Our regional trauma organization, which comprises 7 trauma centers, 30 acute care hospitals and free-standing emergency departments, and 42 emergency medical services agencies, conducted possibly the ...largest mass-casualty drill to date, totaling 445 victims at 3 sites involving 11 hospitals and 25 agencies and organizations.
The drill was preceded by a tabletop exercise 4 months beforehand called Operation Continued Care Full-Scale Exercise, which consisted of simulated terrorist events at 3 sites to wound 445 moulaged patients. Four law enforcement and 5 fire and emergency medical services departments and 16 supporting organizations and agencies were involved in transporting patients to 11 different hospitals. The 7 objectives for the event addressed coordinating emergency operations, sustaining adequate communications, updating regional bed status, processing resource requests, triaging patients, tracking patients, and patient identification.
Of the 445 transported patients, 270 (60%) were entered correctly into the state patient tracking system; 68 (25.2%) upgrades and 34 (12.6%) downgrades from scene triage categories were noted. Multiple opportunities for improvement were identified, with major weaknesses noted in communication and coordination from event sites to the regional trauma organizations and hospitals.
The size and complexity of the drill provided experience and knowledge to facilitate future disaster preparedness and highlighted weaknesses in communication and coordination. Large, multijurisdictional, multiagency exercises provide opportunities to stress, evaluate, and improve regional disaster preparedness.
To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission.
PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature ...searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed.
We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted.
Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme.
One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria.
This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
In early 2013, an online survey of over 200 UK palliative care services published in the British Medical Journal found that most of these services were prioritizing 'community engagement' ...initiatives, most commonly adopting a 'compassionate community' model. Later this same year, a report released by the National Council for Palliative Care and the charity Murray Hall Community Trust, described the increasing uptake of compassionate communities by palliative care services in England. This review examines this new policy and practice development in British end-of-life care explaining its conceptual origins and describing its policy importance to current practice. Why services are increasingly turning to community partnerships and the reasons they believe that this approach might enhance the effectiveness and reach of their clinical work are described.
Summary
Treatment of older adults with hip fracture is a healthcare challenge. Orthogeriatric comanagement that is an integrated model of care with shared responsibility improves time to surgery and ...reduces the length of hospital stay and mortality compared with orthopedic care with geriatric consultation service and usual orthopedic care, respectively.
Introduction
Treatment of fractures in older adults is a clinical challenge due partly to the presence of comorbidity and polypharmacy. The goal of orthogeriatric models of care is to improve clinical outcomes among older people with hip fractures. We compare clinical outcomes of persons with hip fracture cared according to orthogeriatric comanagement (OGC), orthopedic team with the support of a geriatric consultant service (GCS), and usual orthopedic care (UOC).
Methods
This is a single-center, pre-post intervention observational study with two parallel arms, OGC and GCS, and a retrospective control arm. Hip fracture patients admitted to the trauma ward were assigned by the orthopedic surgeon to the OGC (
n
= 112) or GCS (
n
= 108) group. The intervention groups were compared each with others and both with the retrospective control group (
n
= 210) of older adults with hip fracture. Several clinical indicators are considered, including time to surgery, length of stay, in-hospital, and 1-year mortality.
Results
Patients in the OGC (OR 2.62; CI 95% 1.40–4.91) but not those in the GCS (OR 0.74; CI 95% 0.38–1.47) showed a higher probability of undergoing surgery within 48 h compared with those in the UOC. Moreover, the OGC (β, − 1.08; SE, 0.54,
p
= 0.045) but not the GCS (β, − 0.79; SE, 0.53,
p
= 0.148) was inversely associated with LOS. Ultimately, patients in the OGC (OR 0.31; CI 95 % 0.10–0.96) but not those in the GCS (OR 0.37; CI 95% 0.10–1.38) experienced a significantly lower 1-year mortality rate compared with those in the UOC. All analyses were independent of several confounders.
Conclusions
Older adults with hip fracture taken in care by the OGC showed better clinical indicators, including time to surgery, length of stay and mortality, than those managed by geriatric consultant service or usual orthopedic care.
The coronavirus disease 2019 (COVID-19) pandemic has spread worldwide and caused negative economic and health effects. China is one of the most seriously affected countries, and it has adopted grid ...governance measures at the basic level of society, which include city lockdown, household survey and resident quarantine. By the end of April, China had basically brought the pandemic under control within its own borders, and residents' lives and factory production gradually began to return to normal. In referring to the specific cases of different communities, schools, and enterprises in the four cities of Anhui, Beijing, Shenzhen and Zibo, we analyze grid-based governance measures and we summarize the effectiveness and shortcomings of these measures and discuss foundations and future challenges of grid governance. We do so in the expectation (and hope) that the world will gain a comprehensive understanding of China's situation and introduce effective measures that enable the prevention and control of COVID-19.
To compare gynecologic oncology surgical treatment modifications and delays during the first wave of the COVID-19 pandemic between a publicly funded Canadian versus a privately funded American cancer ...center.
This is a retrospective cohort study of all planned gynecologic oncology surgeries at University Health Network (UHN) in Toronto, Canada and Brigham and Women's Hospital (BWH) in Boston, USA, between March 22,020 and July 302,020. Surgical treatment delays and modifications at both centers were compared to standard recommendations. Multivariable logistic regression was performed to adjust for confounders.
A total of 450 surgical gynecologic oncology patients were included; 215 at UHN and 235 at BWH. There was a significant difference in median time from decision-to-treat to treatment (23 vs 15 days, p < 0.01) between UHN and BWH and a significant difference in treatment delays (32.56% vs 18.29%; p < 0.01) and modifications (8.37% vs 0.85%; p < 0.01), respectively.
On multivariable analysis adjusting for age, race, treatment site and surgical priority status, treatment at UHN was an independent predictor of treatment modification (OR = 9.43,95% CI 1.81–49.05, p < 0.01). Treatment delays were higher at UHN (OR = 1.96,95% CI 1.14–3.36 p = 0.03) and for uterine disease (OR = 2.43, 95% CI 1.11–5.33, p = 0.03).
During the first wave of COVID-19 pandemic, gynecologic oncology patients treated at a publicly funded Canadian center were 9.43 times more likely to have a surgical treatment modification and 1.96 times more likely to have a surgical delay compared to an equal volume privately funded center in the United States.
•COVID-19 treatment modifications were more prevalent in a Canadian versus American cancer center•Cases with higher surgical-oncologic priority levels were 80% less like to undergo treatment modifications•Black race and uterine disease were independent factors associated with treatment modification•The impact of the pandemic related oncologic treatment modifications on survival is yet to be determined
In 2015, more than 890,000 asylum seekers were registered in Germany. The provision of medical and psychosocial care for asylum seekers is facing numerous obstacles. Access to health care is mostly ...insufficient, particularly in initial reception centres. The present article describes the development and implementation of an interdisciplinary outpatient clinic for asylum seekers at the main registration authority in the state of Baden-Wuerttemberg operated by physicians of the University Hospital of Heidelberg and the local Medical Association in Heidelberg. A steering committee was appointed to plan and implement the interdisciplinary outpatient clinic. Semi-structured interviews with nine steering committee members were conducted to elucidate perceived barriers during the planning and implementation phase. The steering committee's strong personal commitment and the health authorities' impartial management were cited as the main contributing factors to the success of the implementation process. Significant barriers were seen in the funding of personnel, equipment, and language mediation as well as in legal liability and billing-related aspects. Results are discussed with a focus on financing, administrative and legal framework as well as language mediation, documentation and further matters that are essential to ensure high-quality care.
The convergence of advances in medical science, human biology, data science, and technology has enabled the generation of new insights into the phenotype known as "diabetes." Increased knowledge of ...this condition has emerged from populations around the world, illuminating the differences in how diabetes presents, its variable prevalence, and how best practice in treatment varies between populations. In parallel, focus has been placed on the development of tools for the application of precision medicine to numerous conditions. This Consensus Report presents the American Diabetes Association (ADA) Precision Medicine in Diabetes Initiative in partnership with the European Association for the Study of Diabetes (EASD), including its mission, the current state of the field, and prospects for the future. Expert opinions are presented on areas of precision diagnostics and precision therapeutics (including prevention and treatment), and key barriers to and opportunities for implementation of precision diabetes medicine, with better care and outcomes around the globe, are highlighted. Cases where precision diagnosis is already feasible and effective (i.e., monogenic forms of diabetes) are presented, while the major hurdles to the global implementation of precision diagnosis of complex forms of diabetes are discussed. The situation is similar for precision therapeutics, in which the appropriate therapy will often change over time owing to the manner in which diabetes evolves within individual patients. This Consensus Report describes a foundation for precision diabetes medicine, while highlighting what remains to be done to realize its potential. This, combined with a subsequent, detailed evidence-based review (due 2022), will provide a roadmap for precision medicine in diabetes that helps improve the quality of life for all those with diabetes.
Though much of routine healthcare pauses in a public health emergency, childbirth continues uninterrupted. Crises like COVID-19 put incredible strains on healthcare systems and require strategic ...planning, flexible adaptability, clear communication, and judicious resource allocation. Experiences from obstetric units affected by COVID-19 highlight the importance of developing new teams and workflows to ensure patient and healthcare worker safety. Additionally, adapting a strategy that combines units and staff from different areas and hospitals can allow for synergistic opportunities to provision care appropriately to manage a structure and workforce at maximum capacity.
To identify how organizations prepare clinicians to work together to integrate behavioral health and primary care.
Observational cross-case comparison study of 19 U.S. practices, 11 participating in ...Advancing Care Together, and 8 from the Integration Workforce Study. Practices varied in size, ownership, geographic location, and experience delivering integrated care. Multidisciplinary teams collected data (field notes from direct practice observations, semistructured interviews, and online diaries as reported by practice leaders) and then analyzed the data using a grounded theory approach.
Organizations had difficulty finding clinicians possessing the skills and experience necessary for working in an integrated practice. Practices newer to integration underestimated the time and resources needed to train and organizationally socialize (onboard) new clinicians. Through trial and error, practices learned that clinicians needed relevant training to work effectively as integrated care teams. Training efforts exclusively targeting behavioral health clinicians (BHCs) and new employees were incomplete if primary care clinicians (PCCs) and others in the practice also lacked experience working with BHCs and delivering integrated care. Organizations' methods for addressing employees' need for additional preparation included hiring a consultant to provide training, sending employees to external training programs, hosting residency or practicum training programs, or creating their own internal training program. Onboarding new employees through the development of training manuals; extensive shadowing processes; and protecting time for ongoing education, mentoring, and support opportunities for new and established clinicians and staff were featured in these internal training programs.
Insufficient training capacity and practical experience opportunities continue to be major barriers to supplying the workforce needed for effective behavioral health and primary care integration. Until the training capacity grows to meet the demand, practices must put forth considerable effort and resources to train their own employees.
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