Cancer pain management in the emergency department: a multicenter prospective observational trial of the Comprehensive Oncologic Emergencies Research Network (CONCERN)

PURPOSE

Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.

METHODS

We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.

RESULTS

The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).

CONCLUSIONS

Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.

Lack of racial and ethnic-based differences in acute care delivery in intracerebral hemorrhage

Background and aim

Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH.

Methods

We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale.

Results

Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT (β = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request (β = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome.

Conclusions

We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes.

Approaches to patient satisfaction measurement of the healthcare food services: A systematic review

BACKGROUND & AIMS

Monitoring consumer's satisfaction is important in ensuring effective foodservice improvements and to provide a patient-centred foodservice experience. The aim of this study is to systematically review available patient foodservice satisfaction survey instruments developed and validated within the acute and long-term care settings.

METHODS

A literature search of four scientific databases was performed to identify relevant studies with 50 participants or greater. Study characteristics, such as identifying information, contexts, and descriptive data regarding the tool and its evaluation study, were extracted and synthesised. Quality appraisal of individual studies was undertaken to assess the risk of bias during data collection.

RESULTS

Majority of the survey instruments included utilised a quantitative research approach in the form of self- or interview-administered questionnaires. Tools within the long-term care settings were more likely to be administered via interviews using a shorter and even rating scale, potentially resulting in a higher degree of bias and reduced data sensitivity. Food quality was consistently shown to be the main predictor of the overall satisfaction in food services. Factors that are context-specific to the settings, opportunities to allow open-ended comments, and the involvement of patients' perspectives in instrument development were also critical in improving survey quality.

CONCLUSION

The available validated survey instruments are generally valid and of acceptable quality, enabling effective foodservice satisfaction measurement in the healthcare settings. Nonetheless, gaps have been identified in the literature with limited evidence available for foodservice satisfaction measurement within the paediatric settings, supporting the value of future research in this field.

Validation and psychometric evaluation of the Dutch person-centred care of older people with cognitive impairment in acute care (POPAC) scale

Background

Person-centred care is the preferred model for caring for people with dementia. Knowledge of the level of person-centred care is essential for improving the quality of care for patients with dementia. The person-centred care of older people with cognitive impairment in acute care (POPAC) scale is a tool to determine the level of person-centred care. This study aimed to translate and validate the Dutch POPAC scale and evaluate its psychometric properties to enable international comparison of data and outcomes.

Methods

After double-blinded forward and backward translations, a total of 159 nurses recruited from six hospitals (n=114) and via social media (n=45) completed the POPAC scale. By performing confirmatory factor analysis, construct validity was tested. Cronbach’s alpha scale was utilized to establish internal consistency.

Results

The confirmatory factor analysis showed that the comparative fit index (0.89) was slightly lower than 0.9. The root mean square error of approximation (0.075, p=0.012, CI 0.057–0.092) and the standardized root mean square residual (0.063) were acceptable, with values less than 0.08. The findings revealed a three-dimensional structure. The factor loadings (0.69–0.77) indicated the items to be strongly associated with their respective factors. The results also indicated that deleting Item 5 improved the Cronbach’s alpha of the instrument as well as of the subscale ‘using cognitive assessments and care interventions’. Instead of deleting this item, we suggest rephrasing it into a positively worded item.

Conclusions

Our findings suggest that the Dutch POPAC scale is sufficiently valid and reliable and can be utilized for assessing person-centred care in acute care hospitals. The study enables nurses to interpret and compare person-centred care levels in wards and hospital levels nationally and internationally. The results form an important basis for improving the quality of care and nurse-sensitive outcomes, such as preventing complications and hospital stay length.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06048-x.

PTSD symptoms among trauma-exposed adults admitted to inpatient psychiatry for suicide-related concerns

Individuals admitted to inpatient psychiatry for suicide-related concerns are at increased risk of suicide post-discharge, necessitating an understanding of factors, such as posttraumatic stress disorder (PTSD), that are associated with suicide-related hospitalizations. In this study, we examined if individuals admitted for suicide-related concerns were more likely than those admitted for other reasons to have elevated PTSD symptoms or a probable PTSD diagnosis. We also examined the moderating role of impulsivity. Participants were 188 trauma-exposed adult psychiatric inpatients (M [SD]age = 33.6 y [11.7 y], 63.3% male, 46.3% white). We used the Life Events Checklist for DSM-5, PTSD Checklist for DSM-5, Beck Scale for Suicide Ideation, and Barratt Impulsiveness Scale-11 to assess trauma exposure, PTSD symptoms, suicidal ideation severity, and impulsivity, respectively. We controlled for trauma load, number of psychiatric diagnoses, and comorbid depressive and substance use disorders. Patients admitted for suicide-related concerns (55.3%; n = 104), compared with those admitted for other reasons (44.7%; n = 84), had more severe PTSD symptoms, corresponding to medium-to-large effect sizes; associations were stronger at higher levels of impulsivity. Additionally, patients admitted for suicide-related concerns were nearly four times more likely than their counterparts to screen positive for a provisional PTSD diagnosis. Among the subset of individuals admitted for suicide-related concerns, greater PTSD symptoms were associated with more severe suicidal ideation. In sum, PTSD symptoms are elevated among psychiatric inpatients admitted for suicide-related concerns, and among this subgroup, greater PTSD symptom severity covaries with suicidal ideation severity. Screening for and treating PTSD, and attending to cooccurring impulsivity, in psychiatric inpatients may reduce suicide risk.

Collateral Impact of the COVID-19 Pandemic on Acute Care of Non-COVID Patients: An Internet-based Survey of Critical Care and Emergency Personnel

Purpose

The impact of disruption to the care of non-coronavirus disease (COVID) patients (COVID collateral damage syndrome-CCDS) is largely unknown in resource-limited settings. We investigated CCDS as perceived by healthcare workers (HCWs) providing acute and critical care services in India.

Materials and methods

A clinician and nurse codesigned and validated an internet-based survey, which was disseminated to HCWs using a multiple frame sampling technique.

Results

Responses were received from 468 HCWs (completion rate 84%); at the time of the survey, 48% were working in critical care, 41% aged 30–40 years, and 53% represented public institutions. Respondents perceived a decrease in service utilization and disruption to time-sensitive acute interventions (60.1% and 40.8%, respectively), with fear of infection (score, 63.0; standard deviation (SD), 31.8) and restrictions due to lockdown (61.4; SD 32.5) being cited as the causes of service disruption. Being overwhelmed or lack of protective equipment was perceived to contribute less to CCDS. Insistence on COVID test results X² (p = 0.02) and duty-avoidance (p < 0.01) was perceived as significant causes for CCDS by HCWs from private hospitals and those in leadership roles, respectively.

Conclusions

Fear of infection and the effect of lockdown were perceived as important contributors to CCDS resulting in disruption to services and decreased service utilization. Perceptions were influenced by HCWs’ role and hospital organizational structure.

How to cite this article

Tripathy S, Vijayaraghavan BKT, Panigrahi MK, Shetty AP, Haniffa R, Mishra RC, et al. Collateral Impact of the COVID-19 Pandemic on Acute Care of Non-COVID Patients: An Internet-based Survey of Critical Care and Emergency Personnel. Indian J Crit Care Med 2021;25(4):374–381.

Implementation of general medicine topics for acute care inpatient advanced pharmacy practice experiences

INTRODUCTION

The purpose of this study was to describe the development of a general medicine student workbook to standardize acute care inpatient fourth-year pharmacy rotations among faculty with varied pharmacy practice sites.

METHODS

Four faculty designed an advanced pharmacy practice experience (APPE) student workbook on general medicine topics consisting of short answer and multiple-choice questions to ensure standardization by exposing all students to the same topics. A pre- and posttest was administered on the first and last day of the five-week rotation block to evaluate the effects of the APPE workbook on student understanding of general medicine topics. A paired t-test was used to evaluate the significance of the difference in test scores.

RESULTS

The average of the posttest exam was found to be significantly higher after the completion of the student workbook. The average grade on the pre-rotation 30-item exam was 22.8 (76.73%) and the post-rotation 30-item exam was 25.7 (86.26%), with a difference of 9.53% (P < .001, 95% CI = 7.11 to 11.96).

CONCLUSIONS

Creating a standardized student workbook for an inpatient acute care rotation was a valuable addition. All students assigned to the faculty involved were exposed to the same topics despite variability in preceptors and practice sites. Overall the verbal feedback from the students was positive about the student workbook and discussions, especially since the information was applicable to their patients on rotation. Faculty will continue to use this workbook as a tool to teach various inpatient general medicine topics during the acute care APPE.

Endotracheal intubation to reduce aspiration events in acutely comatose patients: a systematic review

Background

It is customary to believe that a patient with a Glasgow Coma Scale (GCS) score less than or equal to 8 should be intubated to avoid aspiration. We conducted a systematic review to establish if patients with GCS ≤ 8 for trauma or non-traumatic emergencies and treated in the acute care setting (e.g., Emergency Department or Pre-hospital environment) should be intubated to avoid aspiration or aspiration pneumonia/pneumonitis, and consequently, reduce mortality.

Methods

We searched six databases, Pubmed, Embase, Scopus, SpringerLink, Cochrane Library, and Ovid Emcare, from April 15th to October 14th, 2020, for studies involving low GCS score patients of whom the risk of aspiration and related complications was assessed.

Results

Thirteen studies were included in the final analysis (7 on non-traumatic population, 4 on trauma population, 1 pediatric and 1 adult mixed case studies). For the non-traumatic cases, two prospective studies and one retrospective study found no difference in aspiration risk between intubated and non-intubated patients. Two retrospective studies reported a reduction in the risk of aspiration in the intubated patient group. For traumatic cases, the study that considered the risk of aspiration did not show any differences between the two groups. A study on adult mixed cases found no difference in the incidence of aspiration among intubated and non-intubated patients. A study on pediatric patients found increased mortality for intubated versus non-intubated non-traumatic patients with a low GCS score.

Conclusion

Whether intubation results in a reduction in the incidence of aspiration events and whether these are more frequent in patients with low GCS scores are not yet established. The paucity of evidence on this topic makes clinical trials justifiable and necessary.

Trial registration

Prospero registration number: CRD42020136987.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-020-00814-w.

Effects of participatory art-based painting workshops in geriatric inpatients: results of a non-randomized open label trial

BACKGROUND

Art-based activities like painting workshops demonstrated health benefits in older individuals living in home care facilities. Few studies examined the effects of painting workshops in geriatric inpatients.

AIM

The study aims to examine whether the participation in painting workshops performed in patients admitted to a geriatric acute care ward reduced the number of medications taken daily, use of psychoactive medications, the length of stay and inhospital mortality.

METHODS

Based on a non-randomized open label trial, 79 inpatients who participated in painting workshops and 79 control inpatients were recruited in the geriatric acute care ward of the Jewish general hospital (Montreal, Quebec, Canada). Four outcomes were used: the number of medications taken daily and use of psychoactive medications the day of discharge to geriatric acute care ward, the length of hospital stay and inhospital mortality.

RESULTS

The participation in Painting workshops were associated with a lower number of medications taken daily at discharge (Coefficient of regression β =  - 1.35 with P = 0.001) and lower inhospital mortality (odd ratio (OR) = 0.09 with P = 0.031). No significant association was reported with use of psychoactive medications and length of stay.

CONCLUSION

The participation in painting workshops reduced the number of medications taken daily and incident inhospital mortality in geriatric inpatients admitted to a geriatric acute care ward, suggested a positive effect on health condition of this participatory art-based activity.

Acute care for elderly patients in a functional impairment prevention unit

AIM

To determine whether the care of patients with moderate dependency who were hospitalised in a functional impairment prevention unit (FIPU) was superior to that of a conventional unit (CU) in terms of functional impairment and mean stay.

METHODS

We conducted a single-centre, retrospective, controlled intervention study that compared acute treatment in an FIPU and in conventional wards. The study included 466 elderly patients with moderate dependence (Barthel index, 30-70) and older than 75 years. Of these, 280 were included in the intervention group and 186 in the control group. The primary outcomes were loss of functionality attributable to the hospitalisation (measured by the loss of ambulation and urinary continence) and differences in the length of stay.

RESULTS

The patients hospitalised in the FIPU showed less functional impairment as determined by the loss of urinary continence (2.1% of the FIPU patients vs. 9.7% of the CU patients; p<.01) and the loss of walking ability (2.1% vs. 25.3%; p<.01). The patients hospitalised in the FIPU had a shorter mean stay (7.4 vs. 8.5 days; p<.05), with 1 day less of stay than the CU patients.

CONCLUSION

The acute care of elderly patients with moderate dependency in an FIPU was independently associated with less functional decline and shorter stays.

Delayed discharges from a tertiary teaching hospital in Israel- incidence, implications, and solutions

Objectives

The Israeli health system is facing high workloads with average occupancy in certain hospital wards of around 100%. Since there is a shortage of hospitalization beds in institutions for continuous, long-term care, transferring patients from the general hospitals’ wards is often delayed. This situation has many significant ramifications, to the waiting patients themselves, to other patients who are waiting to be treated and to the entire organization. In this study, we describe the phenomenon of the “detained patients” - its extent, characteristics, significance, and possible solutions.

Materials and methods

Rambam Health Care Campus is a tertiary medical center serving the population of the northern part of Israel. In recent years, the hospital management documents data regarding the “detained patients”. We reviewed hospital data of detained patients over a period of nine months. The data concerning adult patients awaiting transfer to an institution for continuous care, between May 2019 and January 2020, were obtained retrospectively from the computerized database of the social service.

Results

During the study period, 12,723 adult patients were discharged. Of those, 857 patients (6.74%) were transferred to one of the facilities providing prolonged institutional care. For that group of patients, median inpatient waiting time from the decision to discharge until the transfer was 8 days (IQR 6–14), translating to 10,821 waiting days or 1202 hospitalization days per month. These hospitalization days account for 9.35% of the total hospitalization days during the study period. The “detained patients” were hospitalized in internal medicine wards (32%), orthopedic (30%), and neurology/neurosurgery (26%) departments. At any given moment, about 40 hospitalized patients were waiting for long-term care facilities.

Conclusions

Health-care systems must adapt to the current patients’ case-mix to achieve optimal utilization of hospital beds and maximal operational efficiency. The number of long-term care beds should be increased, the coordination between general hospitals, health maintenance organizations and long-term facilities improved, and patients that may require long term care after the acute phase of their illness should be early identified and addressed. Meanwhile, establishment of organic units for waiting patients and reorganization of the hospital structure should be considered.

The effect of PARO robotic seals for hospitalized patients with dementia: A feasibility study

Robotic seals have been studied in long-term care settings; though, no studies of patients with dementia in the acute care setting have been reported. The purpose of this study was to evaluate the feasibility of PARO interventions for hospitalized patients with dementia, determine physiological effects and describe social-affective interactions. Using a prospective descriptive design with pre-post PARO intervention physiological measurements, we studied 55 participants who received up to five 15-min PARO interventions. The PARO was favorably accepted for 212 (95%) of the 223 PARO interventions. Differences in pre- and post-physiological measures for mean arterial pressure, pulse, respiration, oxygenation, stress, and pain levels were evaluated using Wilcoxon Signed Rank test with statistically significant pre and post differences (p=<0.05); however, the differences were not clinically significant. Participants (95%) demonstrated beneficial PARO interactions with the most frequent interactions being speaking and petting. The PARO shows promise for enhancing social and affective responses for hospitalized patients with dementia.

Pediatric Critical Care Simulation Curriculum: Training Nurse Practitioners to Lead in the Management of Critically Ill Children

INTRODUCTION

Acute care pediatric nurse practitioners have become frontline providers in the critical care environment and are expected to provide leadership in acutely critical situations. We describe a 2-day, high-fidelity, simulation-based curriculum focused on training the pediatric nurse practitioners for leadership in critical care scenarios.

METHOD

This prospective pre-post interventional study used simulation-based pedagogy. Knowledge tests, time-to-task, and a follow-up survey were used to determine the effectiveness of the training.

RESULTS

Participants (n = 23) improved their knowledge scores by 27% (pretest: 35.2% [standard deviation = 12.1%]; posttest: 62.2% [standard deviation = 13.8%], p < .001). In addition, time-to-task for resuscitation variables improved significantly. At 3 months, 100% of the participants who responded either agreed (15.4%) or strongly agreed (84.6%) that the boot camp prepared them to lead in a critical emergency.

DISCUSSION

Simulation-based training is an effective strategy for educating critical care pediatric nurse practitioners and improves their ability to manage pediatric emergencies rapidly, which can be lifesaving.

Cannabis use, other drug use, and risk of subsequent acute care in primary care patients

BACKGROUND

Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care.

METHOD

This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care.

RESULTS

Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03-1.21) or daily (HR = 1.24; 1.10-1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13-1.59), weekly (HR = 2.21; 1.46-3.35), or daily (HR = 2.53; 1.86-3.45) had greater risk of acute care than those reporting no other drug use.

CONCLUSION

Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

Describing the characteristics and healthcare use of high-cost acute care users at the end of life: a pan-Canadian population-based study

BACKGROUND

A minority of individuals use a large portion of health system resources, incurring considerable costs, especially in acute-care hospitals where a significant proportion of deaths occur. We sought to describe and contrast the characteristics, acute-care use and cost in the last year of life among high users and non-high users who died in hospitals across Canada.

METHODS

We conducted a population-based retrospective-cohort study of Canadian adults aged ≥18 who died in hospitals across Canada between fiscal years 2011/12-2014/15. High users were defined as patients within the top 10% of highest cumulative acute-care costs in each fiscal year. Patients were categorized as: persistent high users (high-cost in death year and year prior), non-persistent high users (high-cost in death year only) and non-high users (never high-cost). Discharge abstracts were used to measure characteristics and acute-care use, including number of hospitalizations, admissions to intensive-care-unit (ICU), and alternate-level-of-care (ALC).

RESULTS

We identified 191,310 decedents, among which 6% were persistent high users, 41% were non-persistent high users, and 46% were non-high users. A larger proportion of high users were male, younger, and had multimorbidity than non-high users. In the last year of life, persistent high users had multiple hospitalizations more often than other groups. Twenty-eight percent of persistent high users had ≥2 ICU admissions, compared to 8% of non-persistent high users and only 1% of non-high users. Eleven percent of persistent high users had ≥2 ALC admissions, compared to only 2% of non-persistent high users and < 1% of non-high users. High users received an in-hospital intervention more often than non-high users (36% vs. 19%). Despite representing only 47% of the cohort, persistent and non-persistent high users accounted for 83% of acute-care costs.

CONCLUSIONS

High users - persistent and non-persistent - are medically complex and use a disproportionate amount of acute-care resources at the end of life. A greater understanding of the characteristics and circumstances that lead to persistently high use of inpatient services may help inform strategies to prevent hospitalizations and off-set current healthcare costs while improving patient outcomes.

Introducing virtual reality therapy for inpatients with dementia admitted to an acute care hospital: learnings from a pilot to pave the way to a randomized controlled trial

Background

Behavioural and psychological symptoms of dementia (BPSD) are difficult to manage, particularly in acute care settings. As virtual reality (VR) technology becomes increasingly accessible and affordable, there is growing interest among clinicians to evaluate VR therapy in hospitalized patients, as an alternative to administering antipsychotics/sedatives or using physical restraints associated with negative side effects.

Objectives

Validate and refine the proposed research protocol for a randomized controlled trial (RCT) that evaluates the impact of VR therapy on managing BPSD in acute care hospitals. Special attention was given to ascertain the processes of introducing non-pharmacological interventions in acute care hospitals.

Methods

Ten patients 65 years or older (mean = 87) previously diagnosed with dementia, admitted to an acute care hospital, were recruited over 3-month period into a prospective longitudinal pilot study. The intervention consisted of viewing 20-min of immersive 360° VR using a head-mounted display. Baseline and outcomes data were collected from the hospital electronic medical records, pre/post mood-state questionnaires, Neuropsychiatric Inventory (NPI) score, and standardized qualitative observations. Comprehensive process data and workflow were documented, including timestamps for each study task and detailed notes on personnel requirements and challenges encountered.

Results

Of 516 patients admitted during the study, 67 met the inclusion/exclusion criteria. In total, 234 calls were initiated to substitute decision makers (SDM) of the 67 patients for the consenting process. Nearly half (45.6%) of SDMs declined participation, and 40% could not be reached in time before patients being discharged, resulting in 57 eligible patients not being enrolled. Ten consented participants were enrolled and completed the study. The initial VR session averaged 53.6 min, largely due to the administration of NPI (mean = 19.5 min). Only four participants were able to respond reliably to questions. Seven participants opted for additional VR therapy sessions; of those providing feedback regarding the VR content, they wanted more varied scenery (animals, fields of flowers, holiday themes). Few sessions (4/18) encountered technical difficulties.

Conclusion

The pilot was instrumental in identifying issues and providing recommendations for the RCT. Screening, inclusion criteria, consenting, data collection, and interaction with SDMs and hospital staff were all processes requiring changes and optimizations. Overall, patients with dementia appear to tolerate immersive VR, and with suggested protocol alterations, it is feasible to evaluate this non-pharmacological intervention in acute care hospitals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-020-00708-9.

The influence of empowered work environments on the psychological experiences of nursing assistants during COVID-19: a qualitative study

Background

Nursing Assistants (NA) who feel empowered tend to perform their duties better, have higher morale and job satisfaction, and are less likely to leave their jobs. Organizational empowerment practices in hospitals likely shape the psychological experiences of empowerment among these personnel; however, little is known about this relationship.

Objective

We used qualitative inquiry to explore the relationship between organizational empowerment structural components and feelings of psychological empowerment among hospital frontline workers during a public health emergency.

Methods

Kanter’s Theory of Structural Empowerment and Spreitzer’s Psychological Empowerment in the Workplace Framework were applied to identify the conceptual influences of organizational practices on psychological experiences of empowerment. In-depth interviews were conducted with a convenience sample of NAs, caring for hospitalized COVID-19 patients. Directed content analysis was performed to generate a data matrix consisting of the psychological experiences of meaning, competence, self-determination, and impact embedded under the organizational structural components of information, resources, support, and opportunity.

Results

Thirteen NAs (mean age = 42 years, 92% female) completed interviews. Information, or lack thereof, provided to the NAs influenced feelings of fear, preparation, and autonomy. Resources (e.g., protocols, equipment, and person-power) made it easier to cope with overwhelming emotions, affected the NAs’ abilities to do their jobs, and when limited, drove NAs to take on new roles. NAs noted that support was mostly provided by nurses and made the NAs feel appreciated, desiring to contribute more. While NAs felt they could consult leadership when needed, several felt leadership showed little appreciation for their roles and contributions. Similar to support, the opportunity to take care of COVID-19 patients yielded a diverse array of emotions, exposed advances and gaps in NA preparation, and challenged NAs to autonomously develop new care practices and processes.

Conclusion

Management and empowerment of healthcare workers are critical to hospital performance and success. We found many ways in which the NAs’ psychological experiences of empowerment were shaped by the healthcare system’s empowerment-related structural conditions during a public health emergency. To further develop an empowered and committed critical workforce, hospitals must acknowledge the organizational practice influence on the psychological experiences of empowerment among NAs.

Development and use of a toolkit to facilitate implementation of an evidence-based intervention: a descriptive case study

Background

Implementation of evidence-based clinical interventions in real-world settings becomes a futile effort when effective strategies to foster adoption are not used. A toolkit, or a collection of adaptable documents to inform and facilitate implementation, can increase the use of evidence-based interventions. Most available toolkits provide resources about the intervention but lack guidance for adaptation to different contexts or strategies to support implementation. This paper describes the development and use of a toolkit to guide the implementation of an evidence-based intervention to identify and intervene for people with risky substance use.

Methods

A descriptive case study describes the development and use of a toolkit throughout a two-year study. Investigators and site coordinators from 14 acute care hospitals developed tools and engaged external stakeholders as they prepared for implementation, integrated the clinical intervention into practice, and reflected on implementation.

Results

The final toolkit included 54 different tools selected or created to define the intervention, engage and communicate with stakeholders, assess for readiness and plan for implementation, train clinical nurses and other stakeholders, evaluate training and implementation effectiveness, create policies and procedures for different contexts, and identify opportunities for reimbursement. Each tool corresponds to one or more implementation strategies.

Conclusion

The approach used to develop this implementation toolkit may be used to create resources for the implementation of other evidence-based interventions.

Unplanned return presentations of older patients to the emergency department: a root cause analysis

Background

In line with demographic changes, there is an increase in ED presentations and unplanned return presentations by older patients (≥70 years). It is important to know why these patients return to the ED shortly after their initial presentation. Therefore, the aim of this study was to provide insight into the root causes and potential preventability of unplanned return presentations (URP) to the ED within 30 days for older patients.

Methods

A prospective observational study was conducted from February 2018 to November 2018 in an academic hospital in Amsterdam. We included 83 patients, aged 70 years and older, with an URP to the ED within 30 days of the initial ED presentation. Patients, GPs and doctors at the ED were interviewed by trained interviewers and basic administrative data were collected in order to conduct a root cause analysis using the PRISMA-method.

Results

One hundred fifty-one root causes were identified and almost half (49%) of them were disease-related. Fifty-two percent of the patients returned to the ED within 7 days after the initial presentation. In 77% of the patients the URP was related to the initial presentation. Patients judged 17% of the URPs as potentially preventable, while doctors at the ED judged 25% and GPs 23% of the URPs as potentially preventable. In none of the cases, there was an overall agreement from all three perspectives on the judgement that an URP was potentially preventable.

Conclusion

Disease-related factors were most often identified for an URP and half of the patients returned to the ED within 7 days. The majority of the URPs was judged as not preventable. However, an URP should trigger healthcare workers to focus on the patient’s process of care and their needs and to anticipate on potential progression of disease. Future research should assess whether this may prevent that patients have to return to the ED.

Life worth living: cross-sectional study on the prevalence and determinants of the wish to die in elderly patients hospitalized in an internal medicine ward

BACKGROUND

Elderly people frequently express the wish to die: this ranges from a simple wish for a natural death to a more explicit request for death. The frequency of the wish to die and its associated factors have not been assessed in acute hospitalization settings. This study aimed to investigate the prevalence and determinants of the wish to die in elderly (≥65 years) patients hospitalized in an internal medicine ward.

METHODS

This cross-sectional study was conducted between 1 May, 2018, and 30 April, 2019, in an acute care internal medicine ward in a Swiss university hospital. Participants were a consecutive sample of 232 patients (44.8% women, 79.3 ± 8.1 years) with no cognitive impairment. Wish to die was assessed using the Schedule of Attitudes toward Hastened Death-senior and the Categories of Attitudes toward Death Occurrence scales.

RESULTS

Prevalence of the wish to die was 8.6% (95% confidence interval [CI]: 5.3-13.0). Bivariate analysis showed that patients expressing the wish to die were older (P = .014), had a lower quality of life (P < .001), and showed more depressive symptoms (P = .044). Multivariable analysis showed that increased age was positively (odds ratio [OR] for a 5-year increase: 1.43, 95% CI 0.99-2.04, P = .048) and quality of life negatively (OR: 0.54, 95% CI 0.39-0.75, P < 0.001) associated with the likelihood of wishing to die. Participants did not experience stress during the interview.

CONCLUSIONS

Prevalence of the wish to die among elderly patients admitted to an acute hospital setting is low, but highly relevant for clinical practice. Older age increases and better quality of life decreases the likelihood of wishing to die. Discussion of death appears to be well tolerated by patients.

Tracheostomy to Noninvasive Ventilation: From Acute Care to Home

The number of patients experiencing prolonged mechanical ventilation is increasing over time. Patients who have a tracheostomy placed in a critical care setting have been described as having an average of 4 separate transitions between the acute care setting, long-term acute care (LTAC), and home. Transition points can be problematic if not addressed adequately; however, proactive planning can optimize patient care. Individual patient factors will determine if the patient will require long-term tracheostomy, transitioned to noninvasive positive pressure ventilation, or able to be decannulated. Patients and caregivers should be included in transition planning to optimize outcomes.

Role of nurses and midwives in improving patient safety during childbirth: Evidence from obstetric trauma in OECD countries

OBJECTIVES

To measure the role of nurses and midwives in reducing obstetric trauma as a proxy for safety failures during childbirth in member countries of Organization for Economic Co-operation and Development (OECD).

METHODS

The number of practicing nurses' and midwives' density per 1000 population and the proportion of third- and fourth-degree obstetric trauma during vaginal delivery with instrument (OT₁) and without instrument (OT₂) in crude rates per 100 vaginal deliveries for patients aged 15 and over collected from World Development Indicators and OECD Health Statistics in 17 OECD countries during 2010-2017 period. The statistical technique of panel data analysis was applied to estimate the impact of nurses and midwives on improving patient safety during childbirth. The number of physicians per 1000 population, health care expenditure (HCE) per capita and total number of hospital beds per 1000 population were added in data analysis as control variables.

RESULTS

The results of panel co-integration test and dynamic long-run models confirm that there were meaningful relationships from the level of nursing and midwifery staff to reducing OECD's obstetric trauma indicators with long-run magnitudes of -15.8614 for OT₁ and -0.0519 for OT₂. In addition, the results of panel error-correction model argue that if the long-run relationships between nursing and midwifery staff and obstetric trauma indicators are disturbed by the shortage in the needed nurses and midwives, then it takes at least 25 years for OT₁ and 18 years for OT₂ to reduce and restore back to equilibrium; that is quite a long time.

CONCLUSION

A higher proportion of nursing and midwifery staff is associated with higher patient safety during childbirth in OECD countries. Overall, our findings alert policy makers to consider the deleterious impacts of shortage in the level of nursing and midwifery staff on declining patient safety during childbirth as well as quality of acute care in OECD.

Prevalence and nature of potential drug-drug interactions among hospitalized HIV patients presenting with suspected meningitis in Uganda

Background

Management of co-infections including cryptococcal meningitis, tuberculosis and other opportunistic infections in persons living with HIV can lead to complex polypharmacotherapy and increased susceptibility to drug-drug interactions (DDIs). Here we characterize the frequency and types of potential DDIs (pDDIs) in hospitalized HIV patients presenting with suspected cryptococcal or tuberculous meningitis.

Methods

In a retrospective review of three cryptococcal meningitis trials between 2010 and 2017 in Kampala, Uganda, medications received over hospitalization were documented and pDDI events were assessed. IBM Micromedex DRUGDEX® online drug reference system was used to identify and describe potential interactions as either contraindicated, major, moderate or minor. For antiretroviral DDIs, the Liverpool Drug Interactions Checker from the University of Liverpool was also used to further describe interactions observed.

Results

In 1074 patients with suspected meningitis, pDDIs were present in 959 (overall prevalence = 89.3%) during the analyzed 30 day window. In total, 278 unique interacting drug pairs were identified resulting in 4582 pDDI events. Of all patients included in this study there was a mean frequency of 4.27 pDDIs per patient. Of the 4582 pDDI events, 11.3% contraindicated, 66.4% major, 17.4% moderate and 5% minor pDDIs were observed. Among all pDDIs identified, the most prevalent drugs implicated were fluconazole (58.4%), co-trimoxazole (25.7%), efavirenz (15.6%) and rifampin (10.2%). Twenty-one percent of the contraindicated pDDIs and 27% of the major ones involved an antiretroviral drug. Increased likelihood of QT interval prolongation was the most frequent potential clinical outcome. Dissonance in drug interaction checkers was noted requiring clinicians to consult more than one database in making clinical decisions about drug combinations.

Conclusions

The overall prevalence of pDDIs in this population is high. An understanding of drug combinations likely to result in undesired clinical outcomes, such as QT interval prolongation, is paramount. This is especially important in resource limited settings where availability of therapeutic drug monitoring and laboratory follow-up are inconsistent. Adequate quantification of the increased likelihood of adverse clinical outcomes from multiple drug-drug interactions of the same kind in a single patient is needed to aid clinical decisions in this setting.

Perceived Quality of Care Transitions between Hospital and the Home in People with Stroke

OBJECTIVES

To explore the perceived quality of care transitions from hospital to the home with referral to subsequent rehabilitation in the home, and factors associated with low perceived quality, in people with stroke.

DESIGN

Observational study.

SETTING AND PARTICIPANTS

Eligible were patients with a suspected acute stroke admitted to 1 of 4 inpatient hospital units in the Stockholm region and discharged home with referral to a neurorehabilitation team in primary care.

METHODS

Data on perceived quality of care transition was collected with the Care Transition Measure (CTM-15) 1 week after discharge. Additional data were mainly retrieved from medical records. To analyze difference in mean total score of the CTM-15 between participants' characteristics, length of hospital stay, disease-related data, and functioning, the Mann-Whitney U test and independent sample t test were used for dichotomized variables and 1-way analysis of variance and the Tukey post hoc test for variables with more than 2 groups. To analyze differences between participants with low and high perceived quality per item, univariable regression analyses were performed. Thereafter, multivariable regression models were created to explore associations between low perceived quality and the independent variables.

RESULTS

Mean age of the 189 participants was 75 years and 91% had a mild or very mild stroke. The majority perceived most areas of the care transition to be of high quality. Nevertheless, several areas for improvement were identified. People with a more severe stroke perceived the quality of the care transition to be lower in comparison with those with a mild stroke. The association was weak between patient or clinical characteristics and the perceived quality.

CONCLUSION AND IMPLICATIONS

Our findings suggest that preparation for discharge and information and support for self-management postdischarge should be enhanced in the referral-based care transition after stroke. Special attention should be given to people with severe stroke.

Impact of the COVID-19 outbreak on acute stroke care

Background and purpose

There are concerns that the coronavirus disease 2019 (COVID-19) outbreak negatively affects the quality of care for acute cardiovascular conditions. We assessed the impact of the COVID-19 outbreak on trends in hospital admissions and workflow parameters of acute stroke care in Amsterdam, The Netherlands.

Methods

We used data from the three hospitals that provide acute stroke care for the Amsterdam region. We compared two 7-week periods: one during the peak of the COVID-19 outbreak (March 16th–May 3th 2020) and one prior to the outbreak (October 21st–December 8th 2019). We included consecutive patients who presented to the emergency departments with a suspected stroke and assessed the change in number of patients as an incidence-rate ratio (IRR) using a Poisson regression analysis. Other outcomes were the IRR for stroke subtypes, change in use of reperfusion therapy, treatment times, and in-hospital complications.

Results

During the COVID-19 period, 309 patients presented with a suspected stroke compared to 407 patients in the pre-COVID-19 period (IRR 0.76 95%CI 0.65–0.88). The proportion of men was higher during the COVID-19 period (59% vs. 47%, p < 0.001). There was no change in the proportion of stroke patients treated with intravenous thrombolysis (28% vs. 30%, p = 0.58) or endovascular thrombectomy (11% vs 12%, p = 0.82) or associated treatment times. Seven patients (all ischemic strokes) were diagnosed with COVID-19.

Conclusion

We observed a 24% decrease in suspected stroke presentations during the COVID-19 outbreak, but no evidence for a decrease in quality of acute stroke care.