Hospital practice (1995)最新文献

Study objectives: Reversal of warfarin-induced anticoagulation using prothrombin complex concentrate (PCC4) is more rapidly achieved than with traditional methods, such as fresh frozen plasma (FFP). In many rural facilities, the availability of both FFP and PCC4 has been limited. A tertiary hospital instituted a program to provide PCC4 to rural sites using an air transport team and pharmacy exchange. We hypothesized that increasing accessibility of PCC4 would shorten time to INR reversal.

Methods: This was a retrospective study with the primary outcome being time to INR reversal (INR ≤ 1.6) and time to PCC4 administration from outside hospital admission. Active warfarin prescription, transfer to a tertiary facility, and administration of anticoagulation reversal between January 2013 and December 2020 were required for inclusion. Patients were grouped by dates before and after implementation of the program in August 2016. Linear regressions were performed to determine the effect of the variable and INR reversal methods on the time to INR reversal as well as the time to PCC4 administration. Time-to-event analysis was used to analyze the primary outcome between comparison groups. p values of less than 0.05 were considered significant.

Results: Chart review identified 189 patients: 56 within the pre-implementation group and 133 within the post-implementation group. Statistics were compared between these two groups. The post-implementation group had a shorter time to INR reversal (median 9.97 h) compared with the pre-implementation group (median 14.58 h, p = 0.00004). Time to PCC4 administration was also significantly decreased (p = 0.023). No statistically significant differences were found for hospital survival or 30-day mortality.

Conclusion: In rural hospitals, increasing availability of PCC4 using air medical transport along with a medication exchange program significantly reduces time to PCC4 administration in warfarin anticoagulated patients.

Objectives: The aim of this study was to measure and compare the serum levels of cystatin C and ADA between stable and exacerbated COPD.

Methods: The study was designed as a cross-sectional comparative study. Cases were defined as subjects who presented in the outpatient and inpatient departments with COPD and were stratified to stable COPD and acute exacerbation of COPD. Controls were healthy age-matched subjects who are not on any drugs and were nonsmokers. Association between cystatin C and ADA between stable and exacerbated COPD was assessed using logistic regression.

Results: There were a total of 182 subjects included in the study, of which, 63 had acute exacerbated COPD, 60 had stable COPD, and 59 were heathy controls. Logistic regression analysis showed that cystatin C (OR, 1.33, 95% CI: 1.16-2.56) and CRP (OR, 2.26, 95% CI: 1.59-2.69) levels were significantly higher, while ADA (OR, 0.82, 95% CI: 0.59-0.91) levels were significantly lower among those with stable COPD, compared to healthy controls. Similarly, cystatin C (OR, 1.48, 95% CI: 1.12-2.12) and CRP (OR, 3.39, 95% CI: 2.34-3.89) levels were significantly higher, while ADA (OR, 0.62, 95% CI: 0.41-0.87) levels were significantly lower among those with acute exacerbated COPD, compared to healthy controls.

Conclusion: Cystatin C and c-reactive protein (CRP) were significantly elevated, while ADA was significantly reduced in both stable and acute exacerbated COPD. Future large-scale studies should further explore the value of these markers in predicting the severity of COPD.

Objectives: Clinical handover is a major part of everyday work in healthcare settings. Clinical handover plays a great role between emergency medical services (EMS) and emergency nurses in providing safe and quality EMS. This study aims to assess the communication and handover mechanism between EMS and the emergency departments (ED) in Palestinian hospitals, to identify opportunities for improvement, and to make recommendations to improve the handover.

Methods: A descriptive, quantitative cross-sectional approach was used in this study. A sample of 220 emergency nurses working in governmental hospital and 130 paramedics working in the Palestine Red Crescent Society were conveniently selected from the West Bank, including Jerusalem.

Results: Our study showed that effective EMS-ED communication was perceived to have a high-degree impact on patient outcomes and patient waiting time in EDs, and a medium-degree impact on the readiness of healthcare providers. One-sample t-tests confirmed that perceived patient outcomes, readiness of healthcare providers, and patient waiting time in EDs were all perceived to be significantly influenced by EMS-ED communication.

Conclusion: Our findings demonstrate that effective EMS-ED communication, as perceived by healthcare providers, significantly influences patient outcomes, healthcare provider readiness, and patient waiting times. The availability of communication tools and the accuracy/adequacy of information are also perceived to significantly impact patient handover effectiveness and patient health/medical procedures, collectively enhancing the perceived quality and efficiency of emergency healthcare services.

Objective: Hospital-at-Home (H@H) models are safe and cost-effective alternatives for patients with acute or subacute conditions, offering care in the comfort and familiarity of their homes. Escalations, where patients are transferred back to traditional inpatient settings, are key performance metrics but represent significant challenges for H@H programs by interrupting the continuity and advantages of home-based treatment. This scoping review analyzes the factors leading to escalations across H@H programs.

Methods: We searched 5 databases: Embase, Google Scholar, PubMed, Scopus, and Web of Science. Our search focused on papers reporting the reasons why patients needed further escalations to Brick and Mortar (B&M) and the sociodemographic characteristics of these patients from 2005 to date. Besides factors leading to escalations, we charted the H@H program's objective, diseases treated, type of visit and personnel visiting, and predictors of escalation.

Results: Our search yielded 2932 papers, with 23 meeting our inclusion criteria. Common reasons for escalation included falling, lack of treatment response, exacerbation of the primary disease, cardiac symptoms, and medication adverse effects. Among our studies, higher escalation rates were observed in patients with infectious diseases (16%) and heart failure (9%). Significant predictors included older age, higher Charlson Comorbidity Index (CCI), and comorbidities such as diabetes and chronic kidney disease.

Conclusion: Escalations in H@H settings are influenced by primary underlying conditions, patient comorbidities, and care complexity. The novelty and ambiguity of the term 'escalation' and the diverse patient populations and H@H protocols limit statistical analysis. Standardizing definitions and consistent documentation of the number of patients needing care escalations and the reasons behind them is pivotal for proper analysis, nuanced understanding, and plausible prevention.

Cutibacterium acnes is a low-virulence pathogen that can cause prosthetic valve endocarditis (PVE), presenting significant diagnostic challenges due to its slow growth and indolent clinical course. We report a case of a 57-year-old male with a history of tissue aortic valve replacement, who presented with 6 months of intermittent fever and a nonproductive cough. Initial tests showed elevated inflammatory markers and moderate aortic regurgitation, but no vegetations were identified on transthoracic or transoesophageal echocardiography. After 13 months of symptoms, a PET scan showed significant FDG uptake around the bioprosthetic valve, and a single blood culture grew C. acnes. Transoesophageal echocardiography revealed abnormal rocking motion of the valve and severe paravalvular regurgitation, suggesting near-complete valve dehiscence. The patient underwent redo surgery for aortic root and valve replacement, and intraoperative cultures confirmed C. acnes infection. This case highlights the importance of considering low-virulence pathogens like C. acnes in patients with prolonged, nonspecific symptoms and initially negative cultures. Advanced imaging, particularly PET/CT, is crucial for early diagnosis and intervention. Early recognition and appropriate treatment are vital for preventing severe complications such as valve dehiscence and tissue destruction.

Background and aims: Diabetes mellitus is one of the more prevalent chronic diseases globally, and healthcare expenditures for diabetes care are on the rise. Intensive diabetes treatment has been associated with reducing the risk of chronic complications. However, hypoglycemia, the most common adverse effect, poses a significant risk to individuals' lives and is linked to high costs for healthcare systems.

Methods: We conducted a retrospective cross-sectional study to determine direct costs by identifying emergency room visits due to hypoglycemia events using diagnostic codes during January 2017 to June 2019. Direct costs were calculated using billed data from the payer and information on outpatient treatment regimens. Differences in median costs were estimated based on length of stay and type of outpatient treatment.

Results: Data from 101 patients and the same number of events were included. Women represented (62.4%) of the patients, the median age was 70 (IQR 59.5-80). Blood glucose levels at admission ranged from 12 mg/dL to 67 mg/dL. Most patients were on insulin for outpatient treatment. The median cost of care per hypoglycemia episode was US $345.35 (IQR US $202-727.8), and the cost per episode was higher in patients treated with regimens that included sulfonylureas.

Conclusions: The management of patients admitted to the emergency department with a diagnosis of hypoglycemia places a significant burden on the Colombian healthcare system, primarily due to the associated hospitalization costs. Patients treated with regimens that included sulfonylureas incurred higher costs per episode. Prevention, patient education, and individualized treatment approaches could help alleviate the burden of hypoglycemia on both patients and the healthcare system.

Aims: This study investigates the differences in patient demographics and outcomes between teaching and non-teaching hospitals in Iran. By analyzing these differences, it aims to provide useful information for policymakers to optimize resource allocation, improve patient care, and balance educational and service delivery goals in teaching hospitals.

Materials and methods: In this cross-sectional investigation, both teaching and non-teaching general hospitals were examined. A comprehensive analysis was carried out on 13 non-teaching and 25 teaching hospitals with homogeneity, utilizing Health Information System (HIS) data comprising 10,611,647 records through census sampling in 2019. Before employing the logistic regression models to clarify the relationship between a binary dependent variable (distinguishing teaching or non-teaching hospitals) and independent variables, we utilize the Recursive Feature Elimination (RFE) technique to select the most crucial predictor variables.

Findings: the optimal logistic regression model revealed that the teaching status of hospitals played a crucial role as an indirect predictor for variables including referral patients, length of stay (<24 hours), patients with partial improvement, and those who received less than 3 services. It also emerged as a direct predictor for variables such as length of stay (>30 days), patients receiving more than the mean services, death rate, and patients with complete improvement. Moreover, the teaching status had an indirect impact on variables like outpatient cases, length of stay (>30 days), and paraclinical services, while directly predicting variables such as patients with supplementary insurance and vulnerable groups insurance type, rehabilitation services, clinic wards, and length of stay (between 4-30 days).

Conclusion: In Iranian teaching hospitals, we observed an increase in patient numbers, extended length of stay, a rise in both the quantity and complexity of services, and more intricate patient admissions. It appears that small teaching hospitals in Iran have transitioned from being referral centers to functioning as outpatient centers with active clinics.

Objective: Long waiting times for elective surgery reflect not just backlog issues but systemic inefficiencies that disrupt the smooth flow of patients through the surgical care pathway. This systematic review adopts a holistic approach to summarize global policies, strategies, and interventions aimed at reducing elective surgery wait times.

Method: A comprehensive electronic search was performed in PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library from December 2019 to January 2020 and updated in April 2022. Eligible studies, published after 2013, focused on waiting lists for major elective surgeries in adults, excluding cancer-related surgeries. Both randomized and non-randomized studies and systematic reviews were included. Study quality was assessed using ROBINS-I, AMSTAR 2, and CASP tools, as appropriate. The review was registered in PROSPERO (CRD42019158455) and reported using a PRISMA flow diagram.

Results: From 7543 records, 92 articles met the inclusion criteria. Evidence was categorized into seven strategic areas: referral management, patient prioritization, preventing scheduled surgery cancellations, perioperative time management, quality improvement methods for surgical care pathways, and waiting time targets for hospitals. Strategies such as referral management, patient prioritization, and preventing cancellations had the most significant impact on reducing waiting times, while perioperative time management and waiting time targets proved less effective.

Conclusion: The review highlights that targeted interventions at different stages of the surgical care pathway yield variable impacts on overall waiting times. While individual measures had limited effects, combining multiple short-term strategies may be more beneficial, particularly for health systems recovering from the COVID-19 pandemic.

Decisions on end-of-life (EOL) care are a complex process that involves multiple stakeholders including patients, their families, and healthcare providers. Myriad factors play a role in making these decisions, such as desires of the patient and surrogates, advance directives, the patient's health condition, expectations about the disease course and prognosis, metaphysical beliefs about life and death, spiritual and socio-cultural backgrounds and views, quality of life considerations, legal connotations, costs of care, and nuances surrounding organ donation and procurement. This treatise utilizes three real-life examples to highlight the complexity and debate surrounding these decisions, especially in terms of interface of medicine and legal process, particularly when a patient is in coma or a vegetative state and decisions transfer to surrogates. This descriptive exposition underscores the need for dialogic and effective communication among healthcare providers, patients, and their families during this challenging EOL decision-making process.