Transforming ORs into ICUs Peters, Alexander W; Chawla, Kashmira S; Turnbull, Zachary A
New England journal of medicine/The New England journal of medicine,
05/2020, Letnik:
382, Številka:
19
Journal Article
Abstract
Objective
The purpose of this review was to identify quality indicators described in the literature that may be used as quality measures in hospital physical therapy units.
Methods
The ...following sources were searched for quality indicators or articles: Web of Science, MEDLINE, IBECS, Latin American and Caribbean Health Sciences Literature, Cumulative Index of Nursing and Allied Health, Academic Search Complete, SportDiscus, SciELO, PsychINFO, Consejo Superior de Investigaciones Cientificas, and Scopus databases; the Agency for Healthcare Research and Quality, National Health System Indicator Portal, Joint Commission on Accreditation of Healthcare Organizations, and Organisation for Economic Co-operation and Development websites; and the National Quality Forum’s measures inventory tool. Search terms included “quality indicator,” “quality measure,” “physiotherapy,” and “physical therapy.” Inclusion criteria were articles written in English, Spanish, French, or Portuguese aimed at measuring the quality of care in hospital physical therapy units. Evidence-based indicators with an explicit formula were extracted by 2 independent reviewers and then classified using the structure-process-outcome model, quality domain, and categories defined by a consensus method.
Results
Of the 176 articles identified, only 19 met the criteria. From these articles and from the indicator repository searches, 178 clinical care indicators were included in the qualitative synthesis and presented in this paper. Process and outcome measures were prevalent, and 5 out of the 6 quality domains were represented. No efficiency measures were identified. Moreover, structure indicators, equity and accessibility indicators, and indicators in the cardiovascular and circulatory, mental health, pediatrics, and intensive care categories were underrepresented.
Conclusions
A broad selection of quality indicators was identified from international resources, which can be used to measure the quality of physical therapy care in hospital units.
Impact
This review identified 178 quality of care indicators that can be used in clinical practice monitoring and quality improvement of hospital physical therapy units. The results highlight a lack of accessibility, equity, and efficiency measures for physical therapy units.
Accessible summary
What is known on the subject?
People with mental health problems have higher rates of physical health concerns and hospital admissions than those without mental health problems. ...These patients have poorer outcomes from surgery and have worse experiences of care when admitted for medical or surgical procedures.
What the paper adds to existing knowledge?
This paper looks to understand why care may be poorer for patients with mental health problems by speaking to staff providing care in these settings. We spoke to 30 general hospital staff about mental health on the wards and found that a lack of leadership and ownership for prioritising mental health led to people not seeing it as their job, and that it was somebody else's business to manage that side of care. We also found that the emotional effect of caring for people who had attempted suicide or had self‐harm injuries was difficult for staff, impacting on staff well‐being and leading them to distance themselves from providing care in those cases.
What are the implications for practice?
There is a need for staff to be supported from the top‐down, with management providing clear leadership around issues and pathways for mental health needs so they know the best way to provide care and encourage collaborative working. In addition, bottom‐up support is needed to help staff personally manage their own well‐being and mental health, including supervision and debriefing from mental health specialists to improve understanding from the patient’s perspective and to provide emotional support to manage difficulties.
Relevance Statement:
This paper places focus on the care of patients with mental health problems in
medical and surgical care settings highlighting the interplay between mental and physical health from a perspective that is less often explored. This paper provides insights into the multidisciplinary nature of nursing and the need for integrated care. This provides findings that build a picture of how mental health nursing specialism is needed beyond psychiatric wards and within medical and surgical settings.
Introduction
Evidence shows that patients with mental health problems have poorer physical health outcomes, increased mortality and experience poorer care during surgery and medical admissions. Issues related to lack of training, stigmatizing attitudes, fear or hopelessness may help understand these poor outcomes.
Aim
To explore the experiences of staff in providing care for people with mental health problems.
Method
A qualitative service evaluation approach was used. Participants working in an acute care hospital in inner‐city London were recruited across professions and job levels using a self‐selection sampling method. A total of 30 participants took part in semi‐structured interviews (n = 17) and two focus groups (n = 13), and data were thematically analysed. Relevant organizational documents and service use data were utilized to inform the evaluation.
Results
Key themes were organized across the macro, meso and micro levels to understand the levels of disconnection and silence around mental health in acute care. Themes include systemic factors surrounding the institutional culture, ward cultures and collaborative working, and individuals’ sense‐making of mental health and personal well‐being.
Implications for practice
These findings signpost the growing need for greater mental health nursing input on medical and surgical wards and within these teams to provide informed knowledge, support and supervision.
Objectives: We examine the dynamics of patient-sharing relations within an Italian regional community of 35 hospitals serving approximately 1,300,000 people. We test whether interorganizational ...relations provide individual patients access to higher quality providers of care. Research Design and Methods: We reconstruct the complete temporal sequence of the 3461 consecutive interhospital patient-sharing events observed between each pair of hospitals in the community during 2005–2008. We distinguish between transfers occurring between and within different medical specialties. We estimate newly derived models for relational event sequences that allow us to control for the most common forms of network-like dependencies that are known to characterize collaborative relations between hospitals. We use 45-day risk-adjusted readmission rate as a proxy for hospital quality. Results: After controls (eg, geographical distance, size, and the existence of prior collaborative relations), we find that patients flow from less to more capable hospitals. We show that this result holds for patient being shared both between as well as within medical specialties. Nonetheless there are strong and persistent other organizational and relational effects driving transfers. Conclusions: Decentralized patient-sharing decisions taken by the 35 hospitals give rise to a system of collaborative interorganizational arrangements that allow the patient to access hospitals delivering a higher quality of care. This result is relevant for health care policy because it suggests that collaborative relations between hospitals may produce desirable outcomes both for individual patients, and for regional health care systems.
Hospitals anchor much of US health care and receive a third of all medical spending, including various subsidies. Nevertheless, some become insolvent and exit the market. Research has documented ...subsequent access problems; however, less is understood about broader implications. We examine over 100 rural hospital closures spanning 2005–2017 to quantify the effects on the local economy. We find sharp and persistent reductions in employment, but these localize to health care occupations and are more impactful in areas experiencing complete closures. Aggregate consumer financial health and housing markets appear unaffected by the shuttering of a rural hospital.
Background
Hospitals are standard of care for acute illness, but hospitals can be unsafe, uncomfortable, and expensive. Providing substitutive hospital-level care in a patient’s home potentially ...reduces cost while maintaining or improving quality, safety, and patient experience, although evidence from randomized controlled trials in the US is lacking.
Objective
Determine if home hospital care reduces cost while maintaining quality, safety, and patient experience.
Design
Randomized controlled trial.
Participants
Adults admitted via the emergency department with any infection or exacerbation of heart failure, chronic obstructive pulmonary disease, or asthma.
Intervention
Home hospital care, including nurse and physician home visits, intravenous medications, continuous monitoring, video communication, and point-of-care testing.
Main Measures
Primary outcome was direct cost of the acute care episode. Secondary outcomes included utilization, 30-day cost, physical activity, and patient experience.
Key Results
Nine patients were randomized to home, 11 to usual care. Median direct cost of the acute care episode for home patients was 52% (IQR, 28%;
p
= 0.05) lower than for control patients. During the care episode, home patients had fewer laboratory orders (median per admission: 6 vs. 19;
p
< 0.01) and less often received consultations (0% vs. 27%;
p
= 0.04). Home patients were more physically active (median minutes, 209 vs. 78; p < 0.01), with a trend toward more sleep. No adverse events occurred in home patients, one occurred in control patients. Median direct cost for the acute care plus 30-day post-discharge period for home patients was 67% (IQR, 77%;
p
< 0.01) lower, with trends toward less use of home-care services (22% vs. 55%;
p
= 0.08) and fewer readmissions (11% vs. 36%;
p
= 0.32). Patient experience was similar in both groups.
Conclusions
The use of substitutive home-hospitalization compared to in-hospital usual care reduced cost and utilization and improved physical activity. No significant differences in quality, safety, and patient experience were noted, with more definitive results awaiting a larger trial.
Trial Registration
NCT02864420.
Job dissatisfaction among nurses contributes to costly labor disputes, turnover, and risk to patients. Examining survey data from 95,499 nurses, we found much higher job dissatisfaction and burnout ...among nurses who were directly caring for patients in hospitals and nursing homes than among nurses working in other jobs or settings, such as the pharmaceutical industry. Strikingly, nurses are particularly dissatisfied with their health benefits, which highlights the need for a benefits review to make nurses' benefits more comparable to those of other white-collar employees. Patient satisfaction levels are lower in hospitals with more nurses who are dissatisfied or burned out-a finding that signals problems with quality of care. Improving nurses' working conditions may improve both nurses' and patients' satisfaction as well as the quality of care.
Hospitals across the country are facing increases in hospital length of stay ranging from 2% to 14%. This results in patients who stay in hospital for long periods of time being three times more ...likely to die in hospital. Therefore, identifying factors that contribute to longer hospital stays enhances the ability to improve services and quality of patient care. However, there is limited documented evidence on factors associated with longer hospital stays among surgical inpatients in Ethiopia and the study area. This study aimed to assess the length of hospital stay and associated factors among adult surgical patients admitted to surgical wards in Amhara Regional State Comprehensive Specialized Hospitals, Ethiopia, 2023. An institutional-based cross-sectional study was conducted among 452 adult surgical patients from April 17 to May 22, 2023. Data were collected based on a pretested, structured, interviewer-administered questionnaire, medical record review, and direct measurement of BMI. Study participants were selected using a systematic random sampling technique. The collected data were cleaned, entered into EpiData version 4.6.0 and exported to STATA version 14 for analysis. Binary logistic regression analysis was used. Variables with a p value <0.05 in the multivariable logistic regression analysis were considered statistically significant. In the current study, the prevalence of prolonged hospital stay was 26.5% (95% CI: 22.7, 30.8). Patients referred from another public health facility (AOR = 2.65; 95% CI: 1.14, 6.14), hospital-acquired pneumonia (AOR = 3.64; 95% CI: 1.43, 9.23), duration of surgery greater than or equal to110 minutes (AOR = 2.54; 95% CI: 1.25, 5.16), being underweight (AOR = 5.21; 95%CI: 2.63, 10.33) and preoperative anemia (AOR = 3.22; 95% CI: 1.77, 5.86) were factors associated with prolonged hospital stays. This study found a significant proportion of prolonged hospital stays among patients admitted to surgical wards. Patients referred from another public health facility, preoperative anemia, underweight, duration of surgery greater than or equal to110 minutes, and hospital-acquired pneumonia were factors associated with prolonged hospital stay. Early screening and treatment of anemia and malnutrition before surgery can shorten the length of stay.
Little is known about cross-hospital differences in critical care units admission rates and related resource utilization and outcomes among patients hospitalized with acute coronary syndromes (ACS) ...or heart failure (HF).
Using a population-based sample of 16,078 patients admitted to a critical care unit with a primary diagnosis of ACS (n=14,610) or HF (n=1467) between April 1, 2003 and March 31, 2013 in Alberta, Canada, we stratified hospitals into high (>250), medium (200 to 250), or low (<200) volume based on their annual volume of all ACS and HF hospitalization. The percentage of hospitalized patients admitted to critical care units varied across low, medium, and high-volume hospitals for both ACS and HF as follows: 77.9%, 81.3%, and 76.3% (P<0.001), and 18.0%, 16.3%, and 13.0% (P<0.001), respectively. Compared to low-volume units, critical care patients with ACS and HF admitted to high-volume hospitals had shorter mean critical care stays (56.6 versus 95.6 hours, P<0.001), more critical care procedures (1.9 versus 1.2 per patient, <0.001), and higher resource-intensive weighting (2.8 versus 1.5, P<0.001). No differences in in-hospital mortality (5.5% versus 6.2%, adjusted odds ratio 0.93; 95% CI, 0.61 to 1.41) were observed between high- and low-volume hospitals; however, 30-day cardiovascular readmissions (4.6% versus 6.8%, odds ratio 0.77; 95% CI, 0.60 to 0.99) and cardiovascular emergency-room visits (6.6% versus 9.5%, odds ratio 0.80; 95% CI, 0.69 to 0.94) were lower in high-volume compared to low-volume hospitals. Outcomes stratified by ACS or HF admission diagnosis were similar.
Cardiac patients hospitalized in low-volume hospitals were more frequently admitted to critical care units and had longer hospitals stays despite lower resource-intensive weighting. These findings may provide opportunities to standardize critical care utilization for ACS and HF patients across high- and low-volume hospitals.
To assess whether a hospital's percentage of Black patients associates with variations in FY2017 overall/domain-specific Hospital Acquired-Condition Reduction Program (HACRP) scores and penalty ...receipt. Differences in socioeconomic status and receipt of disproportionate share hospital payments (a marker of safety-net status) were also assessed.
In FY2015, Medicare began reducing payments to hospitals with high adverse event rates. Concern has been expressed that HACRP penalties could adversely affect minority-serving hospitals, leading to reductions in resources and exasperation of disparities among hospitals with the greatest need.
100% Medicare FFS claims from 2013 to 2014 identified older adult inpatients, aged ≥65 years, presenting for 8 common surgical conditions. Multilevel mixed-effects regression determined differences in FY2017 HACRP scores/penalties among hospitals managing the highest decile of minority patients.
A total of 695,775 patients from 2923 hospitals were included. As a hospital's percentage of Black patients increased, climbing from 0.6% to 32.5% (lowest vs highest decile), average HACRP scores also increased, rising from 5.33 to 6.36 (higher values indicate worse scores). Increases in HACRP penalties did not follow the same stepwise increase, instead exhibiting a marked jump within the highest decile of racial minority-serving extent (45.7% vs 36.7%; OR 95% CI: 1.451.42-1.47). Similar patterns were observed for high disproportionate share hospital (OR 95% CI: 1.44 1.42-1.47; absolute difference: +7.4 percentage-points) and low socioeconomic status-serving (1.381.35-1.40; +7.3% percentage-points) hospitals. Restricted analyses accounting for the influence of teaching status and severity of patient case-mix both accentuated disparities in HACRP penalties when limiting hospitals to those at the highest known penalty-risk (more residents-to-beds, more severe), absolute differences +13.9, +20.5 percentage-points. Restriction to high operative volume, in contrast, reduced the penalty difference, +6.6 percentage-points.
Minority-serving hospitals are being disproportionately penalized by the HACRP. As the program continues to develop, efforts are needed to identify and protect patients in vulnerable institutions to ensure that disparities do not increase.
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