Effectiveness of a combined lifestyle intervention for older people in long-term care: A randomized controlled trial

PURPOSE

Lifestyle medicine interventions combining physical, nutritional, and psychological components have been found effective in general older population. However, evidence from the long-term care (LTC) is scarce.

METHODS

We conducted a pragmatic, two-arm, parallel group, superiority randomized controlled trial. Residents living in a LTC facility for one or more years, able to discern and to express informed consent, and requiring nursing care were considered eligible. The three-months intervention combined bi-weekly physical exercise groups, a healthy diet, and weekly psychological wellbeing sessions. Patients of the control group were subjected to routine care. At the end of the study participants were assessed using Barthel Index, Katz Activities of Daily Living, and Tinetti scales.

RESULTS

A total of 54 patients with a mean age of 84 years took part to the study. Physical exercise and psychological wellbeing sessions were mostly attended by all the subjects of the intervention group. Both groups took less calories than planned in the diets; in addition, the intervention group showed a lower energy and carbohydrates intake than the control group. At the end of the study, the intervention group showed a significant improvement in the total scores of all the scales.

CONCLUSIONS

This intervention was effective in improving functionality in older people living in the LTC setting. Results were achieved in a short timeframe, likely due to synergistic interactions between components. However, a further exploration of underlying factors is needed, to better understand the barriers that hampered a complete intervention delivery in this context.

How different countries respond to adverse events whilst patients' rights are protected

Patient safety is high on the policy agenda internationally. Learning from safety incidents is a core component in achieving the important goal of increasing patient safety. This study explores the legal frameworks in the countries to promote reporting, disclosure, and supporting healthcare professionals (HCPs) involved in safety incidents. A cross-sectional online survey was conducted to ascertain an overview of the legal frameworks at national level, as well as relevant policies. ERNST (The European Researchers' Network Working on Second Victims) group peer-reviewed data collected from countries was performed to validate information. Information from 27 countries was collected and analyzed, giving a response rate of 60%. A reporting system for patient safety incidents was in place in 85.2% (N = 23) of countries surveyed, though few (37%, N = 10) were focused on systems-learning. In about half of the countries (48.1%, N = 13) open disclosure depends on the initiative of HCPs. The tort liability system was common in most countries. No-fault compensation schemes and alternative forms of redress were less common. Support for HCPs involved in patient safety incidents was extremely limited, with just 11.1% (N = 3) of participating countries reporting that supports were available in all healthcare institutions. Despite progress in the patient safety movement worldwide, the findings suggest that there are considerable differences in the approach to the reporting and disclosure of patient safety incidents. Additionally, models of compensation vary limiting patients' access to redress. Finally, the results highlight the need for comprehensive support for HCPs involved in safety incidents.

Gait Monitoring and Analysis: A Mathematical Approach

Gait abnormalities are common in the elderly and individuals diagnosed with Parkinson's, often leading to reduced mobility and increased fall risk. Monitoring and assessing gait patterns in these populations play a crucial role in understanding disease progression, early detection of motor impairments, and developing personalized rehabilitation strategies. In particular, by identifying gait irregularities at an early stage, healthcare professionals can implement timely interventions and personalized therapeutic approaches, potentially delaying the onset of severe motor symptoms and improving overall patient outcomes. In this paper, we studied older adults affected by chronic diseases and/or Parkinson's disease by monitoring their gait due to wearable devices that can accurately detect a person's movements. In our study, about 50 people were involved in the trial (20 with Parkinson's disease and 30 people with chronic diseases) who have worn our device for at least 6 months. During the experimentation, each device collected 25 samples from the accelerometer sensor for each second. By analyzing those data, we propose a metric for the "gait quality" based on the measure of entropy obtained by applying the Fourier transform.

In search of an international multidimensional action plan for second victim support: a narrative review

BACKGROUND

Insights around second victims (SV) and patient safety has been growing over time. An overview of the available evidence is lacking. This review aims to describe (i) the impact a patient safety incident can have and (ii) how healthcare professionals can be supported in the aftermath of a patient safety incident.

METHODS

A literature search in Medline, EMBASE and CINAHL was performed between 1 and 2010 and 26 November 2020 with studies on SV as inclusion criteria. To be included in this review the studies must include healthcare professionals involved in the aftermath of a patient safety incident.

RESULTS

In total 104 studies were included. SVs can suffer from both psychosocial (negative and positive), professional and physical reactions. Support can be provided at five levels. The first level is prevention (on individual and organizational level) referring to measures taken before a patient safety incident happens. The other four levels focus on providing support in the aftermath of a patient safety incident, such as self-care of individuals and/or team, support by peers and triage, structured support by an expert in the field (professional support) and structured clinical support.

CONCLUSION

The impact of a patient safety incident on healthcare professionals is broad and diverse. Support programs should be organized at five levels, starting with preventive actions followed by self-care, support by peers, structured professional support and clinical support. This multilevel approach can now be translated in different countries, networks and organizations based on their own culture, support history, structure and legal context. Next to this, they should also include the stage of recovery in which the healthcare professional is located in.

The impact of emotional support on healthcare workers and students coping with COVID-19, and other SARS-CoV pandemics - a mixed-methods systematic review

BACKGROUND

Pandemics such as COVID-19 pose threats to the physical safety of healthcare workers and students. They can have traumatic experiences affecting their personal and professional life. Increasing rates of burnout, substance abuse, depression, and suicide among healthcare workers have already been identified, thus making mental health and psychological wellbeing of the healthcare workers a major issue. The aim of this systematic review is to synthesize the characteristics of emotional support programs and interventions targeted to healthcare workers and students since the onset of COVID-19 and other SARS-CoV pandemics and to describe the effectiveness and experiences of these programs.

METHOD

This was a mixed method systematic review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the review was registered on PROSPERO [CRD42021262837]. Searches were conducted using Medline, CINAHL, PsycINFO, Cochrane Library, and Scopus databases. The COVIDENCE systematic review management system was used for data selection and extraction by two independent reviewers. The JBI (Joanna Briggs Institute) critical appraisal tools were used to assess the quality of selected studies by two additional reviewers. Finally, data extraction and narrative analysis were conducted.

RESULTS

The search retrieved 3161 results including 1061 duplicates. After screening, a total of 19 articles were included in this review. Participants in studies were nurses, physicians, other hospital staff, and undergraduate medical students mostly working on the front-line with COVID-19 patients. Publications included RCTs (n = 4), quasi-experimental studies (n = 2), cross-sectional studies (n = 6), qualitative interview studies (n = 3), and systematic reviews (n = 4). Most (63.4%) of the interventions used online or digital solutions. Interventions mostly showed good effectiveness (support-seeking, positive emotions, reduction of distress symptoms etc.) and acceptance and were experienced as helpful, but there were some conflicting results.

CONCLUSION

Healthcare organizations have developed support strategies focusing on providing emotional support for these healthcare workers and students, but it is difficult to conclude whether one program offers distinct benefit compared to the others. More research is needed to evaluate the comparative effectiveness of emotional support interventions for health workers.

Prediction Models for Intrauterine Growth Restriction Using Artificial Intelligence and Machine Learning: A Systematic Review and Meta-Analysis

BACKGROUND

IntraUterine Growth Restriction (IUGR) is a global public health concern and has major implications for neonatal health. The early diagnosis of this condition is crucial for obtaining positive outcomes for the newborn. In recent years Artificial intelligence (AI) and machine learning (ML) techniques are being used to identify risk factors and provide early prediction of IUGR. We performed a systematic review (SR) and meta-analysis (MA) aimed to evaluate the use and performance of AI/ML models in detecting fetuses at risk of IUGR.

METHODS

We conducted a systematic review according to the PRISMA checklist. We searched for studies in all the principal medical databases (MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, and Cochrane). To assess the quality of the studies we used the JBI and CASP tools. We performed a meta-analysis of the diagnostic test accuracy, along with the calculation of the pooled principal measures.

RESULTS

We included 20 studies reporting the use of AI/ML models for the prediction of IUGR. Out of these, 10 studies were used for the quantitative meta-analysis. The most common input variable to predict IUGR was the fetal heart rate variability (n = 8, 40%), followed by the biochemical or biological markers (n = 5, 25%), DNA profiling data (n = 2, 10%), Doppler indices (n = 3, 15%), MRI data (n = 1, 5%), and physiological, clinical, or socioeconomic data (n = 1, 5%). Overall, we found that AI/ML techniques could be effective in predicting and identifying fetuses at risk for IUGR during pregnancy with the following pooled overall diagnostic performance: sensitivity = 0.84 (95% CI 0.80-0.88), specificity = 0.87 (95% CI 0.83-0.90), positive predictive value = 0.78 (95% CI 0.68-0.86), negative predictive value = 0.91 (95% CI 0.86-0.94) and diagnostic odds ratio = 30.97 (95% CI 19.34-49.59). In detail, the RF-SVM (Random Forest-Support Vector Machine) model (with 97% accuracy) showed the best results in predicting IUGR from FHR parameters derived from CTG.

CONCLUSIONS

our findings showed that AI/ML could be part of a more accurate and cost-effective screening method for IUGR and be of help in optimizing pregnancy outcomes. However, before the introduction into clinical daily practice, an appropriate algorithmic improvement and refinement is needed, and the importance of quality assessment and uniform diagnostic criteria should be further emphasized.

The determinants of expert opinion in the development of care pathways: insights from an exploratory cluster analysis

BACKGROUND

We performed a secondary exploratory cluster analysis on the data collected from the validation phase of the study leading to the development of the model care pathway (CP) for Myasthenia Gravis (MG), in which a panel of 85 international experts were asked some characteristics about themselves and their opinion about the model CP. Our aim was to identify which characteristics of the experts play a role in the genesis of their opinion.

METHODS

We extracted the questions probing an opinion and those describing a characteristic of the expert from the original questionnaire. We performed a multiple correspondence analysis (MCA) and a subsequent hierarchical clustering on principal component (HCPC) on the opinion variables, integrating the characteristic variables as supplementary (predicted).

RESULTS

After reducing the dimensionality of the questionnaire to three dimensions we noticed that the not-appropriateness judgement of the clinical activities may overlap with the completeness one. From the HCPC it seems that the working setting of the expert may play a crucial role in determining the opinion about the setting of the sub-processes of MG: shifting from a cluster where the experts do not work in sub-specialist settings to one where the experts are working in them, the opinion changes accordingly from a mono-disciplinary setting to a multi-disciplinary one. Another interesting result is that the experience in neuromuscular diseases (NMD) measured in years and the expert typology (whether general neurologist or NMD expert) seem not to contribute significantly to the opinions.

CONCLUSIONS

These findings might indicate a poor ability of the expert to discriminate what is not appropriate from what is not complete. Also, the opinion of the expert might be influenced by the working setting, but not by the experience in NMD (as measured in years).

Efficacy and Safety of Quadrivalent Conjugate Meningococcal Vaccines: A Systematic Review and Meta-Analysis

Over the last decades, different quadrivalent antimeningococcal vaccine formulations (diphteria toxoid conjugate, MenACWY-D; tetanus toxoid conjugate, MenACWY-TT; CRM₁₉₇ protein conjugate, MenACWY-CRM) have been developed. However, their availability varies, both in terms of authorized formulations and of inclusion in vaccination schedules. Furthermore, several countries include only the monovalent meningococcal C (MenC) vaccine in their immunization programmes. Finally, there is currently no updated systematic review that directly compares the MenACWY formulations. Thus, we summarized the evidence on efficacy and safety through four parallel, independent systematic literature reviews with meta-analysis which included randomized controlled trials comparing the abovementioned vaccines. A total of 16 studies have been included. In terms of efficacy, MenACWY-TT outperformed MenACWY-D and MenACWY-CRM for A, W-135, and Y serogroups, while no significant difference was found for serogroup C. Furthermore, we did not find significant differences in efficacy between MenC and MenACWY-TT. Regarding the safety, we were able to perform a quantitative analysis only between MenACWY-TT and MenC, finding no significant differences. Similarly, among the different MenACWY formulations no relevant differences were identified. These findings suggest that MenACWY-TT could be preferable to other formulations to improve current vaccination programs and to better develop future immunization policies.

Extracellular vesicles from human plasma for biomarkers discovery: Impact of anticoagulants and isolation techniques

Extracellular vesicles (EVs) isolated from plasma are increasingly recognized as promising circulating biomarkers for disease discovery and progression, as well as for therapeutic drug delivery. The scientific community underlined the necessity of standard operative procedures for the isolation and storage of the EVs to ensure robust results. The understanding of the impact of the pre-analytical variables is still limited and some considerations about plasma anticoagulants and isolation methods are necessary. Therefore, we performed a comparison study between EVs isolated by ultracentrifugation and by affinity substrate separation from plasma EDTA and sodium citrate. The EVs were characterized by Nano Tracking Analysis, Western Blot, cytofluorimetric analysis of surface markers, and lipidomic analysis. While anticoagulants did not significantly alter any of the analyzed parameters, the isolation methods influenced EVs size, purity, surface markers expression and lipidomic profile. Compared to ultracentrifugation, affinity substrate separation yielded bigger particles highly enriched in tetraspanins (CD9, CD63, CD81), fatty acids and glycerolipids, with a predominant LDL- and vLDL-like contamination. Herein, we highlighted that the isolation method should be carefully evaluated prior to study design and the need of standardized operative procedures for EVs isolation and application to biomarkers discovery.

Vaccination Strategies against Seasonal Influenza in Long Term Care Setting: Lessons from a Mathematical Modelling Study

BACKGROUND

seasonal influenza in nursing homes is a major public health concern, since in EU 43,000 long term care (LTC) facilities host an estimated 2.9 million elderly residents. Despite specific vaccination campaigns, many outbreaks in such institutions are occasionally reported. We explored the dynamics of seasonal influenza starting from real data collected from a nursing home located in Italy and a mathematical model. Our aim was to identify the best vaccination strategy to minimize cases (and subsequent complications) among the guests.

MATERIALS AND METHODS

after producing the contact matrices with surveys of both the health care workers (HCW) and the guests, we developed a mathematical model of the disease. The model consists of a classical SEIR part describing the spreading of the influenza in the general population and a stochastic agent based model that formalizes the dynamics of the disease inside the institution. After a model fit of a baseline scenario, we explored the impact of varying the HCW and guests parameters (vaccine uptake and vaccine efficacy) on the guest attack rates (AR) of the nursing home.

RESULTS

the aggregate AR of influenza like illness in the nursing home was 36.4% (ward1 = 56%, ward2 = 33.3%, ward3 = 31.7%, ward4 = 34.5%). The model fit to data returned a probability of infection of the causal contact of 0.3 and of the shift change contact of 0.2. We noticed no decreasing or increasing AR trend when varying the HCW vaccine uptake and efficacy parameters, whereas the increase in both guests vaccine efficacy and uptake parameter was accompanied by a slight decrease in AR of all the wards of the LTC facility.

CONCLUSION

from our findings we can conclude that a nursing home is still an environment at high risk of influenza transmission but the shift change room and the handover situation carry no higher relative risk. Therefore, additional preventive measures in this circumstance may be unnecessary. In a closed environment such as a LTC facility, the vaccination of guests, rather than HCWs, may still represent the cornerstone of an effective preventive strategy. Finally, we think that the extensive inclusion of real life data into mathematical models is promising and may represent a starting point for further applications of this methodology.

An Evidence and Consensus-Based Definition of Second Victim: A Strategic Topic in Healthcare Quality, Patient Safety, Person-Centeredness and Human Resource Management

The concept of second victims (SV) was introduced 20 years ago to draw attention to healthcare professionals involved in patient safety incidents. The objective of this paper is to advance the theoretical conceptualization and to develop a common definition. A literature search was performed in Medline, EMBASE and CINAHL (October 2010 to November 2020). The description of SV was extracted regarding three concepts: (1) involved persons, (2) content of action and (3) impact. Based on these concepts, a definition was proposed and discussed within the ERNST-COST consortium in 2021 and 2022. An international group of experts finalized the definition. In total, 83 publications were reviewed. Based on expert consensus, a second victim was defined as: "Any health care worker, directly or indirectly involved in an unanticipated adverse patient event, unintentional healthcare error, or patient injury and who becomes victimized in the sense that they are also negatively impacted". The proposed definition can be used to help to reduce the impact of incidents on both healthcare professionals and organizations, thereby indirectly improve healthcare quality, patient safety, person-centeredness and human resource management.

Prevalence of Antimicrobial Prescribing in Long-Term Care Facilities in a Local Health Authority of Northern Italy

BACKGROUND

Almost half of antimicrobial prescriptions in long-term care facilities (LTCFs) is inappropriate. This broad use might represent a strong contributor to antimicrobial resistance in these facilities. This study aimed to assess antibiotic use patterns and potential associated factors with a survey of LTCFs in the local health authority (LHA) of Novara.

METHODS

A cross-sectional study was conducted in 25 LTCFs in the LHA of Novara following the healthcare-associated infection in LCTFs (HALT) protocol. Information on residents and facilities was assessed. Antibiotic usage and potential determinants were also estimated.

RESULTS

In total, 1137 patients were screened for antibiotic usage. Mean age was 84.58 years (SD 9.77), and the majority were female (76.52%). Twenty-six were antibiotic users (prevalence rate 2.29%, 95%CI 1.50-3.33). Antimicrobials were mainly prescribed orally (84.62%). Potential risk factors for antibiotic prescription were catheter use (central and peripheral venous, p-values 0.0475 and 0.0034, respectively, and urinary, p-value 0.0008), immobilization (p-value < 0.0001), and sex (p-value 0.0486).

CONCLUSIONS

This study identified a low prevalence of antimicrobic consumption in LTCFs. Further surveillance studies are warranted to identify trends and changes in pathogen incidence and antimicrobial resistance and to inform public health authorities on the necessity of prudent use of antimicrobials in LCTFs.

A Comparative Study Measuring the Difference of Healthcare Workers Reactions Among Those Involved in a Patent Safety Incident and Healthcare Professionals While Working During COVID-19

OBJECTIVES

This study aimed to describe the differences and similarities in the reaction of the healthcare worker involved in a patient safety incident or during the COVID-19 pandemic. We also compared the differences in support they need.

METHODS

A secondary data analysis was performed based on 2 cross-sectional survey studies. One study evaluated the impact of patient safety incidents on healthcare professionals, and the other evaluated the impact of COVID-19. Measurements on mental health reactions and an evaluation of the experienced support system were compared between 883 doctors and 1970 nurses working in different hospitals.

RESULTS

Anxiety, difficulties concentrating, doubting knowledge and skills, feeling on their own, feeling unhappy and dejected, feeling uncertain in team, flashbacks, hypervigilance, sleep deprivation, stress and wanting to quit profession were statistically higher in the COVID-19-related groups. Second victims tend to speak about it with their own/close colleagues, whereas healthcare workers working during the COVID-19 pandemic talk more often to their partner and friends. Only a small number talked to a psychologist, but the number who needed to talk to a psychologist but did not is higher than the number who did talk to a psychologist or used professional support in all 5 groups.

CONCLUSIONS

The impact of the COVID-19 pandemic on the mental health of healthcare workers is larger than after being involved in a patient safety incident. There is the need for an adequate support system, and the mental health of all healthcare workers needs to be considered. Partners and friend play a more important role in the support experienced during the COVID-19 pandemic, and there is an important need for professional help.

Healthcare Students and Medical Residents as Second Victims: A Cross-Sectional Study

BACKGROUND

The term second victim (SV) describes healthcare professionals who remain traumatized after being involved in a patient safety incident (PSI). They can experience various emotional, psychological, and physical symptoms. The phenomenon is quite common; it has been estimated that half of hospital workers will be an SV at least once in their career. Because recent literature has reported high prevalence (>30%) among nursing students, we studied the phenomenon among the whole population of healthcare students.

METHODS

We conducted a cross-sectional study with an online questionnaire among nursing students, medical students, and resident physicians at the teaching hospital of the University of the Piemonte Orientale located in Novara, Italy. The study included 387 individuals: 128 nursing students, 174 medical students, and 85 residents.

RESULTS

We observed an overall PSI prevalence rate of 25.58% (lowest in medical students, 14.37%; highest in residents, 43.53%). Of these, 62.63% experienced symptoms typical of an SV. The most common temporary symptom was the feeling of working badly (51.52%), whereas the most common lasting symptom was hypervigilance (51.52%). Notably, none of the resident physicians involved in a PSI spoke to the patient or the patient's relatives.

CONCLUSION

Our findings highlighted the risk incurred by healthcare students of becoming an SV, with a possible significant impact on their future professional and personal lives. Therefore, we suggest that academic institutions should play a more proactive role in providing support to those involved in a PSI.

The prevention of falls in patients with Parkinson's disease with in-home monitoring using a wearable system: a pilot study protocol

BACKGROUND

Parkinson's disease (PD) is a chronic, progressive neurodegenerative condition that gradually worsens motor function and leads to postural instability and, eventually, falls. Several factors may influence the frequency of future falls, such as slowness, freezing of gait, loss of balance, and mobility problems, cognitive impairments, and the number of previous falls. The TED bracelet is an advanced technological wearable device able to predict falls.

AIMS

This principal aim is to investigate the feasibility of a full-scale research project that uses the TED bracelet to identify whether individuals with PD are at risk of falling.

METHODS

This study will involve a pilot prospective observational study design; the subjects will include 26 patients suffering from mild PD and 26 others with no PD and no gait problems. Data will be collected from the TED bracelet and then compared to a paper-based fall diary. The enrolled participants will have a scheduled outpatient evaluation to collect both clinical and instrumental data as well as biological samples.

DISCUSSION

This pilot study could then be implemented in a larger form to further evaluate the effectiveness of the TED device. Finally, it will help further develop gait monitoring systems for people with Parkinson's disease and other neurodegenerative diseases that can affect physical function and mobility, such as dementia and Alzheimer's.

CONCLUSIONS

Preventing falls and their complications could lead to major advancements in the quality of home care for patients with PD, which would significantly impact the quality of life of both these patients and their caregivers.

Work-Related Stress among a Cohort of Italian Long-Term Care Workers during the COVID-19 Pandemic: An Observational Study

Despite long-term care (LTC) workers having been identified as particularly subject to chronic stress, only a few studies evaluated the impact of the COVID-19 pandemic on stress in this population. As far as the authors know, no studies have investigated the relationship between work-related stress and chronic stress in the LTC setting. This retrospective observational study aimed to assess the level of chronic stress in LTC workers, to identify some possible predictors and vulnerability factors, and to measure the impact of the COVID-19 pandemic on work-related stress. The study was based on the information gathered from two different questionnaires administered before and one year after the beginning of the pandemic, to a cohort of Italian LTC workers. We found that chronic stress was associated with lower resilience to stress scores (57.42 vs. 60.66) and with higher work-related stress scores (30.48 vs. 20.83). Interestingly, the overall level of work-related stress did not differ between the two questionnaires (27.84 vs. 29.08). However, the main components of the questionnaires changed; fatigue and burnout symptoms became more relevant after the pandemic. Results of this study suggests deepening knowledge of the components of stress to develop and implement effective stress mitigation interventions.

Strategies for the Psychological Support of the Healthcare Workforce during the COVID-19 Pandemic: The ERNST Study

The COVID-19 pandemic led to the implementation of interventions to provide emotional and psychological support to healthcare workers in many countries. This ecological study aims to describe the strategies implemented in different countries to support healthcare professionals during the outbreak. Data were collected through an online survey about the measures to address the impact of the pandemic on the mental health of healthcare workers. Healthcare professionals, researchers, and academics were invited to respond to the survey. Fifty-six professionals from 35 countries contributed data to this study. Ten countries (28.6%) reported that they did not launch any national interventions. Both developed and developing countries launched similar initiatives. There was no relationship between the existence of any type of initiative in a country with the incidence, lethality, and mortality rates of the country due to COVID-19, and per capita income in 2020. The 24 h hotline for psychological support was the most frequent intervention. Tools for self-rescue by using apps or websites were extensively used, too. Other common interventions were the development of action protocols, availability of regular and updated information, implantation of distance learning systems, early detection of infection programs for professionals, economic reinforcements, hiring of staff reinforcement, and modification of leave and vacation dates.

Studies on the second victim phenomenon and other related topics in the pan-European environment: The experience of ERNST Consortium members

Background

Patient safety is a priority worldwide. When things go wrong in the provision of patient care, the healthcare professionals involved can be psychologically affected (second victims, SVs). Recently, different initiatives have been launched to address this phenomenon.

Aim

To identify through the ERNST Pan-European Consortium the current study lines in Europe on SVs and other topics related to how the lack of well-being of healthcare professionals can affect the quality of care.

Methods

A cross-sectional study was conducted based on an ad hoc online survey. All 82 academics and clinicians who had formalized their membership to the COST Action 19113 by September 2020 and represented 27 European and one neighboring country were invited to participate. The survey consisted of 19 questions that explored the participants’ scientific profile, their interests, and previous experiences in the SVs’ topic, and related areas of work in Europe.

Results

Seventy (85.4%) COST Action members responded to the survey. Thirty-seven (37.1%) had conducted SV studies in the past or were doing so at the moment of the survey. Seventeen participants were involved in implementing interventions to support SVs. Future lines of study included legal issues, open disclosure, training programs, and patient safety curricula.

Conclusions

Studies have been conducted in Europe on the magnitude of the SV phenomenon and the usefulness of some techniques to promote resilience among healthcare professionals. New gaps have been identified. The COST Action 19113 aims to foster European collaboration to reinforce the healthcare professionals’ well-being and thus contribute to patient safety.

Association Between Plasma Redox State/Mitochondria Function and a Flu-Like Syndrome/COVID-19 in the Elderly Admitted to a Long-Term Care Unit

Background/Aims: It is widely known that the imbalance between reactive oxygen species (ROS)/antioxidants and mitochondrial function could play a pivotal role in aging and in the physiopathology of viral infections. Here, we correlated the plasma oxidants/antioxidants levels of the elderly admitted to a long-term care (LTC) unit with clinical data in relation to flu-like disease/COVID-19. Moreover, in vitro we examined the effects of plasma on cell viability, ROS release and mitochondrial function. Materials and Methods: In 60 patients admitted to LTC unit for at least 1 year at moderate or high care load, demographic and clinical variables were taken. Blood samples were collected for the evaluations of oxidants/antioxidants, as thiobarbituric acid reactive substances, 8-hydroxy-2-deoxyguanosine, 8-isoprostanes, superoxide dismutase activity, glutathione, and vitamin D. In vitro, human umbilical vascular endothelial cells (HUVEC) were used to examine the effects of plasma on viability, ROS release and mitochondrial membrane potential. Results: The results obtained showed that the redox state of the elderly was quite balanced; mitochondrial membrane potential of HUVEC was reduced by about 20%, only. Also, the correlation analysis evidenced the association between mitochondrial function and the patients' outcomes. Interestingly, lower levels of mitochondrial membrane potential were found in the elderly who had symptoms suggestive of COVID-19 or with a confirmed diagnosis of COVID-19. Conclusion: The results of this study highlight the importance of mitochondrial function in the tendency to get a flu-like syndrome like COVID-19 in the elderly admitted to LTC unit. This information could have clinical implications for the management of old population.

Health-related lifestyles among Italian university students: A cross-sectional study

OBJECTIVES

to investigate lifestyle, health-related behaviours, and nutritional knowledge among a sample of Italian university students and to identify social determinants of - and barriers to - healthier lifestyles.

DESIGN

cross-sectional observational study.

SETTING AND PARTICIPANTS

students attending degree courses in health professions in a single university in Northern Italy (No. 1,495) were invited to participate in a structured web survey.

MAIN OUTCOME MEASURES

a comprehensive, validated questionnaire was used. Questions regarded nutritional knowledge and habits, smoking habit, physical activity, self-efficacy, and barriers to change. Anthropometric and sociodemographic information was collected. Descriptive statistics were used to summarize results. With single and multiple regression models, differences between subgroups and ranked predictors of students' attitudes towards healthy behaviours were analysed. Statistical significance was set at p<0.05.

RESULTS

a total of 554 subjects completed the survey (participation rate: 42%; completion rate: 88%). Students showed good nutritional knowledge (73%), but some deficiencies related to low fruit/high sweets consumption, and a lack of basic macronutrients information. Only 30% of the students led a very active lifestyle and physical inactivity was greatest among overweight/obese students. Sedentary lifestyle and unhealthy diet were mainly associated with modifiable risk factors, e.g., being overweight and smoking.

CONCLUSIONS

this study provides evidence that health profession students have good knowledge, but their health-related lifestyle is a concern, especially given the role of prescribers that they will play. Structured programmes need to be developed to address the modifiable risk factors associated with detrimental behaviours manifest already during the university years.

Development of a Model Care Pathway for Myasthenia Gravis

Myasthenia Gravis (MG) is a chronic, life-lasting condition that requires high coordination among different professionals and disciplines. The diagnosis of MG is often delayed and sometimes misdiagnosed. The goal of the care pathway (CP) is to add value to healthcare reducing unnecessary variations. The quality of the care received by patients affected with MG could benefit from the use of CP. We conducted a study aimed to define an inclusive, comprehensive, and multidisciplinary CP for the diagnosis, treatment, and care of MG. The development of the model CP, key interventions, and process indicators is based on the literature review and 85 international MG experts were involved in their evaluation, expressing a judgment of relevance through the Delphi study. 60 activities are included in the model CP and evaluated by the MG experts were valid and feasible. The 60 activities were then translated into 14 key interventions and 24 process indicators. We believe that the developed model CP will help for MG patients to have a timely diagnosis and high-quality, accessible, and cost-effective treatments and care. We also believe that the development of model CPs for other rare diseases is feasible and could aid in the integration of evidence-based knowledge into clinical practice.

Quality indicators in the treatment of geriatric hip fractures: literature review and expert consensus

PURPOSE

Even though hip fracture care pathways have evolved, mortality rates have not improved during the last 20 years. This finding together with the increased frailty of hip fracture patients turned hip fractures into a major public health concern. The corresponding development of an indicator labyrinth for hip fractures and the ongoing practice variance in Europe call for a list of benchmarking indicators that allow for quality improvement initiatives for the rapid recovery of fragile hip fractures (RR-FHF). The purpose of this study was to identify quality indicators that assess the quality of in-hospital care for rapid recovery of fragile hip fracture (RR-FHF).

METHODS

A literature search and guideline selection was conducted to identify recommendations for RR-FHF. Recommendations were categorized as potential structure, process, and outcome QIs and subdivided in-hospital care treatment topics. A list of structure and process recommendations that belongs to care treatment topics relevant for RR-FHF was used to facilitate extraction of recommendations during a 2-day consensus meeting with experts (n = 15) in hip fracture care across Europe. Participants were instructed to select 5 key recommendations relevant for RR-FHF for each part of the in-hospital care pathway: pre-, intra-, and postoperative care.

RESULTS

In total, 37 potential QIs for RR-FHF were selected based on a methodology using the combination of high levels of evidence and expert opinion. The set consists of 14 process, 13 structure, and 10 outcome indicators that cover the whole perioperative process of fragile hip fracture care.

CONCLUSION

We suggest the QIs for RR-FHF to be practice tested and adapted to allow for intra-hospital longitudinal follow-up of the quality of care and for inter-hospital and cross-country benchmarking and quality improvement initiatives.

Overview on the target population and methods used in care pathway projects: A narrative review

BACKGROUND

There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are.

METHODS

A narrative review of the literature published from 2015 to 2019 was performed.

RESULTS

We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported.

CONCLUSIONS

Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.

The History of Quality: From an Eye for an Eye, Through Love, and Towards a Multidimensional Concept for Patients, Kin, and Professionals

In ancient civilizations, poor quality was dealt with according to the principle of "an eye for an eye." In the modern era we have learned from industry what quality really is. Quality includes standards, protocols, system thinking, and an understanding of variation to ensure good outcomes. In the post-COVID era, quality is not all about predefined specifications but rather about relationships and even love. Quality can now be defined as multidimensional, including person-centered care for patients, kin, and providers. Care should be safe, efficient, effective, timely, equitable, and eco-friendly. High quality is only possible if we include core values of dignity and respect, holistic care, partnership, and kindness with compassion in our daily practice for every stakeholder at every managerial and policy level. PATIENT SUMMARY: Quality of care is a multidimensional concept in which person-centered care is central. The care a patient receives should be safe, efficient, effective, timely, equitable, and eco-friendly. Attention should be given to dignity, respect, kindness, and compassion. There should be a holistic approach that includes partnership with all stakeholders. The only acceptable level of quality a professional should provide is the level they would accept if their loved one were to be the next patient.

Non-pharmacological Approaches to Depressed Elderly With No or Mild Cognitive Impairment in Long-Term Care Facilities. A Systematic Review of the Literature

Introduction: Compared to old people who live at home, depressive symptoms are more prevalent in those who live in long-term care facilities (LTCFs). Different kinds of non-pharmacological treatment approaches in LTCFs have been studied, including behavioral and cognitive-behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy and life review/reminiscence. The aim of the current review was to systematically review non-pharmacological treatments used to treat depressed older adults with no or mild cognitive impairment (as described by a Mini Mental State Examination score > 20) living in LTCFs. Methods: A research was performed on PubMed and Scopus databases. Following the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) flowchart, studies selection was made. The quality of each Randomized Controlled Trial was scored using the Jadad scale, Quasi-Experimental Design studies and Non-Experimental studies were scored based on the Newcastle-Ottawa Scale (NOS) Results: The review included 56 full text articles; according to the type of intervention, studies were grouped in the following areas: horticulture/gardening (n = 3), pet therapy (n = 4), physical exercise (n = 9), psychoeducation/rehabilitation (n = 15), psychotherapy (n = 3), reminiscence and story sharing (n = 14), miscellaneous (n = 8). Discussion and Conclusion: Despite mixed or negative findings in some cases, most studies included in this systematic review reported that the non-pharmacological interventions assessed were effective in the management of depressed elderly in the LTCFs context. Regrettably, the limitations and heterogeneity of the studies described above hinder the possibility to generalize and replicate results.

Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: An exploratory cross-sectional study

BACKGROUND

A patient safety incident (PSI) is considered to have an impact on nursing students. Healthcare professionals often feel personally responsible for the unexpected patient outcome and feel as though they have failed their patient. In this way they may become second victims of the incident. Little is known about possible initiatives from hospitals or teaching institutions regarding the support of their students involved in a PSI.

AIM

The study aims to examine the prevalence, symptoms and support in the aftermath of a PSI in baccalaureate nursing students.

METHODS

A cross-sectional study in four teaching institutions for baccalaureate education across eleven campuses in Belgium. Students completed an online survey between February 2018 and March 2018.

RESULTS

About one in three (38.4%) students were involved in a PSI during their clinical experience. Of these, 84.7% experienced second victim symptoms. Most common symptoms were hypervigilance (65.7%), stress (42.5%) and doubting knowledge and skills (40.6%). Besides negative effects, the PSI also led to a more positive attitude. Students expect most support and room for open discussion from staff nurses (80.8%).

CONCLUSION

Nursing students may already become second victims during their education. PSIs have a major impact on their performance and personal life. Students have the right for a decent treatment, respect, understanding and compassion, support, transparency and the opportunity to contribute to improving procedures. Teaching institutions should therefore bear the responsibility to prepare students of the probability of the occurrence of PSIs during their clinical experience.

Peer support by interprofessional health care providers in aftermath of patient safety incidents: A cross-sectional study

AIM

To investigate the health care professionals' preferences pertaining to support in the aftermath of patient safety incidents and potential variation thereof depending on the degree of harm.

BACKGROUND

Peer support systems are available to support health care professionals in the aftermath of patient safety incidents. It is unclear which type of support is best offered by whom.

METHODS

A cross-sectional study in 32 Dutch hospitals.

RESULTS

In total, 2,362 nurses and 1,404 doctors indicated they were involved in patient safety incidents at any time during their career (86%). Less than 10% of health care providers had spoken with professional support, and less than 20% admitted a need to do so. They used different support. A higher degree of harm related to higher odds of desiring support. Respondents mainly wanted to understand what happened and how it can be prevented.

CONCLUSION

The desired support of health care professionals in the aftermath of patient safety incidents depends on the level of harm.

IMPLICATION FOR NURSING MANAGEMENT

Health care professionals seem to mostly rely on persons they are close with, and they mainly desire information related to the aftermath of patient safety incidents. This should be taken into account when support programmes are set up.

Prediction Models for Public Health Containment Measures on COVID-19 Using Artificial Intelligence and Machine Learning: A Systematic Review

Artificial Intelligence (AI) and Machine Learning (ML) have expanded their utilization in different fields of medicine. During the SARS-CoV-2 outbreak, AI and ML were also applied for the evaluation and/or implementation of public health interventions aimed to flatten the epidemiological curve. This systematic review aims to evaluate the effectiveness of the use of AI and ML when applied to public health interventions to contain the spread of SARS-CoV-2. Our findings showed that quarantine should be the best strategy for containing COVID-19. Nationwide lockdown also showed positive impact, whereas social distancing should be considered to be effective only in combination with other interventions including the closure of schools and commercial activities and the limitation of public transportation. Our findings also showed that all the interventions should be initiated early in the pandemic and continued for a sustained period. Despite the study limitation, we concluded that AI and ML could be of help for policy makers to define the strategies for containing the COVID-19 pandemic.

The Early Detection of Osteoporosis in a Cohort of Healthcare Workers: Is There Room for a Screening Program?

Workforce aging is becoming a significant public health problem due to the resulting emergence of age-related diseases, such as osteoporosis. The prevention and early detection of osteoporosis is important to avoid bone fractures and their socio-economic burden. The aim of this study is to evaluate the sustainability of a screening workplace program able to detect workers with osteoporosis. The screening process included a questionnaire-based risk assessment of 1050 healthcare workers followed by measurement of the bone mass density (BMD) with a pulse-echo ultrasound (PEUS) at the proximal tibia in the at-risk subjects. Workers with a BMD value ≤ 0.783 g/cm² were referred to a specialist visit ensuring a diagnosis and the consequent prescriptions. Any possible association between the outcome variable BMD ≤ 0.783 g/cm² and the risk factors was evaluated. The costs were calculated with a full costing method. We identified 60 pathological subjects. We observed increased risks for women, older ages, and menopause (p < 0.01). The yearly cost of our screening program estimated for this study was 8242 euros, and, considering the fragility bone fracture costs, we hypothesize a considerable economic savings, with a possible positive benefits/cost ratio of 2.07. We can say that the margin between the investment and results leads to a preference for this type of screening program. Osteoporosis is an occupational health problem, and a workplace screening program could be a cost-effective intervention.

A mixed methods multiple case study to evaluate the implementation of a care pathway for colorectal cancer surgery using extended normalization process theory

BACKGROUND

Specific factors that facilitate or prevent the implementation of enhanced recovery protocols for colorectal cancer surgery have been described in previous qualitative studies. This study aims to perform a concurrent qualitative and quantitative evaluation of factors associated with successful implementation of a care pathway (CP) for patients undergoing surgery for colorectal cancer.

METHODS

This comparative mixed methods multiple case study was based on a sample of 10 hospitals in 4 European countries that implemented a specific CP and performed pre- and post-implementation measurements. In-depth post-implementation interviews were conducted with healthcare professionals who were directly involved. Primary outcomes included protocol adherence and improvement rate. Secondary outcomes included length of stay (LOS) and self-rated protocol adherence. The hospitals were ranked based on these quantitative findings, and those with the highest and lowest scores were included in this study. Qualitative data were summarized on a per-case basis using extended Normalization Process Theory (eNPT) as theoretical framework. The data were then combined and analyzed using joint display methodology.

RESULTS

Data from 381 patients and 30 healthcare professionals were included. Mean protocol adherence rate increased from 56 to 62% and mean LOS decreased by 2.1 days. Both measures varied greatly between hospitals. The two highest-ranking hospitals and the three lowest-ranking hospitals were included as cases. Factors which could explain the differences in pre- and post-implementation performance included the degree to which the CP was integrated into daily practice, the level of experience and support for CP methodology provided to the improvement team, the intrinsic motivation of the team, shared goals and the degree of management support, alignment of CP development and hospital strategy, and participation of relevant disciplines, most notably, physicians.

CONCLUSIONS

Overall improvement was achieved but was highly variable among the 5 hospitals evaluated. Specific factors involved in the implementation process that may be contributing to these differences were conceptualized using eNPT. Multidisciplinary teams intending to implement a CP should invest in shared goals and teamwork and focus on integration of the CP into daily processes. Support from hospital management directed specifically at quality improvement including audit may likewise facilitate the implementation process.

TRIAL REGISTRATION

NCT02965794 . US National Library of Medicine, ClinicalTrials.gov . Registered 4 August 2014.

Qualitative Evaluation of the Implementation of a Care Pathway for Colorectal Cancer Surgery

Colorectal cancer care can be standardized by using enhanced recovery protocols. However, adherence to these protocols varies. Using Medical Research Council (MRC) guidance on process evaluations, we examined the experience of health care professionals in the implementation of a care pathway for colorectal surgery, by describing the intervention, context, implementation, mechanisms, and outcomes. Based on data from semi-structured interviews, we divided respondents into two groups: those who perceived positive outcomes of the implementation and those who perceived no effect. Respondents who perceived positive outcomes reported clinical leadership, use of feedback, positive effects of standardization, and teamwork as factors contributing to positive perceived outcomes. Respondents who perceived no effect reported a lack of organizational support, as well as challenging collaboration and standardization as mechanisms potentially explaining the poorer perception of outcomes. Multiple implementation activities were used, focusing on competence, behavior, or workplace. Our findings suggest that feedback is an important implementation activity.

Stress levels among workers: an observational study

Introduction

While some stress is a common part of everyday work for most people, higher or prolonged levels of stress might be harmful. Work-related stress is becoming a study subject because of its important implications: it is related to coronary heart disease and health in general and it also influences employee satisfaction and productivity. Because of this, workers should be aware of their stress levels in order to prevent disease and increase performance levels. Therefore, the aim of our study was to evaluate stress levels among employees.

Methods

We conducted an observational study in collaboration with Anteo, an onlus society based in Biella which employs more than 1000 workers. The first step of our study ran from December 2019 to February 2020, and included 300 workers. Informed consent was gathered trough structure chiefs prior to the intervention. We administered an online questionnaire based on the Kessler Psychological Distress Scale (K10) for screening than, subjects with a high perceived stress level were invited for a personal interview with our medical and psychological staff.

Results

The response rate was 31% with 94 questionnaires completed by the end of February 2020. 80% of respondents were women (75 out of 94). 17% of the employees presented a moderate to high level of stress (16 total, 72% women). Only 5% of workers presented a high level of stress (4 total, 50% women). All Patients presenting a high level of perceived stress went through medical and psychological evaluation, which confirmed the results in 88% cases (14 out of 16).

Conclusions

Our study evidenced that workers are often exposed to high levels of stress, which can influence health, everyday life as well as productivity. The introduction of stress management programs in companies could improve workers health and productivity having a positive impact on one's health, company productivity and society in general.

Key messages

The introduction of stress management programs might improve workers health and productivity. The introduction of stress management programs might have a positive impact on one’s health, company productivity and society in general.

Mangomoments - preconditions and impact on patients and families, healthcare professionals and organisations: a multi-method study in Flemish hospitals

OBJECTIVE

Understanding how small unexpected acts or gestures by healthcare professionals, known as Mangomoments, are translated into practice, what their preconditions are and what their impact is on patients and families, healthcare professionals and organisations.

DESIGN

A multi-method design was used based on four phases: (1) A (media)campaign to collect Mangomoment stories (n=1045), of which 94% (n=983) were defined as Mangomoments; (2) Semi-structured interviews (n=120); (3) Focus group interviews (n=3); and (4) A consensus meeting.

SETTING

Respondents from a hospital and primary care setting.

PARTICIPANTS

Patients, family, healthcare professionals, managers, researchers and a policymaker participated.

RESULTS

Mangomoments are mainly classified in the dimensions 'Respect for values, preferences and needs' and 'Emotional support'. Differences in importance of the dimensions were found between healthcare professionals, oncological patients and family and non-oncological patients and family. The results of the interviews, focus groups and consensus meeting were visualised by the Mangomoment model. It identifies several preconditions on the level of patients, healthcare professionals and leadership. For each of these preconditions a catalyst was identified to increase the prevalence of Mangomoments. In general, Mangomoments improved the patient and family experience and facilitated adherence to therapy and led to a positive perception on the healing process. Positive effects for professionals include personal accomplishment and anti-burnout, joy in work and a positive team atmosphere. This led to positive resonance by a relationship of trust between the patient and the healthcare professionals, feelings of tolerance during negative experiences and open communication and a safe climate. Overall, patients and healthcare workers concluded that Mangomoments led to loyalty to the healthcare organisation.

CONCLUSION

Mangomoments do not only have a positive impact on patient and family but also on the healthcare professional. Leadership should shape several preconditions and catalysts which can lead to positive resonance and loyalty of patients and professionals.

The impact of social determinants and lifestyles on dietary patterns during pregnancy: evidence from the "Mamma & Bambino" study

BACKGROUND

During pregnancy, maternal dietary patterns play a critical role in determining maternal and new-born health. Recent evidence highlighted the influence of either social determinants and lifestyles on the adherence to different dietary patterns.

STUDY DESIGN

In this cross-sectional analysis, we evaluated the association of social determinants and lifestyles with maternal dietary patterns in the "Mother & Child" cohort, a prospective study that enrols mother-child pairs from Catania, Italy.

METHODS

Dietary patterns were derived using Food Frequency Questionnaire and Principal Component Analysis. Logistic regression models were used to evaluate the association between socio-demographic factors (i.e., age, educational level and employment status), lifestyles (i.e., smoking status, body mass index, use of folic acid, multivitamin and multi-mineral supplements) and dietary patterns.

RESULTS

Overall, 332 women were enrolled and the following dietary patterns were derived: the "western" dietary pattern, characterized by high intake of red meat, fries, dipping sauces, salty snacks and alcoholic drinks; the second one, named "prudent", characterized by high intake of potatoes, raw and cooked vegetables, legumes, rice and soup. Multivariable analysis showed that young age, low educational level and smoking were positively associated with the adherence to the western dietary pattern. In contrast, pre-gestational body mass index was negatively associated with the adherence to the prudent dietary pattern.

CONCLUSION

Our results raise the need of strategies for promoting healthy dietary habits among women in their reproductive age, which might also help control their body weight before and during pregnancy. These strategies should be prioritized to young women of low educational level, who generally share other unhealthy behaviours.

Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care

OBJECTIVE

To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care.

DESIGN

A multicenter pre-post intervention study.

SETTING

Eleven acute hospitals.

PARTICIPANTS

Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation.

INTERVENTION

Care pathway covering in-hospital care from emergency services to rehabilitation.

MAIN OUTCOME MEASURES

Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork.

RESULTS

Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on.

CONCLUSIONS

Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.

Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre-post-test study

Adherence to evidence-based recommendations is variable and generally low. This is also followed in colorectal surgery, despite the availability of the ERAS^® protocol. The aim of the study was to evaluate the effect of implementing a care pathway for perioperative care in colorectal cancer surgery on outcomes and protocol adherence. So, we performed an international pre-test-post-test multicenter study, performed in ten hospitals in four European countries. The measures used included length of stay, morbidity and mortality, and documentation and adherence on intervention and patient level. Unadjusted pre-test-post-test differences were analyzed following an analysis adjusted for patient-mix variables. Importance-performance analysis was used to map the relationship between importance and performance of individual interventions. In total, 381 patients were included. Length of stay decreased from 12.6 to 10.7 days (p = 0.0230). Time to normal diet and walking also decreased significantly. Protocol adherence improved from 56 to 62% (p < 0.00001). Adherence to individual interventions remained highly variable. Importance-performance analysis showed 30 interventions were scored as important, of which 19 had an adherence < 70%, showing priorities for improvement. Across hospitals, change in protocol adherence ranged from a 13% decrease to a 22% increase. Implementing a care pathway for colorectal cancer surgery reduced length of stay, time to normal diet and walking. Documentation and protocol adherence improved after implementing the care pathway. However, not in all participating hospitals protocol adherence improved. Only in 25% of patients, protocol adherence of ≥ 70% was achieved, suggesting a large group is at risk for underuse. Importance-performance analysis showed which interventions are important, but have low adherence, prioritizing improvement efforts.

Impact of care pathway implementation on interprofessional teamwork: An international cluster randomized controlled trial

This study evaluates whether the implementation of an in-hospital care pathway (CP) improves interprofessional teamwork across countries and tests whether improved communications ("relational coordination") is the mechanism of action. A hospital-based cluster randomized controlled trial in Ireland, Belgium, Italy, and Portugal was performed. Fifty-six interprofessional teams caring for patients admitted with an exacerbation of chronic obstructive pulmonary disease or for patients with a proximal femur fracture were included and randomly assigned to an intervention group (31 teams and 567 team members), where a CP was implemented, and a control group (25 teams and 417 team members) representing usual care. Multilevel regression and mediation analysis were applied. First, although no significant effect was found on our primary outcome relational coordination, our CP significantly improved several team inputs, team processes (team climate for innovation) and team output (the level of organized care, level of competence) indicators. Second, our team process indicator of team climate for innovation partially mediated the association between CP implementation and team output indicator of better level of organized care. In conclusion, a CP sets in motion various mechanisms that improve some but not all aspects of interprofessional teamwork. Relational coordination does not appear to be the mechanism by which team outputs are enhanced.

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands

OBJECTIVES

To describe healthcare providers' symptoms evoked by patient safety incidents (PSIs), the duration of these symptoms and the association with the degree of patient harm caused by the incident.

DESIGN

Cross-sectional survey.

SETTING

32 Dutch hospitals that participate in the 'Peer Support Collaborative'.

PARTICIPANTS

4369 healthcare providers (1619 doctors and 2750 nurses) involved in a PSI at any time during their career.

INTERVENTIONS

All doctors and nurses working in direct patient care in the 32 participating hospitals were invited via email to participate in an online survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of symptoms, symptom duration and its relationship with the degree of patient harm.

RESULTS

In total 4369 respondents were involved in a PSI and completely filled in the questionnaire. Of these, 462 reported having been involved in a PSI with permanent harm or death during the last 6 months. This had a personal, professional impact as well as impact on effective teamwork requirements. The impact of a PSI increased when the degree of patient harm was more severe. The most common symptom was hypervigilance (53.0%). The three most common symptoms related to teamwork were having doubts about knowledge and skill (27.0%), feeling unable to provide quality care (15.6%) and feeling uncomfortable within the team (15.5%). PSI with permanent harm or death was related to eightfold higher likelihood of provider-related symptoms lasting for more than 1 month and ninefold lasting longer than 6 months compared with symptoms reported when the PSI caused no harm.

CONCLUSION

The impact of PSI remains an underestimated problem. The higher the degree of harm, the longer the symptoms last. Future studies should evaluate how these data can be integrated in evidence-based support systems.

Care pathways are complex interventions in complex systems: New European Pathway Association framework

Care pathway implementation is characterised by a dual complexity. A care pathway itself represents a complex intervention with multiple interacting and interdependent intervention components and outcomes. The organisations in which care pathways are being implemented represent complex systems that need to be directed at change through an in-depth understanding of their external and internal context in which they are functioning in. This study sets out a new evidence-based and pragmatic framework that unpacks how intervention mechanisms, intervention fidelity and care context are converge and represent interacting processes that determine success or failure of the care pathway. We recommend researchers looking to increase the effectiveness of care pathway implementation and accelerate improvement of desired outcomes to adopt this framework from inception to implementation of the intervention.

Defensive practices among non-medical health professionals: An overview of the scientific literature

INTRODUCTION

Defensive medicine (DM) is used when a doctor deviates from good practices to prevent complaints from patients or caregivers. This is a structured phenomenon that may not only affect the physician, but all healthcare personnel. The aim of this review was to determine whether DM is also performed by Non-Medical Health Professionals (NMHP), and the reasons, features, and effects of NMHP-DM.

MATERIALS AND METHODS

The review was conducted according to PRISMA guidelines, and specific inclusion criteria were used to search for relevant documents published up to 12 April 2018 in the main biomedical databases.

RESULTS

A total of 91 potentially relevant studies were identified. After the removal of duplicates, 72 studies were screened for eligibility, separately by two of the authors. Finally, 14 qualitative and quantitative studies were considered relevant for the purpose of the present review. These last studies were assessed for their methodological quality.

CONCLUSIONS

NMHP-DM is quite similar to DM practiced by doctors, and is mainly caused by fear of litigation. Midwives and nursing personnel practiced both active and passive DM, such as over-investigation, over-treatment, and avoidance of high-risk patients. NMHP-DM could increase risks for patient health, costs, risk of burnout for healthcare employees. Further studies are needed to better understand prevalence and features of NMHP-DM in all health professional fields, in order to apply appropriate preventive strategies to contrast DM among health care personnel.

[All-cause mortality from 1970 to 2013 in the municipality of Trino (Piedmont region, Italy), previously home to a nuclear plant]

Mortality studies conducted to date in the area of Trino (Piedmont Region, northern Italy) have been limited to the years from 2000 onwards. These studies have highlighted an increased frequency of brain tumors, leukemia, mesothelioma, peritoneal, prostate, larynx and total tumors in men in the municipality of Trino while for women the increased risk was limited to melanoma. The present study has allowed us to make more robust epidemiological considerations and to analyze the historical trend in mortality in the municipality (starting from 1970) correlating it also to the social and economic changes reported. We calculated the Standard Mortality Ratio (indirect standardization) by retrieving data on observed cases from the years 1980 to 2013 from the Italian national statistics bureau (ISTAT) and the municipal archives, and using regional specific mortality rates in the Piedmont region from 1980 to 2013 for expected cases. Results show a slowly decreasing trend for brain tumors in the last 10-15 years while for leukemia, we observe a sharp increase in the same time period, affecting both men and women indistinctly.

[Evaluating quality and safety in long term care: results from the experimentation of the Smart Star model]

The Smart Star model is a rating system to evaluate the quality of care in nursing homes for the elderly; it uses a five star rating score. We tested the model in a sample of 16 nursing homes in Italy. The Smart Star model showed to be effective in the multidimensional evaluation of the performance of nursing homes. One of the major strengths of the model consisted in its flexibility of application, that suggested its possible adaptation for different areas of healthcare.

Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction

OBJECTIVES

To study the care pathway effect on the percentage of patients with ST-elevation myocardial infarction -(STEMI) receiving timely coronary reperfusion and the percentage of STEMI patients receiving optimal secondary prevention.

METHODS

A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement. One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion. Adjusted (hospital random intercepts and controls for transfer and out-of-office admission) differences in composite outcomes were analyzed by a multilevel logistic regression.

RESULTS

Significant improvements in intervals between the first medical contact (FMC) to percutaneous coronary intervention (PCI) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits. Six out of nine outcomes were significantly poorer in the case of transfer. The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours.

CONCLUSIONS

After care pathway implementation, composite outcomes improved for in-hospital STEMI care. Collaborative efforts exploited heterogeneity in performance between hospitals. Iterative and incremental care pathway implementation maximized performance improvement.

Minimal impact of a care pathway for geriatric hip fracture patients

BACKGROUND

Adherence to guidelines for patients with proximal femur fracture is suboptimal.

OBJECTIVE

To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.

DESIGN

The European Quality of Care Pathways study is a cluster randomized controlled trial.

SETTING

26 hospitals in Belgium, Italy and Portugal.

SUBJECTS

Older adults with a proximal femur fracture (n = 514 patients) were included.

METHODS

Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.

RESULTS

In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.

DISCUSSION

Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00962910.

Prevalence and use of clinical pathways in 23 countries – an international survey by the European Pathway Association

Objectives

To give an overview on the use and prevalence of clinical pathways.

Design

Cross-sectional descriptive study.

Study participants

European Pathway Association (E-P-A) contact persons in 23 countries.

Results

Clinical pathways, also known as critical pathways or integrated care pathways, have been used in health care for 20 years. Although clinical pathways are well established, little information exists on their use and dissemination around the world. The E-P-A has performed their first international survey on the use and dissemination of clinical pathways in 23 countries. At present, pathways are used with a minority of patients, mainly in acute hospital trusts. Our survey showed that clinical pathways were predominantly viewed as a multidisciplinary tool to improve the quality and efficiency of evidence-based care. Pathways were also used as a communication tool between professionals to manage and standardize outcome-oriented care.

Conclusions

There is a future for the use of clinical pathways, but there is a need for international benchmarking and knowledge sharing with regard to their development, implementation and evaluation.

Teamwork and Adherence to Recommendations Explain the Effect of a Care Pathway on Reduced 30-day Readmission for Patients with a COPD Exacerbation

This study aimed to increase our understanding of processes that underlie the effect of care pathway implementation on reduced 30-day readmission rate. Adherence to evidence-based recommendations, teamwork and burnout have previously been identified as potential mechanisms in this association. We conducted a secondary data analysis of 257 patients admitted with chronic obstructive pulmonary disease exacerbation and 284 team members caring for these patients in 19 Belgian, Italian and Portuguese hospitals. Clinical measures included 30-day readmission and adherence to a specific set of five care activities. Teamwork measures included team climate for innovation, level of organized care and burnout (emotional exhaustion, level of competence and mental detachment). Care pathway implementation was significantly associated with better adherence and reduced 30-day readmission. Better adherence and higher level of competence were also related to reduced 30-day readmission. Only better adherence fully mediated the association between care pathway implementation and reduced 30-day readmission. Better team climate for innovation and level of organized care, although both improved after care pathway implementation, did not show any explanatory mechanisms in the association between care pathway implementation and reduced 30-day readmission. Implementation of a care pathway had an impact on clinical and team indicators. To reduce 30-day readmission rates, in the development and implementation of a care pathway, hospitals should measure adherence to evidence-based recommendations during the whole process, as this can give information regarding the success of implementation.

Managing in-hospital quality improvement: An importance-performance analysis to set priorities for ST-elevation myocardial infarction care

BACKGROUND

A focus on specific priorities increases the success rate of quality improvement efforts for broad and complex-care processes. Importance-performance analysis presents a possible approach to set priorities around which to design and implement effective quality improvement initiatives. Persistent variation in hospital performance makes ST-elevation myocardial infarction care relevant to consider for importance-performance analysis.

AIMS

The purpose of this study was to identify quality improvement priorities in ST-elevation myocardial infarction care.

METHODS

Importance and performance levels of ST-elevation myocardial infarction key interventions were combined in an importance-performance analysis. Content validity indexes on 23 ST-elevation myocardial infarction key interventions of a multidisciplinary RAND Delphi Survey defined importance levels. Structured review of 300 patient records in 15 acute hospitals determined performance levels. The significance of between-hospital variation was determined by a Kruskal-Wallis test. A performance heat-map allowed for hospital-specific priority setting.

RESULTS

Seven key interventions were each rated as an overall improvement priority. Priority key interventions related to risk assessment, timely reperfusion by percutaneous coronary intervention and secondary prevention. Between-hospital performance varied significantly for the majority of key interventions. The type and number of priorities varied strongly across hospitals.

CONCLUSIONS

Guideline adherence in ST-elevation myocardial infarction care is low and improvement priorities vary between hospitals. Importance-performance analysis helps clinicians and management in demarcation of the nature, number and order of improvement priorities. By offering a tailored improvement focus, this methodology makes improvement efforts more specific and achievable.