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Higgins JT, Charles RD, Fryman LJ. Original Research: Breaking Through the Bottleneck: Acuity Adaptability in Noncritical Trauma Care. Am J Nurs 2024; 124:24-34. [PMID: 38511707 DOI: 10.1097/01.naj.0001010176.21591.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
BACKGROUND Achieving efficient throughput of patients is a challenge faced by many hospital systems. Factors that can impede efficient throughput include increased ED use, high surgical volumes, lack of available beds, and the complexities of coordinating multiple patient transfers in response to changing care needs. Traditionally, many hospital inpatient units operate via a fixed acuity model, relying on multiple intrahospital transfers to move patients along the care continuum. In contrast, the acuity-adaptable model allows care to occur in the same room despite fluctuations in clinical condition, removing the need for transfer. This model has been shown to be a safe and cost-effective approach to improving throughput in populations with predictable courses of hospitalization, but has been minimally evaluated in other populations, such as patients hospitalized for traumatic injury. PURPOSE This quality improvement project aimed to evaluate implementation of an acuity-adaptable model on a 20-bed noncritical trauma unit. Specifically, we sought to examine and compare the pre- and postimplementation metrics for throughput efficiency, resource utilization, and nursing quality indicators; and to determine the model's impact on patient transfers for changes in level of care. METHODS This was a retrospective, comparative analysis of 1,371 noncritical trauma patients admitted to a level 1 trauma center before and after the implementation of an acuity-adaptable model. Outcomes of interest included throughput efficiency, resource utilization, and quality of nursing care. Inferential statistics were used to compare patients pre- and postimplementation, and logistic regression analyses were performed to determine the impact of the acuity-adaptable model on patient transfers. RESULTS Postimplementation, the median ED boarding time was reduced by 6.2 hours, patients more often remained in their assigned room following a change in level of care, more progressive care patient days occurred, fall and hospital-acquired pressure injury index rates decreased respectively by 0.9 and 0.3 occurrences per 1,000 patient days, and patients were more often discharged to home. Logistic regression analyses revealed that under the new model, patients were more than nine times more likely to remain in the same room for care after a change in acuity and 81.6% less likely to change rooms after a change in acuity. An increase of over $11,000 in average daily bed charges occurred postimplementation as a result of increased progressive care-level bed capacity. CONCLUSIONS The implementation of an acuity-adaptable model on a dedicated noncritical trauma unit improved throughput efficiency and resource utilization without sacrificing quality of care. As hospitals continue to face increasing demand for services as well as numerous barriers to meeting such demand, leaders remain challenged to find innovative ways to optimize operational efficiency and resource utilization while ensuring delivery of high-quality care. The findings of this study demonstrate the value of the acuity-adaptable model in achieving these goals in a noncritical trauma care population.
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Affiliation(s)
- Jacob T Higgins
- Jacob T. Higgins is an assistant professor at the University of Kentucky (UK) College of Nursing, Lexington, as well as a nurse scientist in trauma/surgical services at UK HealthCare, Lexington, where Rebecca D. Charles is a patient care manager and Lisa J. Fryman is the nursing operations director. Contact author: Jacob T. Higgins, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise
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Misset B, Aegerter P, Boulkedid R, Alberti C, Baillard C, Guidet B, Beaussier M. Construction of reference criteria to admit patients to intermediate care units in France: a Delphi survey of intensivists, anaesthesiologists and emergency medicine practitioners (first part of the UNISURC project). BMJ Open 2023; 13:e072836. [PMID: 37487677 PMCID: PMC10373678 DOI: 10.1136/bmjopen-2023-072836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/12/2023] [Indexed: 07/26/2023] Open
Abstract
OBJECTIVES No consensus criteria describe the medical eligibility of the patients to intermediate care units (IMCUs). In this first part of the UNISURC project, we aimed to develop criteria based on a consensus of physicians from the main specialties involved in IMCU admission decisions. DESIGN We selected criteria from IMCU literature, scoring systems and intensive care unit nursing workload. We submitted these criteria to a panel of experts in a Delphi survey. We used a two-round Delphi survey procedure to assess the validity and feasibility of each criterion. SETTING Medical practitioners in either public or private French institutions and proposed by the national scientific societies of anaesthesiology, emergency medicine and intensive care. The Delphi rounds took place in 2015-2016. OUTCOME MEASURES Validity and feasibility of the proposed criteria; uniformity of the judgement across the primary specialty and the hospital category of the responders. RESULTS The criteria submitted to vote were classified as one of: chronic factor (CF); acute factor (AF); specific pathway (SP); nursing activity (NA) and hospital environment (HE). Of 189 experts invited, 81 (41%) responded to the first round and 62 of them (76%) responded to the second round. A definite selection of 63 items was made, distributed across 6 CF, 18 AF, 31 SP, 3 NA and 5 HE. Validity and feasibility were influenced by the specialty or the public/private status of the institution of the responders for a few items. CONCLUSION We created a set of 63 consensus criteria with acceptable validity and feasibility to assess the medical eligibility of the patients to IMCUs. The second part of the UNISURC project will assess the distribution of each criterion in a prospective multicentre national cohort. TRIAL REGISTRATION NUMBER NCT02590172.
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Affiliation(s)
- Benoît Misset
- Department of Intensive Care, Groupe hospitalier Paris Saint-Joseph, Paris, France
- Department of Intensive Care, CHU de Liege - Hopital du Sart Tilman, Liege, Belgium
- Paris University, Paris, France
- University of Rouen Normandie, Rouen, France
- University of Liège, Liège, Belgium
| | - Philippe Aegerter
- Epidemiology and Public Health Service, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicetre, France
- University of Versailles Saint-Quentin, Versailles, France
- INSERM CESP U1018, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Rym Boulkedid
- Unité d'Epidémiologie Clinique, INSERM CIC 1426, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Paris, France
| | | | - Christophe Baillard
- Paris University, Paris, France
- Department of Anesthesia and Intensive Care, Assistance Publique-Hôpitaux de Paris, Hôpital Cochin, Paris, France
| | - Bertrand Guidet
- Department of Intensive Care, Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Paris, France
| | - Marc Beaussier
- Anesthesiology, Institut Mutualiste Montsouris, Paris, France
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Anani S, Goldhaber G, Brom A, Lasman N, Turpashvili N, Shenhav-saltzman G, Avaky C, Negru L, Agbaria M, Ariam S, Portal D, Wasserstrum Y, Segal G. Frailty and Sarcopenia Assessment upon HospitalAdmission to Internal Medicine Predicts Length ofHospital Stay and Re-Admission: A ProspectiveStudy of 980 Patients. J Clin Med 2020; 9:jcm9082659. [PMID: 32824484 PMCID: PMC7464238 DOI: 10.3390/jcm9082659] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/10/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
Background: Frailty and sarcopenia are associated with frequent hospitalizations and poor clinical outcomes in geriatric patients. Ascertaining this association for younger patients hospitalized in internal medicine departments could help better prognosticate patients in the realm of internal medicine. Methods: During a 1-year prospective study in an internal medicine department, we evaluated patients upon admission for sarcopenia and frailty. We used the FRAIL questionnaire, blood alanine-amino transferase (ALT) activity, and mid-arm muscle circumference (MAMC) measurements. Results: We recruited 980 consecutive patients upon hospital admission (median age 72 years (IQR 65–79); 56.8% males). According to the FRAIL questionnaire, 106 (10.8%) patients were robust, 368 (37.5%) pre-frail, and 506 (51.7%) were frail. The median ALT value was 19IU/L (IQR 14–28). The median MAMC value was 27.8 (IQR 25.7–30.2). Patients with low ALT activity level (<17IU/L) were frailer according to their FRAIL score (3 (IQR 2–4) vs. 2 (IQR 1–3); p < 0.001). Higher MAMC values were associated with higher ALT activity, both representing robustness. The rate of 30 days readmission in the whole cohort was 17.4%. Frail patients, according to the FRAIL score (FS), had a higher risk for 30 days readmission (for FS > 2, HR = 1.99; 95CI = 1.29–3.08; p = 0.002). Frail patients, according to low ALT activity, also had a significantly higher risk for 30 days readmission (HR = 2.22; 95CI = 1.26–3.91; p = 0.006). After excluding patients whose length of stay (LOS) was ≥10 days, 252 (27.5%) stayed in-hospital for 4 days or longer. Frail patients according to FS had a higher risk for LOS ≥4 days (for FS > 2, HR = 1.87; 95CI = 1.39–2.52; p < 0.001). Frail patients, according to low ALT activity, were also at higher risk for LOS ≥4 days (HR = 1.87; 95CI = 1.39–2.52; p < 0.001). MAMC values were not correlated with patients’ LOS or risk for re-admission. Conclusion: Frailty and sarcopenia upon admission to internal medicine departments are associated with longer hospitalization and increased risk for re-admission.
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Affiliation(s)
- Sapir Anani
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Gal Goldhaber
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Adi Brom
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Nir Lasman
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Natia Turpashvili
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Gilat Shenhav-saltzman
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Chen Avaky
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Liat Negru
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Muhamad Agbaria
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Sigalit Ariam
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Doron Portal
- Internal Medicine Department, Sackler faculty of medicine, Tel-Aviv University, Tel Aviv 6997801, Israel;
| | - Yishay Wasserstrum
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
| | - Gad Segal
- Internal Medicine Department “T”, Chaim Sheba Medical Center. Sackler faculty of medicine, Tel-Aviv University, Tel Aviv P.O. Box 39040, Tel Aviv 6997801, Israel; (S.A.); (G.G.); (A.B.); (N.L.); (N.T.); (G.S.-s.); (C.A.); (L.N.); (M.A.); (S.A.); (Y.W.)
- Correspondence: ; Tel.: +97-25-2666-9580
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