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Barker RO, Atkin C, Hanratty B, Kingston A, Cooksley T, Gordon AL, Holland M, Knight T, Subbe CP, Lasserson DS. National Early Warning Scores Following Emergency Hospital Transfer: Implications for Care Home Residents. J Am Med Dir Assoc 2023; 24:653-656. [PMID: 36822235 DOI: 10.1016/j.jamda.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/20/2022] [Accepted: 01/17/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVE Care home residents have high rates of hospital admission. The UK National Early Warning Score (NEWS2) standardizes the secondary care response to acute illness. However, the ability of NEWS2 to predict adverse health outcomes specifically for care home residents is unknown. This study explored the relationship between NEWS2 on admission to hospital and resident outcome 7 days later. DESIGN Repeated cross-sectional study. SETTING AND PARTICIPANTS Data on UK care home residents admitted to 160 hospitals in two 24-hour periods (2019 and 2020). METHOD Chi-squared and Kruskal-Wallis tests, and multinomial regression were used to explore the association between low (score ≤2), intermediate (3-4), high (5-6), and critically high (≥7) NEWS2 on admission and each of the following: discharge on day of admission, admission and discharge within 7 days, prolonged hospital admission (>7 days), and death. RESULTS From 665 resident admissions across 160 hospital sites, NEWS2 was low for 54%, intermediate for 18%, high for 13%, and critically high for 16%. The 7-day outcome was 10% same-day discharge, 47% admitted and subsequently discharged, 34% remained inpatients, and 8% died. There is a significant association between NEWS2 and these outcomes (P < .001). Compared with those with low NEWS2, residents with high and critically high NEWS2 had 3.6 and 9.5 times increased risk of prolonged hospitalization [relative risk ratio (RRR) 3.56; 95% CI 1.02-12.37; RRR 9.47; CI 2.20-40.67], respectively. The risk of death was approximately 14 times higher for residents with high NEWS2 (RRR 13.62; CI 3.17-58.49) and 54 times higher (RRR 53.50; CI 11.03-259.54) for critically high NEWS2. CONCLUSION AND IMPLICATIONS Higher NEWS2 measurements on admission are associated with an increased risk of hospitalization up to 7 days duration, prolonged admission, and mortality for care home residents. NEWS2 may have a role as an adjunct to acute care decision making for hospitalized residents.
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Reid JC, Dennis B, Hoad N, Clarke F, Hanmiah R, Vegas DB, Boyle A, Toledo F, Rudkowski JC, Soth M, Heels-Ansdell D, Cheung A, Willison K, Neville TH, Cheung J, Woods A, Cook D. Enhancing end of life care on general internal medical wards: the 3 Wishes Project. BMC Palliat Care 2023; 22:11. [PMID: 36788522 PMCID: PMC9925934 DOI: 10.1186/s12904-023-01133-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/03/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Initially developed in the intensive care unit (ICU) at St. Joseph's Healthcare Hamilton (SJHH) the 3 Wishes Project (3WP) provides personalized, compassionate care to dying patients and their families. The objective of this study was to develop and evaluate 3WP expansion strategies for patients cared for on General Internal Medicine (GIM) wards in our hospital. METHODS From January 2020-November 2021, we developed a phased, multicomponent approach for program expansion. We enrolled patients on the GIM wards who had a high probability of dying in hospital, then elicited, implemented, and documented wishes for them or their families. Data were analyzed descriptively. RESULTS From March 2020 to November 2020, we implemented staff education and engagement activities, created an Expansion Coordinator position, held strategic consultations, and offered enabling resources. From March 2020 to November 2021, we enrolled 62 patients and elicited 281 wishes (median [1st, 3rd quartiles] 4 [4, 5] wishes/patient). The most common wish categories were personalizing the environment (67 wishes, 24%), rituals and spiritual support (42 wishes, 15%), and facilitating connections (39 wishes, 14%). The median [1st, 3rd] cost/patient was $0 [0, $10.00] (range $0 to $86); 91% of wishes incurred no cost to the program. CONCLUSIONS The formal expansion of the 3WP on GIM wards has been successful despite COVID-19 pandemic disruptions. While there is still work ahead, these data suggest that implementing the 3WP on the GIM wards is feasible and affordable. Increased engagement of the clinical team during the pandemic suggests that it is positively received.
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Paulson MR, Shulman EP, Dunn AN, Fazio JR, Habermann EB, Matcha GV, McCoy RG, Pagan RJ, Maniaci MJ. Implementation of a virtual and in-person hybrid hospital-at-home model in two geographically separate regions utilizing a single command center: a descriptive cohort study. BMC Health Serv Res 2023; 23:139. [PMID: 36759867 PMCID: PMC9911182 DOI: 10.1186/s12913-023-09144-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 02/02/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND As providers look to scale high-acuity care in the patient home setting, hospital-at-home is becoming more prevalent. The traditional model of hospital-at-home usually relies on care delivery by in-home providers, caring for patients in urban communities through academic medical centers. Our objective is to describe the process and outcomes of Mayo Clinic's Advanced Care at Home (ACH) program, a hybrid virtual and in-person hospital-at-home model combining a single, virtual provider-staffed command center with a vendor-mediated in-person medical supply chain to simultaneously deliver care to patients living near an urban hospital-at-home command center and patients living in a rural region in a different US state and time zone. METHODS A descriptive, retrospective medical records review of all patients admitted to ACH between July 6, 2020, and December 31, 2021. Patients were admitted to ACH from an urban academic medical center in Florida and a rural community hospital in Wisconsin. We collected patient volumes, age, sex, race, ethnicity, insurance type, primary hospital diagnosis, 30-day mortality rate, in-program mortality, 30-day readmission rate, rate of return to hospital during acute phase, All Patient Refined-Diagnosis Related Groups (APR-DRG) Severity of Illness (SOI), and length of stay (LOS) in both the inpatient-equivalent acute phase and post-acute equivalent restorative phase. RESULTS Six hundred and eighty-six patients were admitted to the ACH program, 408 in Florida and 278 in Wisconsin. The most common diagnosis seen were infectious pneumonia (27.0%), septicemia / bacteremia (11.5%), congestive heart failure exacerbation (11.5%), and skin and soft tissue infections (6.3%). Median LOS in the acute phase was 3 days (IQR 2-5) and median stay in the restorative phase was 22 days (IQR 11-26). In-program mortality rate was 0% and 30-day mortality was 0.6%. The mean APR-DRG SOI was 2.9 (SD 0.79) and the 30-day readmission rate was 9.7%. CONCLUSIONS The ACH hospital-at-home model was able to provide both high-acuity inpatient-level care and post-acute care to patients in their homes through a single command center to patients in urban and rural settings in two different geographical locations with favorable outcomes of low mortality and hospital readmissions.
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Zeidan AJ, Smith M, Leff R, Cordone A, Moran TP, Brackett A, Agrawal P. Limited English Proficiency as a Barrier to Inclusion in Emergency Medicine-Based Clinical Stroke Research. J Immigr Minor Health 2023; 25:181-189. [PMID: 35652977 DOI: 10.1007/s10903-022-01368-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/08/2022] [Accepted: 05/04/2022] [Indexed: 01/07/2023]
Abstract
AIMS Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. METHODS A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. RESULTS A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. CONCLUSIONS As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices.
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Cohen N, Davis AL, Test G, Singer–Harel D, Pasternak Y, Beno S, Scolnik D. Evaluation of activation criteria in paediatric multi-trauma. Paediatr Child Health 2023; 28:17-23. [PMID: 36865755 PMCID: PMC9971577 DOI: 10.1093/pch/pxac085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/21/2022] [Indexed: 11/14/2022] Open
Abstract
Objective To explore the optimal set of trauma activation criteria predicting paediatric patients' need for acute care following multi-trauma, with particular attention to Glasgow Coma Scale (GCS) cut-off value. Methods A retrospective cohort study of paediatric multi-trauma patients aged 0 to 16 years, performed at a Level 1 paediatric trauma centre. Trauma activation criteria and GCS levels were examined with respect to patients' need for acute care, defined as: direct to operating room disposition, intensive care unit admission, need for acute interventions in the trauma room, or in-hospital death. Results We enrolled 436 patients (median age 8.0 years). The following predicted need for acute care: GCS <14 (adjusted odds ratio [aOR] 23.0, 95% confidence interval [CI]: 11.5 to 45.9, P < 0.001), hemodynamic instability: (aOR 3.7, 95% CI: 1.2-8.1, P = 0.01), open pneumothorax/flail chest (aOR: 20.0, 95% CI: 4.0 to 98.7, P < 0.001), spinal cord injury (aOR 15.4, 95% CI; 2.4 to 97.1, P = 0.003), blood transfusion at the referring hospital (aOR: 7.7, 95% CI: 1.3 to 44.2, P = 0.02) and GSW to the chest, abdomen, neck, or proximal extremities (aOR 11.0, 95% CI; 1.7 to 70.8, P = 0.01). Using these activation criteria would have decreased over- triage by 10.7%, from 49.1% to 37.2% and under-triage by 1.3%, from 4.7% to 3.5%, in our cohort of patients. Conclusions Using GCS<14, hemodynamic instability, open pneumothorax/flail chest, spinal cord injury, blood transfusion at the referring hospital, and GSW to the chest, abdomen, neck of proximal extremities, as T1 activation criteria could decrease over- and under-triage rates. Prospective studies are needed to validate the optimal set of activation criteria in paediatric patients.
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Blonigen D, Hyde J, McInnes DK, Yoon J, Byrne T, Ngo T, Smelson D. Integrating data analytics, peer support, and whole health coaching to improve the health outcomes of homeless veterans: Study protocol for an effectiveness-implementation trial. Contemp Clin Trials 2023; 125:107065. [PMID: 36572239 DOI: 10.1016/j.cct.2022.107065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Homelessness is a strong determinant of acute care service utilization (inpatient hospitalization, emergency department visits) among US adults. Data analytics, peer support, and patient-centered approaches can collectively offer high-quality care for homeless patients who frequently utilize acute care ("super utilizers"). However, few outpatient programs have integrated these components and tested their effectiveness for this patient population. OBJECTIVE To test the effectiveness and implementation potential of a novel intervention that integrates data analytics with peers trained in whole health coaching ("Peer Whole Health") to reduce use of acute care among homeless adults. METHODS Using a randomized controlled trial design at two US Veterans Health Administration Medical Centers, we plan to enroll 220 veterans in primary care on VHA's Homeless Registry who are flagged on a super-utilizer clinical dashboard. Participants will complete a baseline interview, be randomized to Enhanced Usual Care (EUC; primary care and data analytics) or EUC plus 18 sessions of Peer Whole Health over 6 months, and be re-interviewed at 3, 6, and 9 months. Qualitative interviews with primary care staff and patients will identify facilitators and barriers to more widespread implementation of the intervention. DISCUSSION The primary hypothesis is that those who receive the intervention will have fewer total days of all-cause hospitalization. If confirmed, the findings can provide healthcare systems that serve homeless super-utilizers with a high-value approach to care that can be integrated into primary care services and reduce overall costs for these patients. CLINICAL TRIAL REGISTRATION The study is registered with ClinicalTrials.gov (NCT05176977).
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Sterner A, Nilsson MS, Eklund A. The value of simulation-based education in developing preparedness for acute care situations: An interview study of new graduate nurses' perspectives. Nurse Educ Pract 2023; 67:103549. [PMID: 36642012 DOI: 10.1016/j.nepr.2023.103549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
AIM This study aimed to explore how new graduated nurses experience a one-day simulation based education, contributing to providing care in acute situations two months after completion. BACKGROUND Simulation-based education is often offered to new graduated nurses as part of important workplace learning. Simulation-based education is a valid learning and teaching strategy and is suggested as a measure to improve nurses' ability in acute situations. However, studies are often conducted as pre-post evaluations immediately after completion of a simulation. Thus, knowledge of the clinical impact of simulation-based education on actual acute care situations could benefit both research and practice. DESIGN/METHOD During the winter of 2021-2022, 14 semi-structured interviews were conducted with newly graduated nurses two months after they completed the simulation-based education and the interviews were analyzed using thematic analysis. RESULTS The results are presented in three themes: a structured and shared strategy to handle acute situations, a developed role in acute situations and a more comprehensive understanding of acute situations. The results revealed that simulation-based education can contribute to the ability to care in acute situations in terms of action readiness and broad contextual understanding. CONCLUSION Simulation-based education can help develop the ability to care for patients in acute situations. However, differences in participant experiences must be acknowledged and processed in order for the implementation and outcome to be successful.
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Osmancevic S, Großschädl F, Lohrmann C. Cultural competence among nursing students and nurses working in acute care settings: a cross-sectional study. BMC Health Serv Res 2023; 23:105. [PMID: 36726095 PMCID: PMC9890795 DOI: 10.1186/s12913-023-09103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 01/24/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The increasing cultural diversity in healthcare in European countries, including Austria, has highlighted the need to enhance nurses' cultural competence. Assessing cultural competence and identifying relevant influencing factors can help to improve culturally competent care. The aim of this study was to assess the cultural competence of nurses and nursing students working in Austrian acute care settings and to identify influencing factors using the Cultural Competence Assessment scale. METHODS A cross-sectional design was used. Data collection was carried out in March 2021 with nurses and nursing students in the last year of their studies who were working in Austrian acute care settings. Descriptive analysis was applied to display the general characteristics of the study participants and the levels of their overall cultural competence. A multiple linear regression analysis was conducted to analyze the influencing factors of cultural competence. RESULTS The nurses' cultural competence level was moderate to high (mean = 3.89; SD = .48). Their age, educational level, cultural diversity training and self-perceived cultural competence significantly influenced the level (F (6, 875) = 18.971, p < .0000, adj. R2 = 1.09). CONCLUSIONS Providing culturally competent healthcare services for culturally diverse patients is essential for all healthcare professionals, and especially for nurses who spend the most time with patients. Effective interventions, such as educational training, need to be implemented in order to deliver culturally competent care and potentially reduce disparities in healthcare and improve patient outcomes.
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Walker RM, Chaboyer W, Cooke M, Whitty JA, Thalib L, Lockwood I, Latimer S, Campbell J, Probert R, Gillespie BM. EffEctiveness of Prophylactic fOam dressings in the prevention of saCral pressure injuries in at-risk hospitalised patients: the EEPOC trial. Trials 2023; 24:70. [PMID: 36721259 PMCID: PMC9887548 DOI: 10.1186/s13063-022-06999-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 12/08/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prophylactic dressings are increasingly used to prevent pressure injuries in hospitalised patients. However, evidence regarding the effectiveness of these dressings is still emerging. This trial aims to determine the clinical and cost-effectiveness of a prophylactic silicone foam border dressing in preventing sacral pressure injuries in medical-surgical patients. METHODS This is a multicentre, pragmatic, parallel group, randomised controlled trial. A sample size of 1320 was calculated to have >90% power to detect a 5% difference in the primary outcome at an alpha of 0.05. Adult patients admitted to participating medical-surgical wards are screened for eligibility: ≥18 years, admitted to hospital within the previous 36 h, expected length of stay of ≥24 h, and assessed high risk for hospital-acquired pressure injury. Consenting participants are randomly allocated to either prophylactic silicone foam dressing intervention or usual care without any dressing as the control group via a web-based randomisation service independent of the trial. Patients are enrolled across three Australian hospitals. The primary outcome is the cumulative incidence of patients who develop a sacral pressure injury. Secondary outcomes include the time to sacral pressure injury, incidence of severity (stage) of sacral pressure injury, cost-effectiveness of dressings, and process evaluation. Participant outcomes are assessed daily for up to 14 days by blinded independent outcome assessors using de-identified, digitally modified sacral photographs. Those who develop a sacral pressure injury are followed for an additional 14 days to estimate costs of pressure injury treatment. Analysis of clinical outcomes will be based on intention-to-treat, per-protocol, and sensitivity analyses. DISCUSSION This trial aims to provide definitive evidence on the effect prophylactic dressings have on the development of hospital-acquired sacral pressure injuries in medical-surgical patients. A parallel economic evaluation of pressure injury prevention and treatment will enable evidence-informed decisions and policy. The inclusion of a process evaluation will help to explain the contextual factors that may have a bearing on trial results including the acceptability of the dressings to patients and staff. The trial commenced 5 March 2020 and has been significantly delayed due to COVID-19. TRIAL REGISTRATION ANZCTR ACTRN12619000763145. Prospectively registered on 22 May 2019.
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Kuntz AA, Stumm EK, Anderson TC, Ibarra SJ, Markart MR, Haske-Palomino M. Use of a nursing-led geriatrics consult service to deliver age-friendly care. Geriatr Nurs 2023; 50:58-64. [PMID: 36641857 DOI: 10.1016/j.gerinurse.2022.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
The Elder Veteran Program (EVP) is a nursing-led approach to deliver inpatient consultative geriatrics care at our academic Midwestern Veterans Hospital. From April to December of 2021, EVP modified its workflow using a Plan-Do-Study-Act approach to include previously under-addressed components of the IHI's "4M's" of Age-Friendly Care (Medication, Mobility, Mentation, and What Matters), with three months of retrospective data review as a Plan phase, three months of monthly Do and Study phases, and a three month Act phase to analyze post-intervention care. We found improvements in frequency of documentation of Medication, Mentation, and What Matters in EVP notes, and maintenance of Mobility documentation. Next steps include translating these documentation and workflow changes into other relevant outcome measures and outreach to other departments. Overall, our project demonstrates a novel way to integrate these Pillars into a hospital system, by leveraging an existing nursing-led geriatric consult service focused on prevention and education.
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Pan Y, Thiamwong L, Xie R. The effects of nurse driven mobility intervention (NDMI) on activities of daily living, mobility, fear of falling, and balance performance in hospitalized older patients: A pilot study. Geriatr Nurs 2023; 49:193-198. [PMID: 36566605 PMCID: PMC9892225 DOI: 10.1016/j.gerinurse.2022.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022]
Abstract
A decrease in mobilization during hospitalization leads to a decline in physical function for older patients, and nurses play a critical role in mobility promotion. The purpose of this pilot study was to examine the feasibility of Nurse Driven Mobility Intervention (NDMI) in improving activities of daily living, mobility, fear of falling, balance performance, and maladaptive fall risk appraisal using a one-group pretest-posttest design. NDMI incorporates a multidisciplinary care team, early assessment, timely and frequent mobilization, and constant encouragement. A post-intervention interview was also conducted to explore the barriers and facilitators for mobilization during hospitalization. The result shows a significant improvement in balance performance.
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Hugunin J, Davis M, Larkin C, Baek J, Skehan B, Lapane KL. Established Outpatient Care and Follow-Up After Acute Psychiatric Service Use Among Youths and Young Adults. Psychiatr Serv 2023; 74:2-9. [PMID: 36223162 PMCID: PMC9812848 DOI: 10.1176/appi.ps.202200047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study explored follow-up after hospitalization and emergency room (ER) use for mental health among youths and young adults with private insurance. METHODS The IBM MarketScan commercial database (2013-2018) was used to identify people ages 12-27 with a mental health hospitalization (N=95,153) or ER use (N=108,576). Factors associated with outpatient mental health follow-up within 7 and 30 days of discharge were determined via logistic models with generalized estimating equations that accounted for state variation. RESULTS Of those hospitalized, 42.7% received follow-up within 7 days (67.4% within 30 days). Of those with ER use, 28.6% received follow-up within 7 days (46.4% within 30 days). Type of established outpatient care predicted follow-up after hospitalization and ER use. Compared with people with no established care, the likelihood of receiving follow-up within 7 days was highest among those with mental health and primary care (hospitalization, adjusted odds ratio [AOR]=2.81, 95% confidence interval [CI]=2.68-2.94; ER use, AOR=4.06, 95% CI=3.72-4.42), followed by those with mental health care only (hospitalization, AOR=2.57, 95% CI=2.45-2.70; ER use, AOR=3.48, 95% CI=3.17-3.82) and those with primary care only (hospitalization, AOR=1.20, 95% CI=1.15-1.26; ER use, AOR=1.22, 95% CI=1.16-1.28). Similar trends were observed within 30 days of discharge. CONCLUSIONS Follow-up rates after acute mental health service use among youths and young adults were suboptimal. Having established mental health care more strongly predicted receiving follow-up than did having established primary care. Improving engagement with outpatient mental health care providers may increase follow-up rates.
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Pelcovitz M, Bennett S, Desai P, Schild J, Beaumont R, Walkup J, Shaffer D, Chiu A. High Rates of Anxiety Among Adolescents in a Partial Hospitalization Program. CHILD & YOUTH CARE FORUM 2023; 52:105-122. [PMID: 35228789 PMCID: PMC8866547 DOI: 10.1007/s10566-022-09680-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 01/28/2023]
Abstract
Background Anxiety disorders are garnering increasing attention for their contribution to high-risk issues and functional impairment. Adolescents are typically admitted to partial hospitalization programs (PHPs) due to high-risk presentations. However, the frequency of anxiety disorders in PHPs is not well-established, in part because anxiety can be overlooked in acute settings due to limited lengths of stay and focus on stabilization. Objective This study aims to evaluate the frequency and severity of anxiety disorders among a sample of adolescent PHP patients to assess the need for anxiety-specific assessment and interventions in higher acuity settings. Methods Participants were 158 youths ages 13 to 19 years old (M = 15.49 years, SD = 1.50) who were admitted to an adolescent PHP and their caregivers. Clinician-reported diagnostic information was collected from the youth's electronic medical record, and self- and caregiver-rated severity of anxiety was collected using the Screen for Child Anxiety Related Emotions Disorders (SCARED-C/P). Frequency of anxiety and related disorder diagnoses and self- and caregiver-reported severity were assessed using descriptive statistical methods. Results 75% of participants were diagnosed with an anxiety disorder (n = 118). On average, participants with anxiety disorders had elevated SCARED-C scores. Youths with depressive disorders had elevated SCARED-C scores even when they did not carry anxiety disorder diagnoses. Caregiver ratings of the youth's anxiety symptoms on the SCARED-P were elevated when youths had anxiety disorders. Conclusions These findings suggest that anxiety is common in an adolescent PHP setting and support investing in evidence-based assessment and treatment of anxiety in high-acuity settings.
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Blonigen D, Smelson D, Smith J, Baldwin N, McInnes DK, Raikov I, Weber J, Hyde J. Peer support and whole health coaching to address the healthcare needs of homeless veterans: a pilot study. BMC PRIMARY CARE 2022; 23:331. [PMID: 36529718 PMCID: PMC9760553 DOI: 10.1186/s12875-022-01927-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Homelessness is a robust social determinant of acute care service utilization among veterans. Although intensive outpatient programs have been developed for homeless veterans who are high utilizers of acute care ("super utilizers"), few scalable programs have been implemented to address their needs. OBJECTIVE Describe the development and pilot testing of a novel intervention that integrates the roles of a peer and whole health coach ("Peer-WHC") in coordination with primary care teams to reduce homeless veterans' frequent use of acute care. DESIGN Single-arm trial in three outpatient primary care clinics at a Veterans Health Administration (VHA) medical center; pre/post design using mixed-methods. PARTICIPANTS Twenty veterans from VHA's homeless registry who were super-utilizers of acute care and enrolled in primary care. INTERVENTION Weekly health coaching sessions with a peer over 12 weeks, including discussions of patients' health care utilization patterns and coordination with primary care. MAIN MEASURES Rates of session attendance and intervention fidelity, patient-reported satisfaction and changes in patient engagement and perceptions of health, pre/post utilization of acute and supportive care services, and qualitative interviews with multiple stakeholders to identify barriers and facilitators to implementation. KEY RESULTS On average, patients attended 6.35 sessions (SD = 3.5, Median = 7). Satisfaction scores (M = 28.75 out of 32; SD = 2.79) exceeded a priori benchmarks. Patients' perceptions of health improved from pre to post [t(df)=-2.26(14), p = 0.04]. In the 3-months pre/post, 45% (n = 9) and 15% (n = 3) of patients, respectively, were hospitalized. Qualitative feedback from patients, providers, and peers and fidelity metrics suggested value in increasing the length of the intervention to facilitate goal-setting with patients and coordination with primary care. CONCLUSION Findings support the feasibility, acceptability, and utility of Peer-WHC to address the healthcare needs of homeless veterans. A future trial is warranted to test the impact of Peer-WHC on reducing these patients' frequent use of acute care.
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Albsoul RA, Hughes J, Alshyyab MA, Fitzgerald G. A scoping review of the literature of interventions for enhancing nurses' resilience in acute care settings. J Health Organ Manag 2022; ahead-of-print. [PMID: 36484639 DOI: 10.1108/jhom-04-2022-0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to identify and evaluate interventions shown to improve nurse resilience in the acute care settings. DESIGN/METHODOLOGY/APPROACH The study was a systematically conducted scoping review of the literature. Databases including MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Emerald insight and Google Scholar were searched and this complemented by reviews of the reference lists. FINDINGS In total, 13 papers were included in the review but there was limited evidence of the effectiveness of individual programs. The authors found that resilience training programs for individuals reviewed provided some evidence for the effectiveness of the training. However, the context of job design, work risks and leadership require attention. ORIGINALITY/VALUE Resilience is an important requirement for nursing staff that helps to mitigate the stress of the working environment, particularly in the acute care setting. However, the managerial strategies required to build resilience are not well known or applied. The findings of this research may help to design cohesive and comprehensive management programs to promote and preserve nursing resilience in acute care settings. Any such program needs to reflect the four key themes that appear to underpin resilience: relationships, motivation, emotions and well-being.
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Alsanie S, Lim S, Wootton SA. Detecting low-intake dehydration using bioelectrical impedance analysis in older adults in acute care settings: a systematic review. BMC Geriatr 2022; 22:954. [PMID: 36510185 PMCID: PMC9743772 DOI: 10.1186/s12877-022-03589-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 11/04/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Dehydration is a frequent cause of excess morbidity and poor health outcomes, particularly in older adults who have an increased risk of fluid loss due to renal senescence, comorbidities, and polypharmacy. Detecting dehydration is key to instigating treatment to resolve the problem and prevent further adverse consequences; however, current approaches to diagnosis are unreliable and, as a result, under-detection remains a widespread problem. This systematic review sought to explore the value of bioelectrical impedance in detecting low-intake dehydration among older adults admitted to acute care settings. METHODS A literature search using MEDLINE, EMBASE, CINAHL, Web of Science, and the Cochrane Library was undertaken from inception till May 2022 and led to the eventual evaluation of four studies. Risk of bias was assessed using the Cochrane tool for observational studies; three studies had a high risk of bias, and one had a low risk. Data were extracted using systematic proofs. Due to insufficient reporting, the data were analysed using narrative synthesis. RESULTS One study showed that the sensitivity and specificity of bioelectrical impedance in detecting low-intake dehydration varied considerably depending on the total body water percentage threshold used to ascertain dehydration status. Other included studies supported the technique's utility when compared to conventional measures of hydration status. CONCLUSIONS Given the scarcity of literature and inconsistency between findings, it is not possible to ascertain the value of bioelectrical impedance for detecting low-intake dehydration in older inpatients.
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Mizutani K, Otaka Y, Kato M, Hayakawa M, Ozeki M, Maeda H, Hirano S, Mukaino M, Shibata S, Kagaya H, Sakurai H, Saitoh E. Functional outcomes in acute care settings vary by disease categories but show a consistent pattern of disability. Ann Phys Rehabil Med 2022; 66:101648. [PMID: 35219896 DOI: 10.1016/j.rehab.2022.101648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 12/03/2022]
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Schonnop R, Dainty KN, McLeod SL, Melady D, Lee JS. Understanding why delirium is often missed in older emergency department patients: a qualitative descriptive study. CAN J EMERG MED 2022; 24:820-831. [PMID: 36138324 DOI: 10.1007/s43678-022-00371-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Unrecognized delirium is associated with significant adverse outcomes. Despite decades of effort and educational initiatives, validated screening tools have not improved delirium recognition in the emergency department (ED). There remains a fundamental knowledge gap of why it is consistently missed. The objective of this study was to explore the perceptions of ED physicians and nurses regarding factors contributing to missed delirium in older ED patients. METHODS We conducted a qualitative descriptive study at two academic tertiary care EDs in Toronto, Canada. Emergency physicians and nurses were interviewed by a trained qualitative researcher using a semi-structured interview guide. We coded transcripts with an iteratively developed codebook. Interviews were conducted until thematic saturation occurred. Thematic data analysis occurred in conjunction with data collection to continuously monitor emerging themes and areas for further exploration. RESULTS We interviewed 26 ED physicians and nurses. We identified key themes at four levels: clinical practice, provider attitudes, systematic processes, and education. The four themes include: (1) there are varied approaches to delirium recognition and infrequent use of screening tools; (2) delirium assessment is perceived as overly time consuming and of lower priority than other symptoms and syndromes; (3) it is unclear whose responsibility it is to recognize delirium; and (4) there is a need for a deeper or "functional" understanding of delirium that includes its consequences. CONCLUSIONS Our findings demonstrate a need for ED leadership to identify clear team roles for delirium recognition, standardize use of delirium screening tools, and prioritize delirium as a symptom of an acute medical emergency.
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Association between changes in frailty during hospitalization in older adults and 3-month mortality after discharge. Eur Geriatr Med 2022; 13:1403-1406. [PMID: 36260280 DOI: 10.1007/s41999-022-00704-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 10/02/2022] [Indexed: 12/30/2022]
Abstract
Frailty is a dynamic status that can worsen or improve. However, changes in their frailty status that occur during hospitalization and their significance have not been comprehensively investigated. In this study, we explored the association between such changes and mortality 3 months after discharge in older adults hospitalized for acute care. In total, 257 participants (mean age 84.95 ± 5.88, 41.6% male) completed comprehensive geriatric assessments, including the Clinical Frailty Scale (CFS) at admission and discharge. Mean CFS score was 5.14 ± 1.35 at admission. CFS scores increased, indicating deteriorating frailty, in 29.2% of the participants (75/257) during hospitalization. Multiple logistic regression analysis demonstrated a positive association between increased CFS score during hospitalization and mortality (odds ratio, 2.987) independent of potential co-founding factors. This deterioration in frailty during hospitalization may be modifiable risk factor of poor prognosis in older adults who need acute care hospitalization.
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Jonker G, Booij E, Vernooij JEM, Kalkman CJ, ten Cate O, Hoff RG. In pursuit of a better transition to selected residencies: a quasi-experimental evaluation of a final year of medical school dedicated to the acute care domain. BMC MEDICAL EDUCATION 2022; 22:807. [PMID: 36419057 PMCID: PMC9684806 DOI: 10.1186/s12909-022-03871-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 11/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Medical schools seek the best curricular designs for the transition to postgraduate education, such as the Dutch elective-based final, 'transitional' year. Most Dutch graduates work a mean of three years as a physician-not-in-training (PNIT) before entering residency training. To ease the transition to selected specialties and to decrease the duration of the PNIT period, UMC Utrecht introduced an optional, thematic variant of the usual transitional year, that enables the development of theme-specific competencies, in addition to physicians' general competencies. METHODS We introduced an optional transitional year for interested students around the theme of acute care, called the Acute Care Transitional Year (ACTY). This study aimed to evaluate the ACTY by judging whether graduates meet postgraduate acute care expectations, indicating enhanced learning and preparation for practice. In a comprehensive assessment of acute care knowledge, clinical reasoning, skills, and performance in simulations, we collected data from ACTY students, non-ACTY students interested in acute care, and PNITs with approximately six months of acute care experience. RESULTS ACTY graduates outperformed non-ACTY graduates on skills and simulations, and had higher odds of coming up to the expectations faculty have of a PNIT, as determined by global ratings. PNITs did better on simulations than ACTY graduates. DISCUSSION ACTY graduates show better resemblance to PNITs than non-ACTY graduates, suggesting better preparation for postgraduate acute care challenges. CONCLUSION Transitional years, offering multidisciplinary perspectives on a certain theme, can enhance learning and preparedness for entering residency.
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Jaworska N, Moss SJ, Krewulak KD, Stelfox Z, Niven DJ, Ismail Z, Burry LD, Fiest KM. A scoping review of perceptions from healthcare professionals on antipsychotic prescribing practices in acute care settings. BMC Health Serv Res 2022; 22:1272. [PMID: 36271347 PMCID: PMC9587627 DOI: 10.1186/s12913-022-08650-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 10/09/2022] [Indexed: 11/24/2022] Open
Abstract
Background Antipsychotic medications are frequently prescribed in acute care for clinical indications other than primary psychiatric disorders such as delirium. Unfortunately, they are commonly continued at hospital discharge and at follow-ups thereafter. The objective of this scoping review was to characterize antipsychotic medication prescribing practices, to describe healthcare professional perceptions on antipsychotic prescribing and deprescribing practices, and to report on antipsychotic deprescribing strategies within acute care. Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Web of Science databases from inception date to July 3, 2021 for published primary research studies reporting on antipsychotic medication prescribing and deprescribing practices, and perceptions on those practices within acute care. We included all study designs excluding protocols, editorials, opinion pieces, and systematic or scoping reviews. Two reviewers screened and abstracted data independently and in duplicate. The protocol was registered on Open Science Framework prior to data abstraction (10.17605/OSF.IO/W635Z). Results Of 4528 studies screened, we included 80 studies. Healthcare professionals across all acute care settings (intensive care, inpatient, emergency department) perceived prescribing haloperidol (n = 36/36, 100%) most frequently, while measured prescribing practices reported common quetiapine prescribing (n = 26/36, 76%). Indications for antipsychotic prescribing were delirium (n = 48/69, 70%) and agitation (n = 20/69, 29%). Quetiapine (n = 18/18, 100%) was most frequently prescribed at hospital discharge. Three studies reported in-hospital antipsychotic deprescribing strategies focused on pharmacist-driven deprescribing authority, handoff tools, and educational sessions. Conclusions Perceived antipsychotic prescribing practices differed from measured prescribing practices in acute care settings. Few in-hospital deprescribing strategies were described. Ongoing evaluation of antipsychotic deprescribing strategies are needed to evaluate their efficacy and risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08650-7.
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Martin-Iñigo L, Ortiz S, Urbano D, Teba Pérez S, Contaldo SF, Alvarós J, Baladon L, Parody-Rúa E, Rubio-Valera M. Assessment of the efficacy of a Crisis Intervention Team (CIT): experience in the Esplugues Mental Health Center (Barcelona). Soc Psychiatry Psychiatr Epidemiol 2022; 57:2109-2117. [PMID: 35246708 DOI: 10.1007/s00127-022-02250-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 02/18/2022] [Indexed: 11/30/2022]
Abstract
AIM Crisis Resolution Teams (CRT) have shown positive clinical and service-use results in various countries but evidence in the south of Europe is scarce. The aim is to assess the impact of the Crisis Intervention Team (CIT) in Spain with respect to the course of symptomatology and mental health services use in patients served. METHODS Prospective observational cohort study. Assessment of the psychopathological severity (HoNOS scale) of the clinical course (CGI scale) and use of medical services. RESULTS A positive clinical course was observed following the intervention. The mean difference in HoNOS (Health of the Nation Outcome Scales) scores between baseline and discharge was 7 points (p < 0.05). On discharge, more than 60% of patients had improved their symptomatology according to the CGI scale (Clinical Global Impression) and most were discharged due to improvement or goal achievement. A tendency to reduction in the number of admissions to acute units and day hospital was observed, along with fewer emergency room visits. In contrast, an increase in the number of admissions to subacute units was seen. During the intervention, the median number of visits to the center was 15 and the median duration of care provision by the CIT was 39 days. CONCLUSIONS The CIT intervention promotes patients' clinical improvement and has a positive impact in terms of reducing acute hospitalizations and emergency room visits.
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Nurse, Provider, and Emergency Department Technician: Perceptions and Experiences of Violence and Aggression in the Emergency Department. J Emerg Nurs 2022; 49:431-440. [PMID: 36180265 DOI: 10.1016/j.jen.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Patient/visitor violence and aggression (V&A) in the emergency department occurs daily. Few interventions exist to decrease V&A. Research describing prevalence, severity, and perceived safety among ED clinicians is limited. METHODS A descriptive survey explored V&A against ED clinicians in one urban emergency department. A sample of nurses, ED technicians, physicians and advanced practice providers participated. Participants completed a demographic survey, Personal Workplace Safety Instrument for Emergency Nurses (PWSI-EN), and ENA V&A frequency checklist. Analysis of Variance (ANOVA) for unadjusted and Analysis of Covariance (ANCOVA) for adjusted associations were used to assess differences in the PWSI-EN survey composite score and "feeling safe in the ED" among ED roles. ANCOVA was adjusted for potential confounders: sex, race, years working in emergency department, and shift worked. RESULTS Sixty-five (46.4%) of the 140 ED clinicians returned surveys, which were almost evenly distributed between ED clinician roles and sex. Mean age was 37.2 (range: 21-64) years. All (100%) nurses and providers reported being verbally abused. More nurses reported physical violence (n = 21, 87.5%) than providers (n = 7, 36.8%) and ED technicians (n = 11, 55%). Nurses and ED technicians reported experiencing greater prevalence of physical violence than providers (p < .05). Nurses (mean 3.29, range 2.95 to 3.63) were more fearful for their personal safety than ED technicians (mean 3.88, range 3.48 to 4.28) (p < .03). DISCUSSION V&A are common creating a fearful environment. However, little research regarding clinician perceptions exists. Our study aids in identifying areas for clinician-targeted strategies to prevent ED V&A.
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Phan HT, Nguyen TH, Watkins C, Lightbody E, Boaden E, Georgiou R, Middleton S, Dale S, Kilkenny MF, Pandian J, Grimley RS, Nguyen TQ, Cadilhac DA. Organisational survey for acute stroke care in Vietnam: Regional Collaboration Programme. J Stroke Cerebrovasc Dis 2022; 31:106792. [PMID: 36174327 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/14/2022] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Low-middle income countries, such as Vietnam have a greater burden from stroke than high-income countries. Few health professionals have stroke specialist training, and the quality of care may vary between hospitals. To support improvements to stroke care, we aimed to gain a better understanding of the resources available in hospitals in Vietnam to manage acute stroke. MATERIALS AND METHODS The survey questions were adapted from the Australian Organisational Survey of Stroke Services (Stroke Foundation). The final 65 questions covered the topics: hospital size and admissions for stroke; use of clinical protocols and assessments conducted; team structure and coordination; communication and team roles. The survey was distributed electronically or via paper form in Vietnamese to clinical leaders of 91 eligible hospitals (November-December 2020). Data were summarised descriptively. RESULTS Sixty-six (73%) hospitals responded, and doctors predominately completed the survey (98%). Approximately 70% of hospitals had a stroke unit; median 630 acute strokes/year (IQR: 250-1200) and >90% used stroke clinical protocols. The daytime nurse-patient ratio was 1:4. There was a perceived lack of access to allied health staff, including psychologists/neuropsychologists, occupational therapists, and speech pathologists. Only 50% reported having a standardised rehabilitation assessment process. CONCLUSIONS This is the first large-scale cross-sectional, national overview of stroke services in Vietnam. Future research should include a systematic clinical audit of stroke care to confirm aspects of the data from these hospitals. Repeating the survey in future years will enable the tracking of progress and may influence capacity building for stroke care in Vietnam.
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Gehring ND, Speed KA, Dong K, Pauly B, Salvalaggio G, Hyshka E. Social service providers' perspectives on caring for structurally vulnerable hospital patients who use drugs: a qualitative study. BMC Health Serv Res 2022; 22:1138. [PMID: 36076267 PMCID: PMC9461250 DOI: 10.1186/s12913-022-08498-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers’ perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care. Methods We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model. Results Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients’ ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs. Conclusions Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care’s ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08498-x.
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