Trends in Adverse Event Rates in Hospitalized Patients, 2010-2019

Defects in Value Associated With Hospital-Acquired Conditions: How Improving Quality Could Save U.S. Healthcare $50 Billion

ABSTRACT

Hospital-acquired conditions in the United States are considered avoidable complications but remain common statistics reflecting on health system performance and are a leading cause of patient fatality. Currently, over 3.7 million patients experience a hospital-acquired condition in the United States each year, which costs the U.S. healthcare delivery system an excess of $48 billion. Evidence-based clinical practice guidelines for common hospital-acquired conditions (e.g., infections, falls, pressure injuries) to reduce risk to the patient. In each of these instances, preventing the outcome with these guidelines costs less than treating the outcome, in addition to keeping the patient safe from harm. By applying the framework of defects in value to hospital-acquired conditions, we estimate that U.S. health systems could avert this $48 billion in spending on treating harmful hospital-acquired conditions; more so, these systems of care could recuperate over $35 billion after investing proportionally in a system that delivers greater quality by preventing hospital-acquired conditions over treating them. Currently, the Centers for Medicare and Medicaid Services only withholds reimbursements for hospital-acquired conditions and penalizes health systems with high rates of these outcomes. However, payers do not offer any reward-based incentives for hospital-acquired condition prevention. A series of policy and health system solutions, including tracking of hospital-acquired condition rates in electronic health records, identifying centers of excellence at reducing rates of harm with the use of clinical practice guidelines, and rewarding them monetarily for reduced rates could create equal-sided risk and opportunity to engage health systems in improved performance.

Patient safety in the intensive care department

Patient safety is a priority for all healthcare systems. Despite this, too many patients still suffer harm as a consequence of healthcare. Furthermore, it has a significant impact on family members, professionals and healthcare institutions, resulting in considerable economic costs. The critically ill patient is particularly vulnerable to adverse events. Numerous safe practices have been implemented, acknowledging the influence of human factors on safety and the significance of the well-being of professionals, as well as the impact of critical episodes at hospital discharge on patients and their families. Training and engagement of professionals, patients and families are of paramount importance. Recently, artificial intelligence has demonstrated its ability to enhance clinical safety. This update on "Patient Safety" reviews all these aspects related to one of the most pivotal dimensions of healthcare quality.

Exploring the use of social network analysis methods in process improvement within healthcare organizations: a scoping review

BACKGROUND

Communication breakdowns among healthcare providers have been identified as a significant cause of preventable adverse events, including harm to patients. A large proportion of studies investigating communication in healthcare organizations lack the necessary understanding of social networks to make meaningful improvements. Process Improvement in healthcare (systematic approach of identifying, analyzing, and enhancing workflows) is needed to improve quality and patient safety. This review aimed to characterize the use of SNA methods in Process Improvement within healthcare organizations.

METHODS

Relevant studies were identified through a systematic search of seven databases from inception - October 2022. No limits were placed on study design or language. The reviewers independently charted data from eligible full-text studies using a standardized data abstraction form and resolved discrepancies by consensus. The abstracted information was synthesized quantitatively and narratively.

RESULTS

Upon full-text review, 38 unique articles were included. Most studies were published between 2015 and 2021 (26, 68%). Studies focused primarily on physicians and nursing staff. The majority of identified studies were descriptive and cross-sectional, with 5 studies using longitudinal experimental study designs. SNA studies in healthcare focusing on process improvement spanned three themes: Organizational structure (e.g., hierarchical structures, professional boundaries, geographical dispersion, technology limitations that impact communication and collaboration), team performance (e.g., communication patterns and information flow among providers., and influential actors (e.g., key individuals or roles within healthcare teams who serve as central connectors or influencers in communication and decision-making processes).

CONCLUSIONS

SNA methods can characterize Process Improvement through mapping, quantifying, and visualizing social relations, revealing inefficiencies, which can then be targeted to develop interventions to enhance communication, foster collaboration, and improve patient safety.

Nurses' perceptions of patient safety culture and adverse events in Hail City, Saudi Arabia: a cross-sectional approach to improving healthcare safety

OBJECTIVE

This study aimed to assess nurses' perceptions of patient safety culture (PSC) and its relationship with adverse events in Hail City, Saudi Arabia.

DESIGN

A cross-sectional study was conducted between 1 August 2023 and the end of November 2023 at 4 governmental hospitals and 28 primary healthcare centres.

SETTING

Hail City, Saudi Arabia.

PARTICIPANTS

Data were collected from 336 nurses using 3 instruments: demographic and work-related questions, PSC and adverse events.

RESULTS

Nurses had positive responses in the dimensions of 'teamwork within units' (76.86%) and 'frequency of events reported' (77.87%) but negative responses in the dimensions of 'handoffs and transitions' (18.75%), 'staffing' (20.90%), 'non-punitive response to errors' (31.83%), 'teamwork across units' (34.15%), 'supervisor/manager expectations' (43.22%) and 'overall perception of patient safety' (43.23%). Significant associations were found between nationality, experience, current position and total safety culture, with p values of 0.015, 0.046 and 0.027, respectively. Nurses with high-ranking perceptions of PSC in 'handoffs and transitions,' 'staffing' and 'teamwork across hospital units' reported a lower incidence of adverse events than those with low-ranking perceptions, particularly in reporting pressure ulcers (OR 0.86, 95% CI 0.78 to 0.94, OR 0.82, 95% CI 0.71 to 0.94 and OR 0.83, 95% CI 0.70 to 0.99, respectively) (p<0.05). Nurses with high-ranking perceptions of PSC in UK 'handoffs and transitions' reported a lower incidence of patient falls. Similarly, those with high-ranking perceptions in both 'handoffs and transitions' and 'overall perception of patient safety reported a lower incidence of adverse events compared with those with low-ranking perceptions, especially in reporting adverse drug events (OR 0.83, 95% CI 0.76 to 0.91 and OR 0.75, 95% CI 0.61 to 0.92, respectively) (p<0.05).

CONCLUSION

From a nursing perspective, hospital PSCs have both strengths and weaknesses. Examples include low trust in leadership, staffing, error-reporting and handoffs. Therefore, to improve staffing, communication, handoffs, teamwork, and leadership, interventions should focus on weak areas of low confidence and high rates of adverse events.

Development and validation of a risk prediction model for community-acquired pressure injury in a cancer population: A case-control study

BACKGROUND

Patients with cancer are susceptible to pressure injuries, which accelerate deterioration and death. In patients with post-acute cancer, the risk of pressure injury is ignored in home or community settings.

OBJECTIVE

To develop and validate a community-acquired pressure injury risk prediction model for cancer patients.

METHODS

All research data were extracted from the hospital's electronic medical record system. The identification of optimal predictors is based on least absolute shrinkage and selection operator regression analysis combined with clinical judgment. The performance of the model was evaluated by drawing a receiver operating characteristic curve and calculating the area under the curve (AUC), calibration analysis and decision curve analysis. The model was used for internal and external validation, and was presented as a nomogram.

RESULTS

In total, 6257 participants were recruited for this study. Age, malnutrition, chronic respiratory failure, body mass index, and activities of daily living scores were identified as the final predictors. The AUC of the model in the training and validation set was 0.87 (95 % confidence interval [CI], 0.85-0.89), 0.88 (95 % CI, 0.85-0.91), respectively. The model demonstrated acceptable calibration and clinical benefits.

CONCLUSIONS

Comorbidities in patients with cancer are closely related to the etiology of pressure injury, and can be used to predict the risk of pressure injury.

IMPLICATIONS FOR PRACTICE

This study provides a tool to predict the risk of pressure injury for cancer patients. This suggests that improving the respiratory function and nutritional status of cancer patients may reduce the risk of community-acquired pressure injury.

Medical Professionals' Responses to a Patient Safety Incident in Healthcare

Objectives: Patient safety incidents (PSIs) are common in healthcare. Open communication facilitated by psychological safety in healthcare could contribute to the prevention of PSIs and enhance patient safety. The aim of the study was to explore medical professionals' responses to a PSI in relation to psychological safety in Slovak healthcare. Methods: Sixteen individual semi-structured interviews with Slovak medical professionals were performed. Obtained qualitative data were transcribed verbatim and analysed using the conventional content analysis method and the consensual qualitative research method. Results: We identified eight responses to a PSI from medical professionals themselves as well as their colleagues, many of which were active and with regard to ensuring patient safety (e.g., notification), but some of them were passive and ultimately threatening patients' safety (e.g., silence). Five superiors' responses to the PSI were identified, both positive (e.g., supportive) and negative (e.g., exaggerated, sharp). Conclusion: Medical professionals' responses to a PSI are diverse, indicating a potential for enhancing psychological safety in healthcare.

Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults

BACKGROUND

Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention.

METHODS

A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death.

RESULTS

The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group.

CONCLUSIONS

The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge.

The impact of COVID-19 trauma on healthcare workers: Examining the relationship between stress and growth through the lens of memory

The COVID-19 pandemic constituted tremendous traumatic stress among the frontline healthcare workers. In the present study, we investigated relationships of two types of rumination, namely brooding and reflection, with traumatic stress and post-traumatic growth and the mediating role of recollective experience in these relationships. A total of 88 healthcare workers (75% female, Mage = 54.91) actively providing service to COVID-19 patients reported two memories of events that impacted them the most at the first peak of the pandemic and rated their recollective experience (i.e., phenomenological characteristics of memories). We used structural equation modelling to test whether recollective experience mediated the link of brooding and reflection with post-trauma reactions of stress and growth. The findings showed that brooding and reflection were associated with higher levels of traumatic stress and post-traumatic growth. Importantly, recollective experience mediated the relationship of rumination with traumatic stress but this differed for the type of rumination. Higher brooding was associated with greater traumatic stress and that relationship was independent of how well the memories were recollected, while for reflection, high reflection was associated with stronger recollective experience, which predicted higher traumatic stress and post-traumatic growth. The present study shows the functional dimensions of reflective rumination and presents novel findings that demonstrates the discrete mnemonic mechanisms underlying the association between brooding, reflection, and post-trauma reactions.

Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events

PURPOSE

To use machine learning to examine health equity and clinical outcomes in patients who experienced a nurse sensitive indicator (NSI) event, defined as a fall, a hospital-acquired pressure injury (HAPI) or a hospital-acquired infection (HAI).

DESIGN

This was a retrospective observational study from a single academic hospital over six calendar years (2016-2021). Machine learning was used to examine patients with an NSI compared to those without.

METHODS

Inclusion criteria: all adult inpatient admissions (2016-2021). Three approaches were used to analyze the NSI group compared to the No-NSI group. In the univariate analysis, descriptive statistics, and absolute standardized differences (ASDs) were employed to compare the demographics and clinical variables of patients who experienced a NSI and those who did not experience any NSIs. For the multivariate analysis, a light grading boosting machine (LightGBM) model was utilized to comprehensively examine the relationships associated with the development of an NSI. Lastly, a simulation study was conducted to quantify the strength of associations obtained from the machine learning model.

RESULTS

From 163,507 admissions, 4643 (2.8%) were associated with at least one NSI. The mean, standard deviation (SD) age was 59.5 (18.2) years, males comprised 82,397 (50.4%). Non-Hispanic White 84,760 (51.8%), non-Hispanic Black 8703 (5.3%), non-Hispanic Asian 23,368 (14.3%), non-Hispanic Other 14,284 (8.7%), and Hispanic 30,271 (18.5%). Race and ethnicity alone were not associated with occurrence of an NSI. The NSI group had a statistically significant longer length of stay (LOS), longer intensive care unit (ICU) LOS, and was more likely to have an emergency admission compared to the group without an NSI. The simulation study results demonstrated that likelihood of NSI was higher in patients admitted under the major diagnostic categories (MDC) associated with circulatory, digestive, kidney/urinary tract, nervous, and infectious and parasitic disease diagnoses.

CONCLUSION

In this study, race/ethnicity was not associated with the risk of an NSI event. The risk of an NSI event was associated with emergency admission, longer LOS, longer ICU-LOS and certain MDCs (circulatory, digestive, kidney/urinary, nervous, infectious, and parasitic diagnoses).

CLINICAL RELEVANCE

Machine learning methodologies provide a new mechanism to investigate NSI events through the lens of health equity/disparity. Understanding which patients are at higher risk for adverse outcomes can help hospitals improve nursing care and prevent NSI injury and harm.

Risk-adjusted trend in national inpatient fall rates observed from 2011 to 2019 in acute care hospitals in Switzerland: a repeated multicentre cross-sectional study

OBJECTIVES

This study aimed to investigate whether a significant trend regarding inpatient falls in Swiss acute care hospitals between 2011 and 2019 could be confirmed on a national level, and whether the trend persists after risk adjustment for patient-related fall risk factors.

DESIGN

A secondary data analysis was conducted based on annual multicentre cross-sectional studies carried out between 2011 and 2019.

SETTING

All Swiss acute care hospitals were obliged to participate in the surveys. Except for emergency departments, outpatient wards and recovery rooms, all wards were included.

PARTICIPANTS

All inpatients aged 18 or older who had given their informed consent and whose data were complete and available were included.

OUTCOME MEASURE

Whether a patient had fallen in the hospital was retrospectively determined on the survey day by asking patients the following question: Have you fallen in this institution in the last 30 days?

RESULTS

Based on data from 110 892 patients from 222 Swiss hospitals, a national inpatient fall rate of 3.7% was determined over the 9 survey years. A significant linear decreasing trend (p=0.004) was observed using the Cochran-Armitage trend test. After adjusting for patient-related fall risk factors in a two-level random intercept logistic regression model, a significant non-linear decreasing trend was found at the national level.

CONCLUSIONS

A significant decrease in fall rates in Swiss hospitals, indicating an improvement in the quality of care provided, could be confirmed both descriptively and after risk adjustment. However, the non-linear trend, that is, an initial decrease in inpatient falls that flattens out over time, also indicates a possible future increase in fall rates. Monitoring of falls in hospitals should be maintained at the national level. Risk adjustment accounts for the observed increase in patient-related fall risk factors in hospitals, thus promoting a fairer comparison of the quality of care provided over time.

Pay-for-performance and patient safety in acute care: A systematic review

Pay-for-performance (p4p) has been tried in all healthcare settings to address ongoing deficiencies in the quality and outcomes of care. The evidence for the effect of these policies has been inconclusive, especially in acute care. This systematic review focused on patient safety p4p in the hospital setting. Using the PRISMA guidelines, we searched five biomedical databases for quantitative studies using at least one outcome metric from database inception to March 2023, supplemented by reference tracking and internet searches. We identified 6,122 potential titles of which 53 were included: 39 original investigations, eight literature reviews and six grey literature reports. Only five system-wide p4p policies have been implemented, and the quality of evidence was low overall. Just over half of the studies (52 %) included failed to observe improvement in outcomes, with positive findings heavily skewed towards poor quality evaluations. The exception was the Fragility Hip Fracture Best Practice Tariff (BPT) in England, where sustained improvement was observed across various evaluations. All policies had a miniscule impact on total hospital revenue. Our findings underscore the importance of simple and transparent design, involvement of the clinical community, explicit links to other quality improvement initiatives, and gradual implementation of p4p initatives. We also propose a research agenda to lift the quality of evidence in this field.

Current perspectives on the use of artificial intelligence in critical patient safety

Intensive Care Units (ICUs) have undergone enhancements in patient safety, and artificial intelligence (AI) emerges as a disruptive technology offering novel opportunities. While the published evidence is limited and presents methodological issues, certain areas show promise, such as decision support systems, detection of adverse events, and prescription error identification. The application of AI in safety may pursue predictive or diagnostic objectives. Implementing AI-based systems necessitates procedures to ensure secure assistance, addressing challenges including trust in such systems, biases, data quality, scalability, and ethical and confidentiality considerations. The development and application of AI demand thorough testing, encompassing retrospective data assessments, real-time validation with prospective cohorts, and efficacy demonstration in clinical trials. Algorithmic transparency and explainability are essential, with active involvement of clinical professionals being crucial in the implementation process.

Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014-2020): Findings From Taiwan Patient Safety Reporting System

OBJECTIVES

Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity.

METHODS

Longitudinal secondary data (over 2014-2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system. The numbers and incidence rates (per 1000 inpatient days) of reported MAEs were calculated. The harm severity levels of six major MAE categories were analyzed. Trend and generalized estimating equation analyses were conducted to investigate changes in MAE patterns.

RESULTS

Trend analyses revealed significant decreasing trends in the number (4763-3107 per year; Jonckheere-Terpstra test = -1.952, P = 0.05) and incidence rates (0.92-0.62 per 1000 inpatient days; β = -0.5017, P = 0.00) of harmful MAEs over 7-year study period. Among the most frequently reported MAEs, tube-related events exhibited the most significant decreasing trend (28%-23.8%; Jonckheere-Terpstra test = -2.854, P = 0.00). The reported numbers, incidence rates, and severity of falls and tube-related events dropped significantly.

CONCLUSIONS

By analyzing representative longitudinal MAE data, this study demonstrated the effectiveness of nationwide patient safety improvement campaigns in Taiwan. Our data reveal significant reductions in the reported numbers, incidence rates, and severity of several major MAEs. Specifically, our data indicate significant reductions in the incidence and severity of tube-related events, which can be beneficial for patient safety improvement efforts.

Contextual Factors Influencing the Implementation of a Multifaceted Intervention to Improve Teamwork and Quality for Hospitalized Patients: A Multisite Qualitative Comparative Case Study

BACKGROUND

Many hospitals have begun to implement models that combine interventions to redesign care for medical patients. These models include localization of physicians to specific units, nurse-physician co-leadership, and interprofessional rounds. Understanding contextual factors, the circumstances surrounding an implementation effort that influence its success, is essential to provide guidance to leaders implementing similar models of care.

METHODS

A multisite qualitative comparative case study was conducted with four hospitals in the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Researchers conducted observations and semistructured interviews with 40 health care professionals and four implementation mentors. Researchers used inductive qualitative content analysis, reviewed fidelity of implementation trends, and performed cross-case analysis to identify contextual factors and their influence on implementation.

RESULTS

Four contextual factors were associated with implementation success: (1) senior hospital leader involvement and organizational support; (2) alignment of RESET with organizational, hospital, and professional group priorities; (3) site leaders' engagement in RESET and relationship with one another; and (4) perceptions of need and intervention benefits among professionals. Implementation was optimal when senior leadership was stable and tangibly involved; organizational, hospital, and group goals were aligned; site leaders were committed and collaborated well; and nurses and physicians perceived a need for and benefits from the interventions.

CONCLUSION

Four interrelated contextual factors are associated with the implementation of combined interventions to redesign care for hospitalized medical patients. Hospital leaders should consider these findings prior to implementing similar interventions and be prepared to address challenges related to these factors during implementation.

Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors

Objective

Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship.

Study Design

A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019.

Results

Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties.

Discussion

Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.

Impact of the Italian Healthcare Outcomes Program (PNE) on the Care Quality of the Poorest Performing Hospitals

One of the main aims of the Italian National Healthcare Outcomes Program (Programma Nazionale Esiti, PNE) is the identification of the hospitals with the lowest performance, leading them to improve their quality. In order to evaluate PNE impact for a subset of outcome indicators, we evaluated whether the performance of the hospitals with the lowest scores in 2016 had significantly improved after five years. The eight indicators measured the risk-adjusted likelihood of the death of each patient (adjusted relative risk-RR) 30 days after the admission for acute myocardial infarction, congestive heart failure, stroke, chronic obstructive pulmonary disease, chronic kidney disease, femur fracture or lung and colon cancer. In 2016, the PNE identified 288 hospitals with a very low performance in at least one of the selected indicators. Overall, 51.0% (n = 147) of these hospitals showed some degree of improvement in 2021, and 27.4% of them improved so much that the death risk of their patients fell below the national mean value. In 34.7% of the hospitals, however, the patients still carried a mean risk of death >30% higher than the average Italian patient with the same disease. Only 38.5% of the hospitals in Southern Italy improved the scores of the selected indicators, versus 68.0% in Northern and Central Italy. Multivariate analyses, adjusting for the baseline performance in 2016, confirmed univariate results and showed a significantly lower likelihood of improvement with increasing hospital volume. Despite the overall methodological validity of the PNE system, current Italian policies and actions aimed at translating hospital quality scores into effective organizational changes need to be reinforced with a special focus on larger southern regions.

Population-Based Trends in Complexity of Hospital Inpatients

Importance

Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression.

Objective

To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period.

Design, Setting and Participants

This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023.

Exposure

The passage of time (15-year study interval).

Main Outcomes and Measures

Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval.

Results

The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively).

Conclusions and Relevance

By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.

Management and treatment outcomes of rheumatoid arthritis in the era of biologic and targeted synthetic therapies: evaluation of 10-year data from the KURAMA cohort

BACKGROUND

Advances in rheumatoid arthritis (RA) treatment, highlighted by biological disease-modifying antirheumatic drugs (bDMARDs) and targeted synthetic DMARDs (tsDMARDs), have altered the paradigm of RA treatment in the last decade. Therefore, real-world clinical evidence is needed to understand how treatment strategies and outcomes have changed.

METHODS

Using an observational cohort of RA from 2012 to 2021, we collected cross-sectional data of RA patients annually to analyze a trend in RA management. For patients who initiated b/tsDMRDs, we evaluated treatment outcomes between b/tsDMARDs. Mixed-effect models were applied to examine the statistical implications of changes over time in treatment outcomes with a background adjustment.

RESULTS

We analyzed annual cross-sectional data from 5070 patients and longitudinal data from 1816 patients in whom b/tsDMARDs were initiated between 2012 and 2021. b/tsDMARD use increased, whereas glucocorticoid use decreased from 2012 to 2021. Disease activity and functional disability measures improved over time. The percentage of tsDMARD prescriptions considerably increased. All b/tsDMARDs showed clinical improvements in disease activity and functional disability. Statistically, TNFi showed better short-term improvements in b/tsDMARD-naïve patients, while IL6Ri demonstrated significant long-term benefits. IL6Ri had better retention rates in switched patients. After adjustment for patient characteristics, the annual change of RA disease activity and functional disability fared significantly better from 2012 to 2021.

CONCLUSIONS

With the development of new RA therapeutics, overall treatment outcomes advanced in the past decade.

Contrastive Transfer Learning for Prediction of Adverse Events in Hospitalized Patients

OBJECTIVE

Deterioration index (DI) is a computer-generated score at a specific frequency that represents the overall condition of hospitalized patients using a variety of clinical, laboratory and physiologic data. In this paper, a contrastive transfer learning method is proposed and validated for early prediction of adverse events in hospitalized patients using DI scores.

METHODS AND PROCEDURES

An unsupervised contrastive learning (CL) model with a classifier is proposed to predict adverse outcome using a single temporal variable (DI scores). The model is pretrained on an unsupervised fashion with large-scale time series data and fine-tuned with retrospective DI score data.

RESULTS

The performance of this model is compared with supervised deep learning models for time series classification. Results show that unsupervised contrastive transfer learning with a classifier outperforms supervised deep learning solutions. Pretraining of the proposed CL model with large-scale time series data and fine-tuning that with DI scores can enhance prediction accuracy.

CONCLUSION

A relationship exists between longitudinal DI scores of a patient and the corresponding outcome. DI scores and contrastive transfer learning can be used to predict and prevent adverse outcomes in hospitalized patients.

CLINICAL IMPACT

This paper successfully developed an unsupervised contrastive transfer learning algorithm for prediction of adverse events in hospitalized patients. The proposed model can be deployed in hospitals as an early warning system for preemptive intervention in hospitalized patients, which can mitigate the likelihood of adverse outcomes.

Effect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients : A Pragmatic Controlled Trial

BACKGROUND

Multiple challenges impede interprofessional teamwork and the provision of high-quality care to hospitalized patients.

OBJECTIVE

To evaluate the effect of interventions to redesign hospital care delivery on teamwork and patient outcomes.

DESIGN

Pragmatic controlled trial. Hospitals selected 1 unit for implementation of interventions and a second to serve as a control. (ClinicalTrials.gov: NCT03745677).

SETTING

Medical units at 4 U.S. hospitals.

PARTICIPANTS

Health care professionals and hospitalized medical patients.

INTERVENTION

Mentored implementation of unit-based physician teams, unit nurse-physician coleadership, enhanced interprofessional rounds, unit-level performance reports, and patient engagement activities.

MEASUREMENTS

Primary outcomes were teamwork climate among health care professionals and adverse events experienced by patients. Secondary outcomes were length of stay (LOS), 30-day readmissions, and patient experience. Difference-in-differences (DID) analyses of patient outcomes compared intervention versus control units before and after implementation of interventions.

RESULTS

Among 155 professionals who completed pre- and postintervention surveys, the median teamwork climate score was higher after than before the intervention only for nurses (n = 77) (median score, 88.0 [IQR, 77.0 to 91.0] vs. 80.0 [IQR, 70.0 to 89.0]; P = 0.022). Among 3773 patients, a greater percentage had at least 1 adverse event after compared with before the intervention on control units (change, 1.61 percentage points [95% CI, 0.01 to 3.22 percentage points]). A similar percentage of patients had at least 1 adverse event after compared with before the intervention on intervention units (change, 0.43 percentage point [CI, -1.25 to 2.12 percentage points]). A DID analysis of adverse events did not show a significant difference in change (adjusted DID, -0.92 percentage point [CI, -2.49 to 0.64 percentage point]; P = 0.25). Similarly, there were no differences in LOS, readmissions, or patient experience.

LIMITATION

Adverse events occurred less frequently than anticipated, limiting statistical power.

CONCLUSION

Despite improved teamwork climate among nurses, interventions to redesign care for hospitalized patients were not associated with improved patient outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

When Mistakes Multiply: How Inadequate Responses to Medical Mishaps Erode Trust in American Medicine

In this essay, we explore consequences of the systemic failure to track and to publicize the prevalence of patient-safety threats in American medicine. Tens of millions of Americans lose trust in medical care every year due to safety shortfalls. Because this loss of trust is long-lasting, the corrosive effects build up over time, yielding a collective maelstrom of mistrust among the American public. Yet no one seems to notice that patient safety is a root cause, because no one is counting. In addition to identifying the origins of this purblindness, we offer an alternative policy approach. This would call for government to transparently track safety threats through the systematic collection and reporting of patients' experiences. This alternative strategy offers real promise for stemming the erosion of trust that currently accompanies patient-safety shortfalls while staying consistent with Americans' preferences for a constrained government role with respect to medical care.

Anticoagulation-Associated Adverse Drug Events in Hospitalized Patients Across Two Time Periods

PURPOSE

Anticoagulants often cause adverse drug events (ADEs), comprised of medication errors and adverse drug reactions, in patients. Our study objective was to determine the clinical characteristics, types, severity, cause, and outcomes of anticoagulation-associated ADEs from 2015-2020 (a contemporary period following implementation of an electronic health record, infusion device technology, and anticoagulant dosing nomograms) and to compare them with those of a historical period (2004-2009).

METHODS

We reviewed all anticoagulant-associated ADEs reported as part of our hospital-wide safety system. Reviewers classified type, severity, root cause, and outcomes for each ADE according to standard definitions. Reviewers also assessed events for patient harm. Patients were followed up to 30 days after the event.

RESULTS

Despite implementation of enhanced patient safety technology and procedure, ADEs increased in the contemporary period. In the contemporary period, we found 925 patients who had 984 anticoagulation-associated ADEs, including 811 isolated medication errors (82.4%); 13 isolated adverse drug reactions (1.4%); and 160 combined medication errors, adverse drug reactions, or both (16.2%). Unfractionated heparin was the most frequent ADE-related anticoagulant (77.7%, contemporary period vs 58.3%, historical period). The most frequent anticoagulation-associated medication error in the contemporary period was wrong rate or frequency of administration (26.1%, n = 253), with the most frequent root cause being prescribing errors (21.3%, n = 207). The type, root cause, and harm from ADEs were similar between periods.

CONCLUSIONS

We found that anticoagulation-associated ADEs occurred despite advances in patient safety technologies and practices. Events were common, suggesting marginal improvements in anticoagulant safety over time and ample opportunities for improvement.

Relationship Between In-Hospital Adverse Events and Hospital Performance on 30-Day All-cause Mortality and Readmission for Patients With Heart Failure

BACKGROUND

Hospitals with high mortality and readmission rates for patients with heart failure (HF) might also perform poorly in other quality concepts. We sought to evaluate the association between hospital performance on mortality and readmission with hospital performance rates of safety adverse events.

METHODS

This cross-sectional study linked the 2009 to 2019 patient-level adverse events data from the Medicare Patient Safety Monitoring System, a randomly selected medical records-abstracted patient safety database, to the 2005 to 2016 hospital-level HF-specific 30-day all-cause mortality and readmissions data from the United States Centers for Medicare & Medicaid Services. Hospitals were classified to one of 3 performance categories based on their risk-standardized 30-day all-cause mortality and readmission rates: better (both in <25th percentile), worse (both >75th percentile), and average (otherwise). Our main outcome was the occurrence (yes/no) of one or more adverse events during hospitalization. A mixed-effect model was fit to assess the relationship between a patient's risk of having adverse events and hospital performance categories, adjusted for patient and hospital characteristics.

RESULTS

The study included 39 597 patients with HF from 3108 hospitals, of which 252 hospitals (8.1%) and 215 (6.9%) were in the better and worse categories, respectively. The rate of patients with one or more adverse events during a hospitalization was 12.5% (95% CI, 12.1-12.8). Compared with patients admitted to better hospitals, patients admitted to worse hospitals had a higher risk of one or more hospital-acquired adverse events (adjusted risk ratio, 1.24 [95% CI, 1.06-1.44]).

CONCLUSIONS

Patients admitted with HF to hospitals with high 30-day all-cause mortality and readmission rates had a higher risk of in-hospital adverse events. There may be common quality issues among these 3 measure concepts in these hospitals that produce poor performance for patients with HF.

Classification of Adverse Events in Adult Surgery

Successful surgery combines quality (achievement of a positive outcome) with safety (avoidance of a negative outcome). Outcome assessment serves the purpose of quality improvement in health care by establishing performance indicators and allowing the identification of performance gaps. Novel surgical quality metric tools (benchmark cutoffs and textbook outcomes) provide procedure-specific ideal surgical outcomes in a subgroup of well-defined low-risk patients, with the aim of setting realistic and best achievable goals for surgeons and centers, as well as supporting unbiased comparison of surgical quality between centers and periods of time. Validated classification systems have been deployed to grade adverse events during the surgical journey: (1) the ClassIntra classification for the intraoperative period; (2) the Clavien-Dindo classification for the gravity of single adverse events; and the (3) Comprehensive Complication Index (CCI) for the sum of adverse events over a defined postoperative period. The failure to rescue rate refers to the death of a patient following one or more potentially treatable postoperative adverse event(s) and is a reliable proxy of the institutional safety culture and infrastructure. Complication assessment is undergoing digital transformation to decrease resource-intensity and provide surgeons with real-time pre- or intraoperative decision support. Standardized reporting of complications informs patients on their chances to realize favorable postoperative outcomes and assists surgical centers in the prioritization of quality improvement initiatives, multidisciplinary teamwork, surgical education, and ultimately, in the enhancement of clinical standards.

Hospital quality reporting in the pandemic era: to what extent did hospitals' COVID-19 census burdens impact 30-day mortality among non-COVID Medicare beneficiaries?

OBJECTIVES

Highly visible hospital quality reporting stakeholders in the USA such as the US News & World Report (USNWR) and the Centers for Medicare & Medicaid Services (CMS) play an important health systems role via their transparent public reporting of hospital outcomes and performance. However, during the pandemic, many such quality measurement stakeholders and pay-for-performance programmes in the USA and Europe have eschewed the traditional risk adjustment paradigm, instead choosing to pre-emptively exclude months or years of pandemic era performance data due largely to hospitals' perceived COVID-19 burdens. These data exclusions may lead patients to draw misleading conclusions about where to seek care, while also masking genuine improvements or deteriorations in hospital quality that may have occurred during the pandemic. Here, we assessed to what extent hospitals' COVID-19 burdens (proportion of hospitalised patients with COVID-19) were associated with their non-COVID 30-day mortality rates from March through November 2020 to inform whether inclusion of pandemic-era data may still be appropriate.

DESIGN

This was a retrospective cohort study using the 100% CMS Inpatient Standard Analytic File and Master Beneficiary Summary File to include all US Medicare inpatient encounters with admission dates from 1 April 2020 through 30 November 2020, excluding COVID-19 encounters. Using linear regression, we modelled the association between hospitals' COVID-19 proportions and observed/expected (O/E) ratios, testing whether the relationship was non-linear. We calculated alternative hospital O/E ratios after selective pandemic data exclusions mirroring the USNWR data exclusion methodology.

SETTING AND PARTICIPANTS

We analysed 4 182 226 consecutive Medicare inpatient encounters from across 2601 US hospitals.

RESULTS

The association between hospital COVID-19 proportion and non-COVID O/E 30-day mortality was statistically significant (p<0.0001), but weakly correlated (r²=0.06). The median (IQR) pairwise relative difference in hospital O/E ratios comparing the alternative analysis with the original analysis was +3.7% (-2.5%, +6.7%), with 1908/2571 (74.2%) of hospitals having relative differences within ±10%.

CONCLUSIONS

For non-COVID patient outcomes such as mortality, evidence-based inclusion of pandemic-era data is methodologically plausible and must be explored rather than exclusion of months or years of relevant patient outcomes data.

Off-Hours Intensive Care Unit Transfer Is Associated With Increased Mortality and Failure to Rescue

BACKGROUND

Cardiac postoperative intensive care unit (ICU) beds are a limited resource, and when a patient no longer requires this level of care they are quickly transferred out. We hypothesized that complications and ICU readmission increased when transfer occurred during off-hours compared with regular work hours.

METHODS

From 2010 to 2021, patients who underwent a Society of Thoracic Surgeons index operation at a single center were assigned a group based on their ICU transfer time, defined as when they physically arrived on the acute care floor. Patients were stratified into off-hours vs regular hours by their transfer time. Off-hours was defined as 9 pm to 5 am. Risk-adjusted multivariable logistic regression analyzed the association of ICU readmission, postoperative complications, operative mortality, and failure to rescue by group.

RESULTS

The cohort included 5951 patients (off-hours n = 292 [4.9%], regular-hours n = 5659 [95.1%]). Patients in the off-hours group had significantly greater odds of risk-adjusted ICU readmission (odds ratio 1.99, 95% CI 1.25-3.04, P < .002) and mortality (odds ratio 3.88, 95% CI 2.27-6.33, P < .001). In the major complications subgroup (Off-hours n = 55, Regular-hours n = 603), Off-hours transfer was associated with increased mortality (failure to rescue) (odds ratio 3.05, 95% CI 1.58-5.69, P = .001).

CONCLUSIONS

Off-hours ICU to floor transfer was associated with increased postoperative complications, ICU readmission, and mortality, suggesting that the timing of ICU transfer may impact outcomes. This elucidates targets for quality and process improvement for our center and others facing the same resource constraints.

The Safety of Inpatient Health Care

BACKGROUND

Adverse events during hospitalization are a major cause of patient harm, as documented in the 1991 Harvard Medical Practice Study. Patient safety has changed substantially in the decades since that study was conducted, and a more current assessment of harm during hospitalization is warranted.

METHODS

We conducted a retrospective cohort study to assess the frequency, preventability, and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during the 2018 calendar year. The occurrence of adverse events was assessed with the use of a trigger method (identification of information in a medical record that was previously shown to be associated with adverse events) and from review of medical records. Trained nurses reviewed records and identified admissions with possible adverse events that were then adjudicated by physicians, who confirmed the presence and characteristics of the adverse events.

RESULTS

In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%). There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care-associated infections (11.9%).

CONCLUSIONS

Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement. (Funded by the Controlled Risk Insurance Company and the Risk Management Foundation of the Harvard Medical Institutions.).

Early platelet level reduction as a prognostic factor in intensive care unit patients with severe aspiration pneumonia

Introduction: This study investigates risk factors underlying the prognosis of severe aspiration pneumonia (SAP) in intensive care unit (ICU) patients and attempts to provide early prognosis reference for clinical tasks. Methods: Patients diagnosed with SAP and admitted to the ICU of Jinshan Hospital, Fudan University, Shanghai, China, between January 2021 and December 2021 were recruited in this retrospective cohort study. Clinical data on a patient's general condition, underlying diseases, laboratory indicators, and 90-day outcomes (survival or death) were recorded. Results: Multivariate logistic regression analysis showed that a low platelet count was an independent risk factor affecting the prognosis of death (OR = 6.68, 95% CI:1.10-40.78, β = 1.90, P = 0.040). Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of variables; cut-off values were calculated and the area under the curve was 0.7782 [(95% CI:0.686-0.871), p < 0.001] for the prediction of death at 90 days in all patients. The Kaplan-Meier curve used for survival analysis showed that, compared with the normal platelet group, the overall survival rate of patients with low platelet levels was significantly lower, and the difference was statistically significant [HR = 2.11, (95% CI:1.47-3.03), p = 0.0001, z = 4.05, X ² = 14.89]. Cox regression analysis, used to further verify the influence of prognostic risk factors, showed that a concurrent low platelet count was the most important independent risk factor affecting the prognosis of SAP (HR = 2.12 [95% CI:1.12-3.99], X² = 50.95, p = 0.021). Conclusion: These findings demonstrate an association between SAP mortality and platelet levels on admission. Thus, platelet level at admission may be used as a readily available marker for assessing the prognosis of patients with SAP.

Development, dissemination and evaluation of a smartphone-based app for pressure ulcer/injury prevention and treatment for use at the bedside

OBJECTIVE

After launching the 2019 International Pressure Ulcer/Injury Guideline, the National Pressure Injury Advisory Panel (NPIAP), the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) collaborated with Sensorydata Corp., US, to develop a guideline app (InterPIP App). The app was designed to: present evidence-based guideline recommendations; incorporate search capacities and functionality to facilitate easy access to clinical guidance; provide accessibility in multiple languages; and to be available worldwide at a reasonable price, including opportunities for free access in low-resource countries. This paper describes the development, dissemination and formative evaluation of a mobile app providing evidence-based recommendations for pressure injury prevention, assessment/classification, and treatment at the point of care.

METHOD

An evaluation tool was designed based on a framework developed by Nouri et al. and made available to all app subscribers.

RESULTS

The InterPIP App is currently available in 11 languages and had been downloaded 3616 times by February 2022 in 78 countries. A total of 62 individuals responded to the survey of end-users. In this formal evaluation of user experiences, the app was rated positively on criteria of: information/content; usability; design; functionality; ethics; and security/privacy (median=4 on a 1-5 Likert scale). Overall perceived value was ranked lower with a median of three. Users provided suggestions for ongoing app enhancement.

CONCLUSION

The InterPIP App offers a unique opportunity to bring evidence-based guidance to the point of care. Formal evaluation of end-user experiences identified opportunities for quality improvement, and informed plans for future development and evaluation.

Participación de enfermería en la vigilancia y prevención de la resistencia antimicrobiana

Highlights: El control de la resistencia antimicrobiana es uno de los mayores problemas que el hospital moderno enfrenta. Las estimativas de la Organización Mundial de la Salud (OMS) para el año 2020 fueron de 700.000 muertes/año atribuidas a las infecciones por gérmenes resistentes y podrán alcanzar la marca de 10 millones de muertes/año en 2050. El desarrollo de nuevos antimicrobianos es complejo y una aproximación multidisciplinaria es fundamental para el control de la infección hospitalaria, en la cual la Enfermaría es clave. La infección nosocomial tiene sus orígenes en el propio nacimiento de los hospitales. Sin embargo, antes del desarrollo de los antibióticos, los hospitales eran instituciones para los pobres necesitados de cuidado, con una elevada tasa de mortalidad, causada no solamente por las enfermedades de base para las cuales no había tratamiento, sino incluso por las condiciones que propiciaban la infección nosocomial. La Guerra de la Crimea en 1854 fue la primera cubierta por la prensa, que destacaron las malas condiciones en el cuidado de los soldados heridos en combate, con tasas de mortalidad alrededor del 42%. La presión popular inglesa incentivó a que Florence Nightingale (1820-1910) se desplazase hasta Crimea y las medidas sanitarias implementadas derrumbaron la tasa de mortalidad hasta el 2% rápidamente. Mientras aún no se conocía la Teoría de los Gérmenes, es posible afirmar que el éxito ocurrió a causa del control de la infección en las heridas. Esos esfuerzos garantizaron a Florence Nightingale la notoriedad para que le encargasen el perfeccionamiento de las condiciones sanitarias hospitalarias cuando regresó a Inglaterra, fortaleciendo la asepsia (la limpieza seguida por la esterilización de los equipos para procedimientos) y la antisepsia (el uso de substancias esterilizantes). Uno de sus cambios fue justamente el desarrollo de la Enfermería como profesión, que ya nace asociada al control de las infecciones. La transformación del hospital se completó con el descubrimiento de los antibióticos en la década de 1940, el nacimiento de la Anestesia y los cambios sociales de las ciudades. Nacía el hospital moderno, capacitado para realizar procedimientos quirúrgicos y tratamientos que lo convirtieron en el centro de la Salud actual, hecho que se incrementó después de los reportes de Flexner acerca de las condiciones de enseñanza en las facultades de medicina en los EEUU. Los antibióticos impactaron de modo tan exitoso las tasas de infección en los principios de su utilización, que el énfasis en las otras medidas de prevención disminuyó. Además, la incidencia de resistencia a los antibióticos fue detectada tempranamente, casi al mismo tiempo que su introducción. En conjunto, esos dos puntos añadidos al incremento de procedimientos invasivos y al uso indiscriminado en otras áreas fuera de la Salud, como la ganadería, contribuyeron para que la resistencia a los antibióticos se convirtiese en la calamidad que vivimos actualmente. Mientras se sigan buscando nuevos antibióticos, mucho de la investigación es dedicada a la búsqueda de otras soluciones como las vacunas, inmunoterápicos, nanobios, terapia fágica, células madre y moléculas de adhesión. Sin embargo, aunque mucho se haya descubierto, aún no estamos preparados para aplicarlos a la clínica diaria. Como citar este artículo: Pazin-Filho Antonio. Participación de enfermería en la vigilancia y prevención de la resistencia antimicrobiana. Revista Cuidarte. 2022;13(3):e2980. http://dx.doi.org/10.15649/cuidarte.2980