COVID-19 is a multisystem illness that has considerable long-term physical, psychological, cognitive, social and vocational sequelae in survivors. Given the scale of this burden and lockdown measures ...in most countries, there is a need for an integrated rehabilitation pathway using a tele-medicine approach to screen and manage these sequelae in a systematic and efficient way.
A multidisciplinary team of professionals in the UK developed a comprehensive pragmatic telephone screening tool, the COVID-19 Yorkshire Rehabilitation Screen (C19-YRS), and an integrated rehabilitation pathway, which spans the acute hospital trust, community trust and primary care service within the National Health Service (NHS) service model.
The C19-YRS telephone screening tool, developed previously, was used to screen symptoms and grade their severity. Referral criteria thresholds were applied to the output of C19-YRS to inform the decision-making process in the rehabilitation pathway. A dedicated multidisciplinary COVID-19 rehabilitation team is the core troubleshooting forum for managing complex cases with needs spanning multiple domains of the health condition.
The authors recommend that health services dealing with the COVID-19 pandemic adopt a comprehensive telephone screening system and an integrated rehabilitation pathway to manage the large number of survivors in a timely and effective manner and to enable the provision of targeted interventions.
Multiple studies have shown that quality of care for dementia in primary care is poor, with physician adherence to dementia quality indicators (QIs) ranging from 18% to 42%. In response, the ...University of California at Los Angeles (UCLA) Health System created the UCLA Alzheimer's and Dementia Care (ADC) Program, a quality improvement program that uses a comanagement model with nurse practitioner dementia care managers (DCM) working with primary care physicians and community‐based organizations to provide comprehensive dementia care. The objective was to measure the quality of dementia care that nurse practitioner DCMs provide using the Assessing Care of Vulnerable Elders (ACOVE‐3) and Physician Consortium for Performance Improvement QIs. Participants included 797 community‐dwelling adults with dementia referred to the UCLA ADC program over a 2‐year period. UCLA is an urban academic medical center with primarily fee‐for‐service reimbursement. The percentage of recommended care received for 17 dementia QIs was measured. The primary outcome was aggregate quality of care for the UCLA ADC cohort, calculated as the total number of recommended care processes received divided by the total number of eligible quality indicators. Secondary outcomes included aggregate quality of care in three domains of dementia care: assessment and screening (7 QIs), treatment (6 QIs), and counseling (4 QIs). QIs were ed from DCM notes over a 3‐month period from date of initial assessment. Individuals were eligible for 9,895 QIs, of which 92% were passed. Overall pass rates of DCMs were similar (90–96%). All counseling and assessment QIs had pass rates greater than 80%, with most exceeding 90%. Wider variation in adherence was found among QIs addressing treatments for dementia, which patient‐specific criteria triggered, ranging from 27% for discontinuation of medications associated with mental status changes to 86% for discussion about acetylcholinesterase inhibitors. Comprehensive dementia care comanagement with a nurse practitioner can result in high quality of care for dementia, especially for assessment, screening, and counseling. The effect on treatment QIs is more variable but higher than previous reports of physician‐provided dementia care.
The coronavirus disease 2019 (COVID-19) pandemic has burdened health care resources and disrupted care of patients with cancer. Virtual care (VC) represents a potential solution. However, few ...quantitative data support its rapid implementation and positive associations with service capacity and quality.
To examine the outcomes of a cancer center-wide virtual care program in response to the COVID-19 pandemic.
This cohort study applied a hospitalwide agile service design to map gaps and develop a customized digital solution to enable at-scale VC across a publicly funded comprehensive cancer center. Data were collected from a high-volume cancer center in Ontario, Canada, from March 23 to May 22, 2020.
Outcome measures were care delivery volumes, quality of care, patient and practitioner experiences, and cost savings to patients.
The VC solution was developed and launched 12 days after the declaration of the COVID-19 pandemic. A total of 22 085 VC visits (mean, 514 visits per day) were conducted, comprising 68.4% (range, 18.8%-100%) of daily visits compared with 0.8% before launch (P < .001). Ambulatory clinic volumes recovered a month after deployment (3714-4091 patients per week), whereas chemotherapy and radiotherapy caseloads (1943-2461 patients per week) remained stable throughout. No changes in institutional or provincial quality-of-care indexes were observed. A total of 3791 surveys (3507 patients and 284 practitioners) were completed; 2207 patients (82%) and 92 practitioners (72%) indicated overall satisfaction with VC. The direct cost of this initiative was CAD$ 202 537, and displacement-related cost savings to patients totaled CAD$ 3 155 946.
These findings suggest that implementation of VC at scale at a high-volume cancer center may be feasible. An agile service design approach was able to preserve outpatient caseloads and maintain care quality, while rendering high patient and practitioner satisfaction. These findings may help guide the transformation of telemedicine in the post COVID-19 era.
Quality improvement initiatives demonstrate the contribution of reliable nursing care to gains in clinical and safety outcomes in neonatal intensive care units (NICUs); when core care is missed, ...outcomes can worsen.
To evaluate the association of NICU nurse workload with missed nursing care.
A prospective design was used to evaluate associations between shift-level workload of individual nurses and missed care for assigned infants from March 1, 2013, through January 31, 2014, at a 52-bed level IV NICU in a Midwestern academic medical center. A convenience sample of registered nurses who provided direct patient care and completed unit orientation were enrolled. Nurses reported care during each shift for individual infants whose clinical data were extracted from the electronic health record. Data were analyzed from January 1, 2015, through August 13, 2018.
Workload was assessed each shift with objective measures (infant-to-nurse staffing ratio and infant acuity scores) and a subjective measure (the National Aeronautics and Space Administration Task Load Index NASA-TLX).
Missed nursing care was measured by self-report of omission of 11 essential care practices. Cross-classified, multilevel logistic regression models were used to estimate associations of workload with missed care.
A total of 136 nurses provided reports of shift-level workload and missed nursing care for 418 infants during 332 shifts of 12 hours each. When workload variables were modeled independently, 7 of 12 models demonstrated a significant worsening association of increased infant-to-nurse ratio with odds of missed care (eg, nurses caring for ≥3 infants were 2.51 times more likely to report missing any care during the shift 95% credible interval, 1.81-3.47), and all 12 models demonstrated a significant worsening association of increased NASA-TLX subjective workload ratings with odds of missed care (eg, each 5-point increase in a nurse's NASA-TLX rating during a shift was associated with a 34% increase in the likelihood of missing a nursing assessment for his or her assigned infants during the same shift 95% credible interval, 1.30-1.39). When modeling all workload variables jointly, only 4 of 12 models demonstrated significant association of staffing ratios with odds of missed care, whereas the association with NASA-TLX ratings remained significant in all models. Few associations of acuity scores were observed across modeling strategies.
The workload of NICU nurses is significantly associated with missed nursing care, and subjective workload ratings are particularly important. Subjective workload represents an important aspect of nurse workload that remains largely unmeasured despite high potential for intervention.
Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and ...mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.
To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2013) and reference lists of retrieved studies.
All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.
All review authors evaluated methodological quality. Two review authors checked data extraction.
We included 13 trials involving 16,242 women. Women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.83, 95% confidence interval (CI) 0.76 to 0.90), episiotomy (average RR 0.84, 95% CI 0.76 to 0.92), and instrumental birth (average RR 0.88, 95% CI 0.81 to 0.96), and were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.16, 95% CI 1.04 to 1.31), spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.08), attendance at birth by a known midwife (average RR 7.83, 95% CI 4.15 to 14.80), and a longer mean length of labour (hours) (mean difference (hours) 0.50, 95% CI 0.27 to 0.74). There were no differences between groups for caesarean births (average RR 0.93, 95% CI 0.84 to 1.02).Women who were randomised to receive midwife-led continuity models of care were less likely to experience preterm birth (average RR 0.77, 95% CI 0.62 to 0.94) and fetal loss before 24 weeks' gestation (average RR 0.81, 95% CI 0.66 to 0.99), although there were no differences in fetal loss/neonatal death of at least 24 weeks (average RR 1.00, 95% CI 0.67 to 1.51) or in overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 1.00).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in the midwifery-led continuity care model. Similarly there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.
Most women should be offered midwife-led continuity models of care and women should be encouraged to ask for this option although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.
Abstract China successfully achieved universal health insurance coverage in 2011, representing the largest expansion of insurance coverage in human history. While the achievement is widely ...recognized, it is still largely unexplored why China was able to attain it within a short period. This study aims to fill the gap. Through a systematic political and socio-economic analysis, it identifies seven major drivers for China's success, including (1) the SARS outbreak as a wake-up call, (2) strong public support for government intervention in health care, (3) renewed political commitment from top leaders, (4) heavy government subsidies, (5) fiscal capacity backed by China's economic power, (6) financial and political responsibilities delegated to local governments and (7) programmatic implementation strategy. Three of the factors seem to be unique to China (i.e., the SARS outbreak, the delegation, and the programmatic strategy.) while the other factors are commonly found in other countries’ insurance expansion experiences. This study also discusses challenges and recommendations for China's health financing, such as reducing financial risk as an immediate task, equalizing benefit across insurance programs as a long-term goal, improving quality by tying provider payment to performance, and controlling costs through coordinated reform initiatives. Finally, it draws lessons for other developing countries.
As a result of the coronavirus disease 2019 pandemic, many Pediatric Surgery Fellowship programs were forced to convert their normal in-person interviews into virtual interviews. This study sought to ...determine the perceived value of virtual interviews for Pediatric Surgery Fellowship.
An anonymous survey was distributed to the applicants and faculty at a university-affiliated, free-standing children's hospital with a Pediatric Surgery fellowship program that conducted one of three interview days using a virtual format.
All applicants who responded to the survey had at least one interview that was converted to a virtual interview. Faculty (75%) and applicants (87.5%) preferred in-person interviews over virtual interviews; most applicants (57%) did not feel they got to know the program as well with the virtual format. Applicants and faculty felt that virtual interviews could potentially be used as a screening tool in the future (7/10 Likert) but did not recommend they be used as a complete replacement for in-person interviews (3.5-5/10 Likert). Applicants were more likely than faculty to report that interview type influenced their final rank list (5 versus 3/10 Likert).
Faculty and applicants preferred in-person interviews and did not recommend that virtual interviews replace in-person interviews. As the coronavirus disease 2019 pandemic continues, more virtual interviews will be necessary, and innovations may be necessary to ensure an optimal interview process.
Survey.
N/A.
Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and ...mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care.
To compare midwife-led continuity models of care with other models of care for childbearing women and their infants.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.
All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth.
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.
We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e., regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and overall fetal loss and neonatal death (fetal loss was assessed by gestation using 24 weeks as the cut-off for viability in many countries) using the GRADE methodology: All primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = 8; high quality) and less overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = 4), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss/neonatal death before 24 weeks (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = 7), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = 3) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = 7). There were no differences between groups for fetal loss or neonatal death more than or equal to 24 weeks, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models.
This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and overall fetal loss/neonatal death associated with midwife-led continuity models of care.
Aim
To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living ...in long‐term care residential settings.
Background
Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted.
Design
Quantitative systematic review.
Data sources
Twelve electronic databases were searched (1966–2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group.
Review methods
Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria.
Results
Four prospective studies conducted in the USA and reported in 15 papers were included. Long‐term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services.
Conclusion
Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long‐term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.
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