The universal bed model for patient care improves outcome and lowers cost in cardiac surgery

Critical Care 1950 to 2022: Evolution of Medicine, Nursing, Technology, and Design

Critical care units-designed for concentrated and specialized care-came from multiple parallel advances in medical, surgical, and nursing techniques and training taking advantage of new therapeutic technologies. Regulatory requirements and government policy impacted design and practice. After WWII, medical practice and education promoted further specialization. Hospitals offered newer, more extreme, and specialized surgeries and anesthesia enabled more complex procedures. ICUs developed in the 1950s, providing a recovery room's level of observation and specialized nursing to serve the critically ill, whether medical or surgical.

Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review

Background

Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients.

Objectives

To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions.

Data sources

Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence.

Review methods

Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis.

Findings

A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehabilitation, implemented to improve recovery from either colorectal surgery or lower limb arthroplasty. Six other surgical categories and four other intervention types were identified. Meta-analysis found that enhanced recovery protocols were associated with 1.5 days’ reduction in hospital stay among patients undergoing colorectal surgery (Cohen’sd = –0.51, 95% confidence interval –0.78 to –0.24;p < 0.001) and with 5 days’ reduction among those undergoing upper abdominal surgery (Cohen’sd = –1.04, 95% confidence interval –1.55 to –0.53;p < 0.001). Evidence from the UK was not pooled (owing to mixed study designs), but it echoed findings from the international literature. Length of stay usually was reduced with intervention or was no different. Other clinical outcomes also improved or were no worse with intervention. Patient-reported outcomes were not frequently reported. Cost and cost-effectiveness evidence came from 15 highly heterogeneous studies and was less conclusive.

Limitations

Studies were usually of moderate or weak quality. Some intervention or treatment types were under-reported or absent. The reporting of variance data often precluded secondary analysis.

Conclusions

Enhanced recovery and prehabilitation interventions were associated with reduced hospital stay without detriment to other clinical outcomes, particularly for patients undergoing colorectal surgery, lower limb arthroplasty or upper abdominal surgery. The impacts on patient-reported outcomes, health-care costs or additional service use are not well known.

Future work

Further studies evaluating of the effectiveness of new enhanced recovery pathways are not required in colorectal surgery or lower limb arthroplasty. However, the applicability of these pathways to other procedures is uncertain. Future studies should evaluate the implementation of interventions to reduce service variation, in-hospital patient-reported outcomes, impacts on health and social care service use, and longer-term patient-reported outcomes.

Study registration

This study is registered as PROSPERO CRD42017080637.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Developing Evidence-Based Design Guidelines for Medical/Surgical Hospital Patient Rooms That Meet the Needs of Staff, Patients, and Visitors

OBJECTIVES

This research investigated medical/surgical (Med/Surg) patient room design to accommodate the needs of hospital staff, while at the same time accommodating the needs of patients and their visitors.

BACKGROUND

Designing hospital patient rooms that provide a comfortable healing experience for patients, while at the same time meeting the needs of the hospital staff, is a challenging process. Prior research has shown that many hospital patient room designs adversely affect the ability of hospital staff to perform their tasks effectively, efficiently, and safely.

METHOD

Twenty-seven design sessions were conducted in which 104 participants, representing 24 different occupations, worked in small mixed occupational groups to design an ideal single patient Med/Surg patient room to fit their collective needs using a full-scale mock-up. During analysis, the investigators reduced the resulting 27 room designs to 5 hybrid designs that were sequentially reviewed by patients and visitors and by staff to address design conflicts.

RESULTS

This design process identified 51 desirable room design features that were incorporated into 66 evidence-based design guidelines for the different areas within the Med/Surg patient room including the entry way (16 guidelines), the patient clinical area (22 guidelines), the bathroom (17 guidelines), the family area (8 guidelines), and storage areas for patients and their visitors (3 guidelines).

CONCLUSIONS

The guidelines developed through this study identified many opportunities for improving the design of hospital Med/Surg rooms to allow staff to be more effective, efficient, and safer, while at the same time addressing the design needs of patients and their visitors.

Patient and family description of receiving care in acuity adaptable care model

AIM

To explore patient and family perspectives of hospital care in an acuity adaptable care model implemented in an urban, public safety-net hospital.

BACKGROUND

Specialty care units result in reactionary bed management. Changes in acuity generate costly, disruptive, intra-hospital patient transfers, which negatively affect clinical outcomes while increasing nurse workload. The acuity adaptable care model is a universal bed model structured to support patients in one room while providing staff, equipment and other resources across varying levels of acuity.

METHOD

Qualitative descriptive methods were used to analyse the narratives of a purposive sample of patients and family members about receiving care in an acuity adaptable care delivery model.

RESULTS

Three content areas emerged from the narratives and were categorized as feeling safe, perceiving continuity of care and valuing family, which culminated in a sense of comfort and healing while in the hospital.

CONCLUSION

By bringing care services to the patient instead of taking the patient to the services, the acuity adaptable care model facilitated a perception of a healing environment for patients and family members.

IMPLICATIONS FOR NURSING MANAGEMENT

The acuity adaptable care model should be considered when hospital facilities are undergoing major renovation or replacement.

Direct stroke unit admission of intravenous tissue plasminogen activator: safety, clinical outcome, and hospital cost savings

BACKGROUND

In the USA, stable intravenous tissue plasminogen activator (IV tPA) patients have traditionally been cared for in an intensive care unit (ICU). We examined the safety of using an acuity-adaptable stroke unit (SU) to manage IV tPA patients.

METHODS

We conducted an observational study of consecutive patients admitted to our acuity-adaptable SU over the first 3 years of operation. Safety was assessed by symptomatic intracerebral hemorrhage (sICH) rates, systemic hemorrhage (SH) rates, tPA-related deaths, and transfers from SU to ICU; cost savings and length of stay (LOS) were determined.

RESULTS

We admitted 333 IV tPA patients, of which 302 were admitted directly to the SU. A total of 31 (10%) patients had concurrent systemic hemodynamic or pulmonary compromise warranting direct ICU admission. There were no differences in admission National Institutes of Health Stroke Scale scores between SU and ICU patients (9.0 versus 9.5, respectively). Overall sICH rate was 3.3% (n = 10) and SH rate was 2.9 (n = 9), with no difference between SU and ICU patients. No tPA-related deaths occurred, and no SU patients required transfer to the ICU. Estimated hospital cost savings were US$362,400 for 'avoided' ICU days, and hospital LOS decreased significantly (p = 0.001) from 9.8 ± 15.6 days (median 5) in year 1, to 5.2 ± 4.8 days (median 3) by year 3.

CONCLUSIONS

IV tPA patients may be safely cared for in a SU when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for monitoring may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Identification of the GPR55 antagonist binding site using a novel set of high-potency GPR55 selective ligands

GPR55 is a class A G protein-coupled receptor (GPCR) that has been implicated in inflammatory pain, neuropathic pain, metabolic disorder, bone development, and cancer. Initially deorphanized as a cannabinoid receptor, GPR55 has been shown to be activated by non-cannabinoid ligands such as l-α-lysophosphatidylinositol (LPI). While there is a growing body of evidence of physiological and pathophysiological roles for GPR55, the paucity of specific antagonists has limited its study. In collaboration with the Molecular Libraries Probe Production Centers Network initiative, we identified a series of GPR55 antagonists using a β-arrestin, high-throughput, high-content screen of ~300000 compounds. This screen yielded novel, GPR55 antagonist chemotypes with IC50 values in the range of 0.16-2.72 μM [Heynen-Genel, S., et al. (2010) Screening for Selective Ligands for GPR55: Antagonists (ML191, ML192, ML193) (Bookshelf ID NBK66153; PMID entry 22091481)]. Importantly, many of the GPR55 antagonists were completely selective, with no agonism or antagonism against GPR35, CB1, or CB2 up to 20 μM. Using a model of the GPR55 inactive state, we studied the binding of an antagonist series that emerged from this screen. These studies suggest that GPR55 antagonists possess a head region that occupies a horizontal binding pocket extending into the extracellular loop region, a central ligand portion that fits vertically in the receptor binding pocket and terminates with a pendant aromatic or heterocyclic ring that juts out. Both the region that extends extracellularly and the pendant ring are features associated with antagonism. Taken together, our results provide a set of design rules for the development of second-generation GPR55 selective antagonists.