducing patients’ average pain.

Exploring the landscape of congenital and idiopathic neutropenia in Moroccan children: a comprehensive retrospective analysis.

Congenital neutropenia (CoN) is a heterogeneous group of inborn errors of immunity (IEI) characterized by recurrent infections and early onset of neutropenia (NP). This study aimed to investigate the demographic and clinical data of children with CoN and idiopathic neutropenia (IN) in Morocco. We performed a retrospective study of patients with CoN and analyzed the clinical and laboratory findings of patients with CoN and IN diagnosed between 1999 and 2018 in a clinical immunology unit of a large pediatric hospital. We identified 88 patients, 51 with IN and 37 with CoN. Fifty-seven percent were males, and 43% were females, ranging from 1month to 19years. The median age at onset was 8months, and the median at diagnosis was 36months. Consanguinity was observed in 57% of the cases, and a history of recurrent infections in the siblings was found in 27.3%. The most common infectious complications were ear, nose, and throat (ENT) infections, skin and soft tissue infections, and lung infections. Patients with CoN were classified into seven syndromes: 9 with severe congenital neutropenia, 11 with cyclic neutropenia, 6 with glycogen storage disease type 1b, 5 with poikiloderma with neutropenia, 3 with Griscelli syndrome, 2 with Hermansky-Pudlak syndrome type II, and 1 with Cohen syndrome. This study provides a comprehensive overview of CoN and IN in a pediatric cohort from Morocco, representing the country's most considerable single-center investigation of these conditions. Our findings highlight the significant burden of CoN, accounting for 5% of IEI in the Moroccan registry, a proportion higher than in some neighboring countries. The study emphasizes the early onset and severity of bacterial infections in CoN patients, underlining the critical need for timely and accurate diagnosis.

Focal Scleral Nodules: Retrospective Case Series and Novel Insight.

The objective of this study was to add to the limited literature of Focal Scleral Nodule (FSN). This study was a single-centre, retrospective, observational case series performed at Manchester Royal Eye Hospital (United Kingdom). Nineteen eyes from nineteen patients over a thirteen year period (January 2011 to January 2024) were included. The principal observations were taken from patient demographic data, fundal and autofluorescence imaging, and OCT-EDI imaging. Most patients with FSN were female, with median age of 47 years and median visual acuity of 20/20 Snellen. FSN were yellow, yellow-white, orange or orange halo in appearance. Median horizontal length of a FSN was 2.02mm (range 0.34mm-4.79mm) and median thickness was 417μm (range 272μm-803μm). The choroid above the FSN was thinned in 9 and absent in 10 cases. Most FSN appeared hyper-autofluorescent on autofluorescence imaging. Extramacular FSN appeared directly inferiorly to the optic disc in 7, infero-temporally in 5, supero-nasally in 2, and supero-temporally in 5 cases. Seven patients demonstrated FSN within the macula, and 2 of these had subretinal fluid. Further investigation revealed one of these patients with subretinal fluid had polypoidal choroidal vasculopathy (PCV) at the same area as the FSN. This study analysed FSN lesions of a medium-sized group over a large timeframe. It provides more data in the literature for an uncommon ophthalmic lesion. Furthermore, the study described the first known case in the literature of FSN with PCV in the same area. This finding highlights a potential new complication of the condition.

Lessons Learned from a Quality Improvement Initiative to Increase COVID-19 Vaccination in Hospitalized Children.

Pediatric coronavirus disease 2019 (COVID-19) vaccination rates in the United States remain lower compared with adults. We aimed to (1) implement a quality improvement initiative to increase COVID-19 vaccination 2-fold in hospitalized patients 12-21 years of age from 4.7% during the baseline period (August 10, 2021-November 1, 2021) to 9.4% during the intervention phase (November 2, 2021-March 31, 2023) and (2) assess the importance of existing interventions and obtain feedback for future interventions to increase COVID-19 vaccination via a provider survey. We conducted the quality improvement initiative in the inpatient units of a freestanding children's hospital. Interventions included provider education, electronic medical record best practice alerts, monthly competition, parental counseling to increase vaccine acceptance, and ensuring vaccine availability. The primary outcome measure was the percentage of hospitalized patients 12-21 years of age who received COVID-19 vaccine. Providers addressing COVID-19 vaccination with patients, as documented by COVID-19-specific problem lists, were a process measure. Length of stay was a balancing measure. Although COVID-19 vaccination increased 1.6-fold during the initial 5 months of interventions, the interrupted time series analysis did not show a significant impact of our interventions on vaccination. Documentation of COVID-19 vaccine-specific problem lists increased 1.9-fold during most of the intervention period. There was no significant (P = 0.61) difference in length of stay between children in the baseline and intervention groups. Despite our best efforts, we could not increase the number of COVID-19 vaccinations in our patients. Lessons learned suggest that creating a nurse-driven COVID-19 vaccine screening/ordering protocol and integrating COVID-19/influenza vaccination annually during influenza season can potentially increase vaccination rates, but further research is required.

The Value of Heparin Binding Protein in Early Identification of Sepsis-Induced Coagulopathy Disease and Prognosis.

The aim of this study was to explore the value of heparin-binding protein (HBP) in the early recognition of sepsis coagulopathy (SIC) and the prognosis of sepsis patients. A retrospective analysis was performed for 139 patients with sepsis admitted to the Intensive Care Unit (ICU) of Hefei Third People's Hospital from April 2022 through April 2024. The clinical baseline data, disease scores [sequential organ failure (SOFA) score, acute physiology and chronic health status (APACHE II) score, and SIC score], inflammatory markers [HBP, procalcitonin (PCT), and interleukin 6 (IL-6)], coagulation-related indexes [platelet count (PLT), prothrombin time (PT), prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), fibrinogen (Fib), and D dimer (D-D)], and the survival time and 28-day prognosis of all patients were observed. The correlation between HBP and disease scores, inflammatory indexes, and coagulation-related indexes was analyzed. The receiver operating characteristic (ROC) curve was used to analyze the predictive value of HBP for SIC and the value of HBP and SIC score for the prognosis of sepsis, the risk stratification was carried out according to the optimal cutoff value of HBP, the differences in the occurrence of major clinical events under different HBP stratifications were compared, and the Kaplan-Meier survival curve was used to analyze the 28-day cumulative survival rate under different HBP stratifications. Among the 139 patients, 98 developed SIC, 41 did not, 73 died at 28 days, and 66 survived. The disease score, inflammation index, and coagulation-related indexes of the non-SIC group were better than those of the SIC group, and the disease scores, inflammation indexes, and coagulation-related indexes of the survival group were better than those of the death group. Correlation analysis showed that HBP was positively correlated with disease score and inflammation index. Coagulation-related index was positively correlated with PT, APTT, PT-INR, Fib, and D-D, and negatively correlated with PLT, among which HBP had the best correlation with disease score (HBP was best correlated with SIC, SOFA, and APACHE II scores; r = 0.818, 0.847, and 0.829, p < 0.001). ROC analysis showed that HBP had a high efficacy in identifying SIC (AUC = 0.934, sensitivity 96.9%, specificity 87.8%, p < 0.001), and the AUC of HBP and SIC score and their combination for 28-day death prediction were 0.802, 0.773, and 0.844 (p < 0.001), respectively. Compared with the HBP ≤ 118.25 ng/mL group (n = 52), the 28-day mortality rate, SIC incidence, APACHE II, and SOFA scores were higher in the HBP > 118.25 ng/mL group (n = 52) (p < 0.001). Kaplan-Meier survival curve analysis showed that the cumulative survival rate of the HBP > 118.25 ng/mL group was significantly lower than that of the HBP ≤ 118.25 ng/mL group (p < 0.001). HBP has a high predictive value in the early identification of SIC and the prognosis evaluation of sepsis, and patients with sepsis with an early HBP > 118.25 ng/mL in the ICU have a higher risk of SIC and death.

‘It is an emotional rollercoaster!!!’ Experiences of mothers of preterm newborns seeking care at a tertiary hospital in Ghana: a qualitative phenomenological study

ObjectiveTo describe, through the phenomenological lens, the experiences of mothers following preterm birth and admitted at a tertiary hospital.MethodsDesignDescriptive phenomenological study.SettingNeonatal intensive care unit (NICU) of a tertiary hospital in...

Introduction of molecular point-of-care testing for SARS-CoV-2 in a triage unit of a large maternity hospital: An evaluation of staff experiences.

Recent advances in the development of rapid SARS-CoV-2 point of care (POC) testing provided an opportunity to aid clinical decision making in front-line healthcare settings. Perspectives of POC COVID-19 screening of pregnant women are under-researched. To assess the impact of a SARS-CoV-2 POC testing platform implemented in a busy maternity hospital, with limited isolation capacity, during the third wave of the COVID-19 pandemic. We conducted a before and after comparison of two consecutive 12-month periods and a retrospective evaluation of staff attitudes and POC test acceptance. Turnaround Time (TAT) and testing numbers were assessed by computer audit. Qualitative data was collected using confidential questionnaires. Mean TAT for the POC platform was 5.3x quicker (p < 0.001, chi-square test) when compared with local virus laboratory PCR testing. Samples sent for laboratory testing reduced by almost one third, following introduction of the POC device. A total of 27 staff members completed a POC testing satisfaction survey, which documented ease of use and benefits for diagnosis assistance, patient management and patient experience. In this single-center maternity setting, POC testing decreased laboratory testing volume and SARS-Cov-2 result TAT for symptomatic women and those awaiting crucial investigations. POC COVID-19 investigation was deemed acceptable by the clinical team for facilitating patient placement, management, and use of limited isolation capacity.

Identifying specific subgroups of older patients at risk of repeated hospital readmissions and death after discharge in a prospective multicentre cohort in France

ObjectiveTo identify specific subgroups of older patients at risk of repeated hospital readmissions and death.DesignProspective, multicentre, DAMAGE (Patient Outcomes After Hospitalization in Acute Geriatric Unit) cohort of adults aged 75...

Peak serum lactate as a robust predictor of imminent death in life-sustaining treatment decisions: A study of 73,927 patients.

The physician order for life-sustaining treatment has been implemented in clinical practice for several years. However, the determination that a patient is in the terminal phase of life, a prerequisite for the withdrawal of life-sustaining treatment, lacks objective criteria. This study aimed to evaluate whether hyperlactatemia could serve as a reliable objective indicator for determining the terminal phase. In this retrospective cohort study, we included 73,927 patients admitted to our institution from 2018 to 2023 who had at least one blood lactate measurement. We collected data on the highest blood lactate level measured during hospitalization, mortality, medical department, and intensive care unit (ICU) details. The primary endpoint was 30-day mortality, and we analyzed how well the highest lactate level during hospitalization predicted 30-day mortality across different age groups, medical departments, and ICUs. Among the patients, 5493 died within 30 days of the maximum lactate measurement. The area under the receiver operating characteristic curve (AUROC) for predicting 30-day mortality based on the maximum lactate level was 0.870 (95% confidence interval [CI] 0.865-0.875) in all patients, indicating high accuracy. Setting the cutoff for the maximum lactate level at 20 mmol/L resulted in a precision of 87% and specificity of 99.8%. Subgroup analyses by age, medical department, and ICU yielded consistent results. Severe hyperlactatemia during hospitalization showed high precision and specificity for predicting 30-day mortality across various patient groups. These findings suggest that hyperlactatemia could serve as an objective auxiliary indicator for determining the terminal phase, potentially improving consistency in end-of-life decision-making in clinical practice.

Benefits and harms associated with the use of AI-related algorithmic decision-making systems by healthcare professionals: a systematic review

Despite notable advancements in artificial intelligence (AI) that enable complex systems to perform certain tasks more accurately than medical experts, the impact on patient-relevant outcomes remains uncertain. To address this gap, this systematic review assesses the benefits and harms associated with AI-related algorithmic decision-making (ADM) systems used by healthcare professionals, compared to standard care. In accordance with the PRISMA guidelines, we included interventional and observational studies published as peer-reviewed full-text articles that met the following criteria: human patients; interventions involving algorithmic decision-making systems, developed with and/or utilizing machine learning (ML); and outcomes describing patient-relevant benefits and harms that directly affect health and quality of life, such as mortality and morbidity. Studies that did not undergo preregistration, lacked a standard-of-care control, or pertained to systems that assist in the execution of actions (e.g., in robotics) were excluded. We searched MEDLINE, EMBASE, IEEE Xplore, and Google Scholar for studies published in the past decade up to 31 March 2024. We assessed risk of bias using Cochrane's RoB 2 and ROBINS-I tools, and reporting transparency with CONSORT-AI and TRIPOD-AI. Two researchers independently managed the processes and resolved conflicts through discussion. This review has been registered with PROSPERO (CRD42023412156) and the study protocol has been published. Out of 2,582 records identified after deduplication, 18 randomized controlled trials (RCTs) and one cohort study met the inclusion criteria, covering specialties such as psychiatry, oncology, and internal medicine. Collectively, the studies included a median of 243 patients (IQR 124-828), with a median of 50.5% female participants (range 12.5-79.0, IQR 43.6-53.6) across intervention and control groups. Four studies were classified as having low risk of bias, seven showed some concerns, and another seven were assessed as having high or serious risk of bias. Reporting transparency varied considerably: six studies showed high compliance, four moderate, and five low compliance with CONSORT-AI or TRIPOD-AI. Twelve studies (63%) reported patient-relevant benefits. Of those with low risk of bias, interventions reduced length of stay in hospital and intensive care unit (10.3 vs. 13.0 days, p=0.042; 6.3 vs. 8.4 days, p=0.030), in-hospital mortality (9.0% vs. 21.3%, p=0.018), and depression symptoms in non-complex cases (45.1% vs. 52.3%, p=0.03). However, harms were frequently underreported, with only eight studies (42%) documenting adverse events. No study reported an increase in adverse events as a result of the interventions. The current evidence on AI-related ADM systems provides limited insights into patient-relevant outcomes. Our findings underscore the essential need for rigorous evaluations of clinical benefits, reinforced compliance with methodological standards, and balanced consideration of both benefits and harms to ensure meaningful integration into healthcare practice. This study did not receive any funding.

Evaluating the prognostic value of DECAF score and procalcitonin in patients with COPD exacerbation.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) frequently result in emergency department (ED) visits, necessitating accurate risk stratification. The aim of this study was to evaluate and compare the prognostic utility of the DECAF score and serum procalcitonin levels in predicting clinical outcomes in patients with AECOPD. This retrospective cohort study encompassed AECOPD patients presenting to the ED over a three-year period who had serum procalcitonin levels measured. The primary outcome was one-month mortality, with secondary outcomes including ED re-admission, hospitalization, and intensive care unit (ICU) admission. Receiver operating characteristic (ROC) curve analysis was employed to assess the prognostic performance of DECAF score and procalcitonin, and differences between areas under the curve (AUC) were compared. A total of 130 patients were analyzed, comprising 105 survivors and 25 non-survivors. The median DECAF score was significantly higher in non-survivors [4 (IQR: 3-4)] compared to survivors [3 (IQR: 2-4)] (p<0.001). Similarly, median procalcitonin levels were elevated in non-survivors [0.26ng/mL (IQR: 0.11-2.77)] relative to survivors [0.08ng/mL (IQR: 0.04-0.21)] (p<0.001). The AUC for the DECAF score was 0.758 (95% CI: 0.673-0.842), while that for procalcitonin was 0.764 (95% CI: 0.668-0.860). The difference between AUCs was 0.006 (95% CI: -0.140 to 0.127), (p=0.927). The negative predictive value (NPV) was 90.6% for the 4-point DECAF score and 96.2% for a 0.075ng/mL procalcitonin cut-off. Notably, when used in combination, the NPV reached 100% (95% CI: 89.1-100). The DECAF score and serum procalcitonin levels both exhibit robust prognostic capabilities in excluding adverse outcomes in AECOPD patients, with their predictive accuracy enhanced when used in tandem.

Augmented and virtual reality in surgery: fields of application and exploratory studies exemplified by VIVATOP : Perioperative surgical planning and intraoperative support

Digital technologies, such as virtual and augmented reality (VR and AR) are mainly used in the preclinical and clinical phases in neurosurgery and orthopedics. In contrast, they are used less frequently in visceral surgery as the intraoperative deformation is challenging for the clinical use. The application of VR is used successfully particularly in education and training. In addition to current areas of application, this article highlights the results of the Federal Ministry of Education and Research (BMBF) project "Versatile Immersive Virtual and Augmented Tangible OP (= surgery)" (VIVATOP). In this project AR and VR technologies in combination with 3D printing as demonstrators were newly or further developed. AVR planning tool for partial liver resection, the development of 3D holograms for intraoperative AR support and an avatar telemedicine function as well as a3D printed model for training purposes were developed. The clinical results of the intraoperative AR support with the primary endpoint of operation duration and the secondary endpoints of the duration of hospitalization and intensive care unit stay as well as complication rates are compared with ahistorical cohort and the results are contextualized.

Patient and Family Experience: Targets for Improvements in Care and Communication in the ICU

This process improvement project sought to further explore the experience of patients and family members within an intensive care unit (ICU) hospital setting to develop specific interventions that can be executed to provide better patient-centered outcome. We surveyed 103 family members using the satisfaction with care subscale of Family Satisfaction with the ICU survey (FS-ICU) (validated ICU experience survey). 103 patients also completed FS-ICU subscale with a modification to make it applicable to patients. Additional questions explored their interest in supportive services and factors contributing to distress with the goal of understanding the gaps in multidisciplinary care and supportive services. Overall, the findings of this project emphasize the importance of (1) understanding patients’ experience and satisfaction with care, in addition to families’, (2) gathering data with measurement tools that is specific enough to the care environment allowing for unique feedback and areas for improvement, and (3) identifying psychological needs and faith-based support to intervene on challenging experiences.