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Fundamental care combines the needs of the person being cared for with the caregiver’s actions. The approach is not just about addressing an individual’s physical needs but about understanding and addressing the psychosocial and relational needs of the person receiving care while providing support, generating trust, and associated appropriate actions and behaviours. It is a relationship process that takes place within the framework of an organisation with solid policies and systems that place the person at the centre of attention while enabling workers' job satisfaction. These fundamental needs are only met through a positive and trusting relationship with the care recipient, including their family and everyone involved. Abstracto. Los cuidados fundamentales combinan las necesidades de la persona atendida con las acciones de quien la cuida. No se trata solo de las necesidades físicas, sino que también comprenden las necesidades psicosociales y relacionales de la persona, respaldadas por la confianza y acciones adecuadas de los que la cuidan. El proceso se desarrolla en el marco de una organización que cuenta con políticas y sistemas sólidos que sitúan a la persona en el centro de la atención, mientras habilitan la satisfacción laboral de los trabajadores. Estas necesidades fundamentales sólo se satisfacen a través de una relación positiva y de confianza con la persona que recibe los cuidados, incluyendo a su familia y a todos los involucrados en el proceso. Pinero de Plaza & Kitson, 2023 - Spanish adaptation of the Fundamentals of Care Framework: White paper in Spanish and English. Flinders University. DOI: 10.25451/flinders.23280881 Prepared for the first research symposium on care and humanisation and revised by Ana María Porcel Gálvez (PhD, BSc, RN) & Regina Allande Cusso (PhD, RN). Conference Organised by INVESCARE Granada, Spain. (12 of June 2023). The English version is accessible from pages 12 -21.

Healthcare-associated infections (HCAIs) are a threat to patient safety and cause substantial medical and economic burden in acute care and long-term care facilities. Risk factors for HCAIs include patient characteristics, the type of care and the setting. Local surveillance data and microbiological characterization are crucial tools for guiding antimicrobial treatment and informing efforts to reduce the incidence of HCAI. Skin and soft tissue infections, including superficial and deep incisional surgical site infections, are among the most frequent HCAIs. Other skin and soft tissue infections associated with healthcare settings include vascular access site infections, infected burns and traumas, and decubitus ulcer infections.

Background Patient portals play an important role in connecting patients with their medical care team, which improves patient engagement in treatment plans, decreases unnecessary visits, and reduces costs. During natural disasters, patients’ needs increase, whereas available resources, specifically access to care, become limited. Objective This study aims to examine patients’ health needs during a natural crisis by analyzing the electronic messages sent during Hurricane Harvey to guide future disaster planning efforts. Methods We explored patient portal use data from a large Greater Houston area health care system focusing on the initial week of the Hurricane Harvey disaster, beginning with the date of landfall, August 25, 2017, to August 31, 2017. A mixed methods approach was used to assess patients’ immediate health needs and concerns during the disruption of access to routine and emergent medical care. Quantitative analysis used logistic regression models to assess the predictive characteristics of patients using the portal during Hurricane Harvey. This study also included encounters by type (emergency, inpatient, observation, outpatient, and outpatient surgery) and time (before, during, and after Hurricane Harvey). For qualitative analysis, the content of these messages was examined using the constant comparative method to identify emerging themes found within the message texts. Results Out of a total of 557,024 patients, 4079 (0.73%) sent a message during Hurricane Harvey, whereas 31,737 (5.69%) used the portal. Age, sex, race, and ethnicity were predictive factors for using the portal and sending a message during the natural disaster. We found that prior use of the patient portal increased the likelihood of portal use during Hurricane Harvey (odds ratio 13.688, 95% CI 12.929-14.491) and of sending a portal message during the disaster (odds ratio 14.172, 95% CI 11.879-16.907). Having an encounter 4 weeks before or after Hurricane Harvey was positively associated with increased use of the portal and sending a portal message. Patients with encounters during the main Hurricane Harvey week had a higher increased likelihood of portal use across all five encounter types. Qualitative themes included: access, prescription requests, medical advice (chronic conditions, acute care, urgent needs, and Hurricane Harvey–related injuries), mental health, technical difficulties, and provider constraints. Conclusions The patient portal can be a useful tool for communication between patients and providers to address the urgent needs and concerns of patients as a natural disaster unfolds. This was the first known study to include encounter data to understand portal use compared with care provisioning. Prior use was predictive of both portal use and message sending during Hurricane Harvey. These findings could inform the types of demands that may arise in future disaster situations and can serve as the first step in intentionally optimizing patient portal usability for emergency health care management during natural disasters.

Background: Both clinical pathways (CPs) and electronic health records (EHRs) increase the quality and efficiency of health care; however, no known studies have examined the integration of CPs into the EHR during an organizational EHR launch. Aim: To understand how nursing leadership perceives the nursing practice changes that accompanied the transition from paper to EHR-based CPs. Methods: A case study design was utilized, focusing on CPs utilized by one acute care unit within a tertiary care organization. Findings: Transfer of paper CPs into an EHR not built for the Canadian health care context proved to be difficult. In the integration process, a single paper document became spread throughout the EHR. EHR-based CPs are not as clear, and represent a larger documentation burden, than their paper counterparts. Conclusion: Nursing agency has been greatly affected by the change in format of CPs. Further exploration of nursing agency regarding CPs is warranted.

Animals may be present in healthcare facilities for multiple reasons. Although specific laws regarding the use of service animals in public facilities were established in the United States in 1990, the widespread presence of animals in hospitals, including service animals, animals used to assist in patient therapy, and research animals, has resulted in the increased presence of animals in acute care hospitals and ambulatory medical settings. The role of animals in the transmission of zoonotic pathogens and cross-transmission of human pathogens in these settings remains poorly studied. Until more definitive information is available, healthcare facilities should establish policies and procedures to prioritize patient and healthcare provider safety and to use standard infection prevention and control measures to prevent animal-to-human transmission in healthcare settings. This paper is based on recently published consensus recommendations from a panel of experts, representing the Society of Healthcare Epidemiology of America (SHEA), regarding the management of animals in healthcare (AHC) (Murthy R, Bearman G, Brown S, Bryant K, Chinn R, Hewlett A et al, Infect Control Hosp Epidemiol 36:495–516, 2015). However, this paper aims to review the controversies related to animals in healthcare with respect to infection prevention, identify potential steps for mitigation of risks and areas for future study, and provide updated information where available; any opinions noted beyond the consensus SHEA guidance document reflect the opinions of only the authors of this document.

Background : The exponential increase in SARS-CoV-2 infections during the first wave of the pandemic created an extraordinary overload and demand on hospitals, especially intensive care units (ICUs), across Europe. European countries have implemented different measures to address the surge ICU capacity, but little is known about the extent. The aim of this paper is to compare the rates of hospitalised COVID-19 patients in acute and ICU care and the levels of national surge capacity for intensive care beds across 16 European countries and Lombardy region during the first wave of the pandemic (28 February to 31 July). Methods : For this country level analysis, we used data on SARS-CoV-2 cases, current and/or cumulative hospitalised COVID-19 patients and current and/or cumulative COVID-19 patients in ICU care. To analyse whether capacities were exceeded, we also retrieved information on the numbers of hospital beds, and on (surge) capacity of ICU beds during the first wave of the COVID-19 pandemic from the COVID-19 Health System Response Monitor (HSRM). Treatment days and mean length of hospital stay were calculated to assess hospital utilisation. Results : Hospital and ICU capacity varied widely across countries. Our results show that utilisation of acute care bed capacity by patients with COVID-19 did not exceed 38.3% in any studied country. However, the Netherlands, Sweden, and Lombardy would not have been able to treat all patients with COVID-19 requiring intensive care during the first wave without an ICU surge capacity. Indicators of hospital utilisation were not consistently related to the number of SARS-CoV-2 infections. The mean number of hospital days associated with one SARS-CoV-2 case ranged from 1∙3 (Norway) to 11∙8 (France). Conclusion : In many countries, the increase in ICU capacity was important to accommodate the high demand for intensive care during the first COVID-19 wave.

Background Research has shown that the clinical learning environment can both facilitate and hinder students' learning. Students' perceptions need to be evaluated, preferably using nationally and internationally validated instruments. In Sweden, there is a lack of research about students' evaluation in acute care settings and from the perspectives of different levels of students. Objectives The aim was to explore and compare perceptions of the clinical learning environment of first- and second-cycle nursing students in an acute care setting using the Clinical Learning Environment, Supervision and Nurse Teacher scale (CLES+T). Design The design involves cross-sectional data collection with comparisons between groups. Setting and participants Data were collected from a convenience sample of first- and second-cycle students at the end of their clinical placements in an acute care setting at a university hospital. Methods A paper version and a web version of the culturally adapted version of CLES+T was filled out by the students. An independent t-test was used to explore the differences between CLES+T scores and distribution methods and educational level. Internal consistency was evaluated using Cronbach's alpha. Results Overall, the students (N = 179) were satisfied with the clinical learning environment. There was no significant difference in the total score (m = 4.31, SD = 0.63) between first- and second-cycle students except for the subscale of “Premises of nursing on the ward” and the individual items “The ward's nursing philosophy was clearly defined” and “Patients received individual nursing care”, showing that the first-cycle students were more satisfied compared to the second-cycle students. The scale demonstrated high internal consistency (α = 0.97 vs. 0.96) for the paper survey and the web survey, respectively. Conclusions Our findings provide initial support for the CLES+T as a useful instrument to evaluate the clinical learning environment at different levels of education and in different contexts regardless of distribution method.

Care provided according to guideline recommendations improves the outcomes for people with stroke, but not all patients receive evidence-based care. This thesis includes five published/submitted papers and one traditional chapter of results that contribute to a greater understanding of the benefits of different facilitator roles, together with audit and feedback interventions, for improving access to evidence-based care after stroke. The presence of coordinators, as internal facilitators, was shown to be associated with improved evidence-based care delivery and patient outcomes. Investment in, and development of, facilitator roles within organisations (such as stroke coordinators), are essential to maximising evidence-based care delivery.

Background Nurses play an important role in caring for patients who are dying in hospital, so it is important to understand their perceptions of the factors that may influence the quality of that care. Much of the existing literature is focused on end-of-life care provision in western settings. Little is known about how nurses’ perceptions of end-of-life care provision may differ across Asian and Western locations. Understanding the similarities and differences between the perceptions of nurses in Asian and Western locations about the barriers to the provision of high-quality end-of-life care may help guide education and policy initiatives to improve end-of-life care in each location. Aim To compare the perceptions of nurses from Australia, South Korea, and Hong Kong regarding barriers to high-quality end-of-life care provision for people dying in hospitals. Methods A cross-sectional study of hospital-based nurses from Australia (n = 153), South Korea (n = 241), and Hong Kong (n = 188) completed a survey between December 2016 and June 2018. Nurses indicated the extent to which they perceived 40 items across five domains to be a barrier to high-quality end-of-life care provision. Findings Significant variation between the perceptions of nurses in each location was found in two-thirds of the survey items. The greatest difference was seen in the item doctors continue life-sustaining medical interventions for too long, which was considered a significant barrier by 60.1% of Australian nurses, 32.9% of South Korean nurses and 13.8% of Hong Kong nurses. The greatest cross-location agreement related to differences in religious beliefs and languages. These items were considered a significant barrier by fewer than one-quarter of nurses. Conclusion Nurses in Hong Kong, South Korea and Australia perceived a range of challenges to the provision of optimal end-of-life care. The significant differences observed in two-thirds of response items support the hypothesis that strategies to improve the quality of end-of-life care in one location may not be effective in another. For interventions to be effective they must be tailored to the unique nature of care-provision in each location. Gaining an understanding of the potential reasons for these differences may highlight potential targets for interventions that address the unique factors associated with care provision in each location. Summary of relevance Problem Barriers to the provision of high-quality end-of-life care in Asian hospitals may be different from those in western hospitals. Nurses are well-placed to understand the factors that can both hinder, and enhance, care provision, in each location. However, little is known about how nurses’ perceptions of the barriers to end-of-life care provision in Asian hospitals differ from those of nurses in western hospitals. What is already known about the topic? • End-of-life care is increasingly being provided in hospital settings. • Nurses have an integral role in supporting dying patients and their families. • Few studies have explored the similarities and differences between the perceptions of nurses in Asian and Western locations about the factors that hinder end-of-life care provision across all domains of healthcare provision. What this paper adds • There are a number of differences between the perceptions of nurses in Western and Asian locations about the factors that hinder end-of-life care provision. • Comparing the similarities and differences between the perceptions of nurses in each location can help develop an understanding of the potential for different practice styles, cultural considerations, and system-based factors to impact the provision of end-of-life care in hospitals. • The findings of this international comparison study may help to inform education programs and policy initiatives to improve end-of-life care in Asian and Western hospitals.

Hospital social workers often engage in health literacy activities to support patients’ and families’ functioning and adjustment to illness, but social work literature has seldom used health literacy terminology. This paper reports on a qualitative study of paediatric hospital social workers’ understanding of the needs of parents with acutely ill children and how their contributions may accommodate these needs to strengthen parental health literacy. Utilising systematic text condensation, the study reveals four themes: (1) understanding of medical information, (2) counselling and service coordination, (3) emotional needs, and (4) timing of information. The findings suggest that hospital social workers make valuable additions to health literacy. Sykehussosionomer jobber med å fremme sykdomsmestring hos pasienter og deres familier. Sette arbeidet har i liten grad blitt omtalt som et bidrag til å styrke helsekompetansen til pasienter og pårørende. Artikkelen bygger på en kvalitativ studie med pediatriske sykehussosionomer, om deres forståelse av foreldres behov når et barn er akutt og kritisk sykt, og hvordan de møter disse behovene på måter som kan bidra til å styrke foreldrenes helsekompetanse. Det har blitt benyttet Systematisk tekstkondensering som analysemetode for å komme frem til fire temaer; (1) å forstå medisinsk informasjon, (2) veiledning og koordinering av tjenester, (3) følelsesmessige behov, og (4) timing av informasjon. Funnene støtter opp om at sykehussosionomenes arbeid kan bidra til å styrke pasienter og pårørendes helsekompetanse. Deres helhetlige tilnærming kan utgjøre verdifulle bidra til helsekompetansefeltet.

Families of persons with acquired brain injuries need to be supported from the early phase of hospitalization. To date, no known early family intervention is available for this population. Using the Medical Research Council Framework, we developed a new intervention based on the Calgary Assessment and Intervention Models that includes the family preferences, clinician’s expertise, and the contextual resources. This paper aims to describe the complete development process including a scoping review, an assessment of families and clinicians’ needs, an evaluation of the contextual resources, and an adaptation of the theoretical framework. Using a systemic perspective, we tailored the new intervention to involve the stakeholder’s preferences. The result is an early family intervention named SAFIR©, led by a clinical nurse specialist, including five core components and structured around three phases and a follow-up. The next steps will be focused on assessment of the clinical feasibility of this new intervention.

Background In some acute care trials, immediate informed consent is not possible, but deferred consent is often considered problematic. We investigated the opinions of patients, proxies, and physicians about deferred consent in an acute stroke trial to gain insight into its acceptability and effects. Methods Paper-based surveys were sent to patients who were randomly assigned in the Ultra-early Tranexamic Acid After Subarachnoid Hemorrhage (ULTRA) trial between 2015 and 2018 in two tertiary referral centers and to physicians of centers who agreed or declined to participate. The primary outcome measure was the proportion of respondents who agreed with deferral of consent in the ULTRA trial. Secondary outcomes included respondents’ preferred consent procedure for the ULTRA trial, the effect of deferred consent on trust in physicians and scientific research, and the willingness to participate in future research. Results Eighty-nine of 135 (66%) patients or proxies and 20 of 30 (67%) physicians completed the survey. Of these, 82 of 89 (92%) patients or proxies and 14 of 20 (70%) physicians agreed with deferral of consent in the ULTRA trial. When asked for their preferred consent procedure for the ULTRA trial, 31 of 89 (35%) patients or proxies indicated deferred consent, 15 of 89 (17%) preferred immediate informed consent, and 32 of 89 (36%) had no preference. None of the patients’ or proxies’ trust in physicians or scientific research had decreased because of the deferred consent procedure. Willingness to participate in future studies remained the same or increased in 84 of 89 (94%) patients or proxies. Conclusions A large majority of the surveyed patients and proxies and a somewhat smaller majority of the surveyed physicians agreed with deferred consent in the ULTRA trial. Deferred consent may enable acute care trials in an acceptable manner without decreasing trust in medicine. Future research should investigate factors facilitating the responsible use of deferred consent, such as in-depth interviews, to study the minority of participants who agreed with deferred consent but still preferred immediate informed consent.

Purpose This paper aims to assess how patient safety culture and incident reporting differs across different professional groups and between long-term and acute care. The Hospital Survey On Patient Safety Culture (HSPOSC) questionnaire was used to assess patient safety culture. Data from the organizations’ incident reporting system was also used to determine the number of reported patient safety incidents. Design/methodology/approach Patient safety culture is part of the organizational culture and is associated for example to rate of pressure ulcers, hospital-acquired infections and falls. Managers in health-care organizations have the important and challenging responsibility of promoting patient safety culture. Managers generally think that patient safety culture is better than it is. Findings Based on statistical analysis, acute care professionals’ views were significantly positive in 8 out of 12 composites. Managers assessed patient safety culture at a higher level than other professional groups. There were statistically significant differences (p = 0.021) in frequency of events reported between professional groups and between long-term and acute care (p = 0.050). Staff felt they did not get enough feedback about reported incidents. Originality/value The study reveals differences in safety culture between acute care and long-term care settings, and between professionals and managers. The staff felt that they did not get enough feedback about reported incidents. In the future, education should take these factors into consideration.

Background: Ostomy formation is life-changing surgery, and patient numbers are increasing globally. Knowledge of stoma care and management among nurses in acute settings is vital to provide holistic care, support patients' return to normal life and prevent complications. Aim: To estimate the knowledge of stoma care among nurses working in acute settings using an integrative review. Method: Five databases were searched between 2009 and 2020. A methodological approach for integrative reviews and a thematic analysis framework were used to identify themes from 10 papers. Reporting followed PRISMA guidelines, and quality appraisal was conducted. Findings: Nurses working in acute care settings have limited knowledge of stoma care, and confidence in care provision to patients with ostomies is affected by a lack of exposure. Confusion exists regarding the responsibilities of nurses when stoma care is required for an inpatient. Conclusion: Knowledge deficits regarding stoma care need to be addressed via exposure and support to deliver stoma care, access to evidence-based policies and protocols and clear referral pathways.

Patient outcomes are improved when healthcare professionals work collaboratively. In order for future professionals to have these entry-level skills, students from different disciplines must work together in scenarios simulating patient care. This paper provides an overview of a large-scale, acute care simulation involving students of different disciplines, including nursing and pharmacy. A survey using the validated Student Perceptions of Interprofessional Clinical Education Revised (SPICE-R2) tool was administered to students participating in the simulation prior to and within 1 week of the simulation. There were between-group statistically significant differences on two items on the pre-simulation survey and two items on the post-simulation survey. Student participants reported more positive perceptions after the simulation on every item except for “During their education, health professional students should be involved in teamwork with students from other health professions to understand their perspective roles”. The authors concluded that an interprofessional acute care simulation allowed students in both professions to recognize the value of a team approach to patient care.

Despite the widespread use of contact precautions in acute care hospitals, even after decades of experience, the use of contact precautions (CP) remains controversial. This paper aims to review the current controversies related to CP in acute care hospital settings, identify potential areas for future study, and provides updated information where available.

Objectives Low-middle income countries, such as Vietnam have a greater burden from stroke than high-income countries. Few health professionals have stroke specialist training, and the quality of care may vary between hospitals. To support improvements to stroke care, we aimed to gain a better understanding of the resources available in hospitals in Vietnam to manage acute stroke. Materials and methods The survey questions were adapted from the Australian Organisational Survey of Stroke Services (Stroke Foundation). The final 65 questions covered the topics: hospital size and admissions for stroke; use of clinical protocols and assessments conducted; team structure and coordination; communication and team roles. The survey was distributed electronically or via paper form in Vietnamese to clinical leaders of 91 eligible hospitals (November–December 2020). Data were summarised descriptively. Results Sixty-six (73%) hospitals responded, and doctors predominately completed the survey (98%). Approximately 70% of hospitals had a stroke unit; median 630 acute strokes/year (IQR: 250-1200) and >90% used stroke clinical protocols. The daytime nurse-patient ratio was 1:4. There was a perceived lack of access to allied health staff, including psychologists/neuropsychologists, occupational therapists, and speech pathologists. Only 50% reported having a standardised rehabilitation assessment process. Conclusions This is the first large-scale cross-sectional, national overview of stroke services in Vietnam. Future research should include a systematic clinical audit of stroke care to confirm aspects of the data from these hospitals. Repeating the survey in future years will enable the tracking of progress and may influence capacity building for stroke care in Vietnam.

Simulation is a critical component of nursing and medical education used to teach skills and assess student performance. In March 2020, faculty members-including the authors-at the Grace Center for Innovation in Nursing Education at the Edson College of Nursing and Health Innovation (Edson College) simulation programs at Arizona State University (ASU) quickly responded to the crisis presented by COVID-19. Within a few days, all nursing simulations were transitioned from a predominately in-person design to fully online. Maintaining simulation activities throughout the first several months of the pandemic allowed students at Edson College to meet clinical assessment objectives. This transition, implemented in two phases, included a detailed plan of action for all Doctor of Nursing Practice (DNP) nurse practitioner (NP) objective structured clinical exams (OSCEs). The challenges required innovative planning and flexibility while maintaining the integrity of the OSCE and simulation experience. The methods implemented out of necessity are now an important part of the authors' curricular toolbox, providing options for continued and future educational practice. This paper details the simulations designed and implemented in two DNP programs: the family nurse practitioner (FNP) and acute care pediatric nurse practitioner (ACPNP) programs.

Background Failure to identify severely ill obstetric patients seeking acute care, and hence delaying treatment, can lead to maternal morbidity and mortality. Triage is the prioritization of patients seeking emergency care, based on clinical decision-making tools assessing medical urgency. While triage has been applied in general emergency medicine for 30 years, there are only a few obstetric triage systems (OTS) and obstetric triage has hitherto been unknown in Sweden. Obstetric triage is more complex than general triage since both mother and fetus require assessment, and pregnancy-related physiological changes must be taken into account. This paper aims to describe the development and an initial evaluation of the first OTS in Sweden. Methods A multidisciplinary team surveyed reasons to seek acute obstetric care and the current patient flow at the largest obstetric unit in Scandinavia, Sahlgrenska University Hospital, Gothenburg, Sweden, with about 10,000 deliveries/year. A semi-structured literature review on obstetric triage was undertaken. Based on the survey and the literature review the first Swedish OTS was developed and implemented. Patient satisfaction was followed by electronical questionnaires. Initial validity evaluation was performed, defined by the system’s ability to identify patients with need for hospital admission, stratified by acuity level. Results The Gothenburg Obstetrical Triage System (GOTS) addresses the patient to one of five acuity levels based on both vital signs and 14 chief complaint algorithms. It entails recommendations for initial procedures of care as well as an acuity form for documentation. Initial evaluation of the system indicates good correlation between need for admission and acuity level. The implementation has provided the staff with an improved medical overview of the patients and patient flow and enabled the unit to monitor emergency care in a structured way. Implementation came along with increased patient and staff satisfaction. Conclusion The GOTS is the first OTS developed in and for Sweden and implementation has improved management of obstetric patients seeking acute care. Patients are now prioritized according to level of acuity and the time to assessment and treatment of severely ill patients can be structurally evaluated. Both patients and staff express improved satisfaction with obstetric triage.

Background Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed. Methods A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020. Results Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs. Conclusions An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH

The COVID-19 pandemic has revolutionized health care for patients and providers alike. Telemedicine has moved from the periphery of our health care system to center stage more rapidly than anyone could have envisioned. Currently, virtual care has quite effectively replicated the traditional health system’s care delivery model and reimbursement structure—a patient makes an appointment, then sees a physician (except with video or phone replacing in-office visits) who makes a care plan, and the patient and physician meet again at a later timepoint to assess progress. Replicating this episodic care paradigm virtually has been invaluable for delivering care swiftly during the COVID-19 pandemic; however, we can and should do more with the connectedness and convenience that telemedicine technology enables. Continuous remote care, with a data-driven, proactive outreach to patients, represents a decisive step forward in contrast to the currently available episodic, reactive, patient-initiated care. In the context of continuous remote care, patient biometric and symptom data (patient entered and connected data) are assimilated in real time by artificial intelligence–enabled clinical platforms to bring physicians' and other health care team members’ attention to those patients who need intervention, whether this is via medication adjustments, acute care management, or lifestyle coaching. In this paper, we discuss how an innovative continuous remote care approach has improved outcomes in another deadly pandemic—type 2 diabetes mellitus.

Objective The objective of this paper is to describe the day-to-day activities, known as practice patterns, of nurse practitioners (NPs) across a four-site academic healthcare network in Ontario, which comprises acute, primary, rehabilitation and complex continuing care. Background Information regarding NP practice patterns is available from other jurisdictions and practice settings, but information specific to large, urban and multi-site organizations is available to a lesser extent. This information can inform and support leaders' decisions about NP roles and responsibilities. Method A cross-sectional online survey was sent to the 125 NPs employed in this healthcare network. Results Respondents (n = 45) were primarily experienced, graduate-prepared NPs, who work with specialized populations and support the education of healthcare professional trainees. The majority of these NPs' activities focused on direct and indirect care, with fewer activities centred on leadership/administration, education, research and personal breaks. Clinical care activities varied among NPs and were contextual to the population and program. Conclusion While direct and indirect care are vital components of NP practice, the overwhelming emphasis on these components indicates that the organization and the healthcare system are losing opportunities to capitalize on advanced nursing practice knowledge and skills in the domains of leadership, research and education.

The provision of acute healthcare within patients own home (i.e. hospital in the home) is an important method of providing individualised patient-centred care that reduces the need for acute hospital admissions and enables early hospital discharge for appropriate patient groups. The Hospital in the Home (HitH) model of care ensures that this approach maximises patient safety and limits potential risk for patients. As HitH services have seen record numbers of patient referrals in the past 2 years, there is now a greater need to measure and understand the acuity and dependency levels of the caseload. Through an expert clinician development process at one NHS trust, aspects of procedural complexity, interdisciplinary working, risk stratification and comorbidities were used to quantify acuity and dependency. This paper uses a case study approach to present a new method of measuring this important concept.

Families of persons with acquired brain injuries need to be supported from the early phase of hospitalization. To date, no known early family intervention is available for this population. Using the Medical Research Council Framework, we developed a new intervention based on the Calgary Assessment and Intervention Models that includes the family preferences, clinician’s expertise, and the contextual resources. This paper aims to describe the complete development process including a scoping review, an assessment of families and clinicians’ needs, an evaluation of the contextual resources, and an adaptation of the theoretical framework. Using a systemic perspective, we tailored the new intervention to involve the stakeholder’s preferences. The result is an early family intervention named SAFIR©, led by a clinical nurse specialist, including five core components and structured around three phases and a follow-up. The next steps will be focused on assessment of the clinical feasibility of this new intervention.

Recent health reforms have created incentives for cardiologists and accountable care organizations to participate in value-based care models for heart failure (HF). Accurate risk stratification of HF patients is critical to efficiently deploy interventions aimed at reducing preventable utilization. The goal of this paper was to compare deep learning approaches with traditional logistic regression (LR) to predict preventable utilization among HF patients. We conducted a prognostic study using data on 93,260 HF patients continuously enrolled for 2-years in a large U.S. commercial insurer to develop and validate prediction models for three outcomes of interest: preventable hospitalizations, preventable emergency department (ED) visits, and preventable costs. Patients were split into training, validation, and testing samples. Outcomes were modeled using traditional and enhanced LR and compared to gradient boosting model and deep learning models using sequential and non-sequential inputs. Evaluation metrics included precision (positive predictive value) at k, cost capture, and Area Under the Receiver operating characteristic (AUROC). Deep learning models consistently outperformed LR for all three outcomes with respect to the chosen evaluation metrics. Precision at 1% for preventable hospitalizations was 43% for deep learning compared to 30% for enhanced LR. Precision at 1% for preventable ED visits was 39% for deep learning compared to 33% for enhanced LR. For preventable cost, cost capture at 1% was 30% for sequential deep learning, compared to 18% for enhanced LR. The highest AUROCs for deep learning were 0.778, 0.681 and 0.727, respectively. These results offer a promising approach to identify patients for targeted interventions. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): internally funded by Diagnostic Robotics Inc.

Recent research points to the fact that new medical technological innovations are just as relevant in the context of long-term care or chronic care as they are in the context of acute care. In the spirit of the Nuffield Foundation recommendations, this paper explores the possibilities of using robotic aides in long-term care and identifies the tensions that must be considered and addressed if robotics is to be introduced successfully in nursing homes. Our examination is two-pronged. First, we delve into a fundamental issue surrounding AI, namely that of consciousness. We argue that automation will always have only a limited use in caregiving since caregiving as an activity requires the use of human-type, that is, organic, consciousness. We support the thesis that the emergence and formation of human-type consciousness require feelings such as empathy and the sense of touch, which, in turn, create the sense of kinship with fellow human beings. And second, we examine the benefits as well as risks of using robotic aides such as ZORA and PARO in long-term care facilities. More specifically, we look at ZORA's use in a group setting, and PARO's use in an individual setting. We emphasize that long-term care is one-on-one care, including but not limited to intimate care. Crucially, we argue that touch is at the heart of this type of care. We argue that some of the tensions with the use of robotic aides are generated precisely because of the lack of human touch.

Targeted nutritional therapy should be started early in severe illness and sustained through to recovery if clinical and patient-centred outcomes are to be optimised. The coronavirus disease 2019 (COVID-19) pandemic has shone a light on this need. The literature on nutrition and COVID-19 mainly focuses on the importance of nutrition to preserve life and prevent clinical deterioration during the acute phase of illness. However, there is a lack of information guiding practice across the whole patient journey (e.g., hospital to home) with a focus on targeting recovery (e.g., long COVID). This review paper is of relevance to doctors and other healthcare professionals in acute care and primary care worldwide, since it addresses early, multi-modal individualised nutrition interventions across the continuum of care to improve COVID-19 patient outcomes. It is of relevance to nutrition experts and non-nutrition experts and can be used to promote inter-professional and inter-organisational knowledge transfer on the topic. The primary goal is to prevent complications and support recovery to enable COVID-19 patients to achieve the best possible nutritional, physical, functional and mental health status and to apply the learning to date from the COVID-19 pandemic to other patient groups experiencing acute severe illness.

Purpose of Review Acute care re-utilization, i.e., hospital readmission and post-discharge Emergency Department (ED) use, is a significant driver of healthcare costs and a marker for healthcare quality. Diabetes is a major contributor to acute care re-utilization and associated costs. The goals of this paper are to (1) review the epidemiology of readmissions among patients with diabetes, (2) describe models that predict readmission risk, and (3) address various strategies for reducing the risk of acute care re-utilization. Recent Findings Hospital readmissions and ED visits by diabetes patients are common and costly. Major risk factors for readmission include sociodemographics, comorbidities, insulin use, hospital length of stay (LOS), and history of readmissions, most of which are non-modifiable. Several models for predicting the risk of readmission among diabetes patients have been developed, two of which have reasonable accuracy in external validation. In retrospective studies and mostly small randomized controlled trials (RCTs), interventions such as inpatient diabetes education, inpatient diabetes management services, transition of care support, and outpatient follow-up are generally associated with a reduction in the risk of acute care re-utilization. Data on readmission risk and readmission risk reduction interventions are limited or lacking among patients with diabetes hospitalized for COVID-19. The evidence supporting post-discharge follow-up by telephone is equivocal and also limited. Summary Acute care re-utilization of patients with diabetes presents an important opportunity to improve healthcare quality and reduce costs. Currently available predictive models are useful for identifying higher risk patients but could be improved. Machine learning models, which are becoming more common, have the potential to generate more accurate acute care re-utilization risk predictions. Tools embedded in electronic health record systems are needed to translate readmission risk prediction models into clinical practice. Several risk reduction interventions hold promise but require testing in multi-site RCTs to prove their generalizability, scalability, and effectiveness.

Introduction Health care systems are faced with an increase in older adults requiring acute care services. This rise is accompanied by an increase of multiple chronic conditions among these patients. For older adults with multi-morbidity, hospitalization outcomes are poor and hospitalization costs are high. This has led to the development of models of care that provide an alternative to conventional hospitalization. We will describe existing practices of admission to acute geriatric unit in intermediate care in Europe: from Sanitari Pere Virgili, in Barcelona, Spain and from Amsterdam University Medical Centers (AUMC) in Amsterdam, the Netherlands. The aim of this paper is to provide preliminary data comparing settings, baseline characteristics and outcomes of two acute geriatric units in intermediate care.Methods Patient data were collected in both completed and ongoing prospective cohort studies. The Subacute Care Unit (SCU) in Barcelona, located in an intermediate care hospital and the Acute Geriatric Community Hospital (AGCH), located in a nursing home, are acute geriatric units with 16-24 beds. Admission criteria for both settings are 1) chronic condition exacerbation or “minor” acute medical problems requiring hospitalization 2) hemodynamic stability 3) no need for complex diagnostic testing 4) a return to previous living situation within 10-14 days. Demographic characteristics, main admission diagnosis, comorbidities, discharge destination and length of stay were compared between the two settings.Results Data from 909 patients admitted to the SCU and 174 to the AGCH were available. The mean age was (standard deviation, SD): 85.8 years (6.7) at the SCU and 81.9 years (8.5) (p

Introduction:the blended SORT-IT model uses a combination of online modules and teleconferences with local and international mentors to teach operational research. We modified SORT-IT to create the Acute Care Operational Research (ACOR) course directed to anesthesiology residents in Kigali, Rwanda. This course takes students from an initial research idea through submitting a paper for publication. Our viewpoint on entering this study was that ACOR participants would have adequate resources to complete the course, but be hampered by cultural unfamiliarity with the blended teaching approach. Methods:we conducted a qualitative analysis of the experiences of all those who participated in the ACOR course to understand obstacles and improve future course iterations. Six anesthesiology residents participated in the first iteration of the course, with 4 local mentors and 2 secondary mentors, one of whom was based at the University of Virginia, with a total of 12 participants. Semi-structured interviews were conducted with all participants and mentors, which were independently coded for topics by two reviewers. Results:there was a 50% publication rate for those enrolled in the course and an expected 100% acceptance rate for those who completed the course. Some reported benefits to the course included improved research knowledge, societal improvements, and knowledge exchange. Some reported obstacles to successful course completion included time limitations, background knowledge, and communication. Of note, only 4 out of 12 participants recognized cultural barriers. Conclusion:although successful in the sense that all participants completed their research project, ACOR did not fully solve the main issues hindering research training. Our results show that research training in low-resource settings needs a continuing and formal focus on the factors that hinder participants´ success: mentorship and time.

Background During hospitalization patients frequently have a low level of physical activity, which is an important risk factor for functional decline. Function Focused Care (FFC) is an evidence-based intervention developed in the United States to prevent functional decline in older patients. Within FFC, nurses help older patients optimally participate in functional and physical activity during all care interactions. FFC was adapted to the Dutch Hospital setting, which led to Function Focused Care in Hospital (FFCiH). FFCiH consists of four components: (1) ‘Environmental and policy assessment’; (2) ‘Education’; (3) ‘Goal setting with the patient’ and (4) ‘Ongoing motivation and mentoring’. The feasibility of FFCiH in the Dutch hospital setting needs to be assessed. Objective Introduce FFCiH into Dutch hospital wards, to assess the feasibility of FFCiH in terms of description of the intervention, implementation, mechanisms of impact, and context. Design Mixed method design Setting(s) A Neurological and a Geriatric ward in a Dutch Hospital. Participants 56 Nurses and nursing students working on these wards. Methods The implementation process was described and the delivery was studied in terms of dose, fidelity, adaptions, and reach. The mechanisms of impact were studied by the perceived facilitators and barriers to the intervention. Qualitative data were collected via focus group interviews, observations, and field notes. Quantitative data were collected via evaluation forms and attendance/participation lists. Results A detailed description of FFCiH in terms of what, how, when, and by whom was given. 54 Nurses (96.4%) on both wards attended at least 1 session of the education or participated in bedside teaching. The nurses assessed the content of the education sessions with a mean of 7.5 (SD 0.78) on a 0–10 scale. The patient files showed that different short and long-term goals were set. Several facilitators and barriers were identified, which led to additions to the intervention. An important facilitator was that nurses experienced FFCiH as an approach that fits with the principles underpinning their current working philosophy. The experienced barriers mainly concern the implementation elements of the FFCiH-components ‘Education’ and ‘Ongoing motivation and mentoring’. Optimizing the team involvement, improving nursing leadership during the implementation, and enhancing the involvement of patients and their family were activities added to FFCiH to improve future implementation. Conclusions FFCiH is feasible for the Dutch hospital setting. Strong emphasis on team involvement, nursing leadership, and the involvement of patients and their families is recommended to optimize future implementation of FFCiH in Dutch hospitals. What is already known • Function Focused Care is an evidence-based intervention that prevents functional decline among hospitalized elderly; • It is proven to be effective in assistant living facilities, nursing homes, home care, and acute care settings in the United States; • It is unknown if the intervention can be implemented in the Dutch Hospital Setting. What this paper adds • This study showed the feasibility of Function Focused Care in Hospital and the challenges in some elements of the intervention; • Optimizing the team involvement, improving nursing leadership during the implementation, and enhancing the involvement of patients and their family were added to FFCiH to improve future implementation. • This feasibility study can guide the use of process evaluation in examining the feasibility of an intervention in daily practice.

The association between the Short Physical Performance Battery (SPPB) score and several adverse health outcomes, including mortality, has been reported in the scientific literature. We conducted a comprehensive literature review of studies on the relationship between SPPB and mortality. The current paper synthesizes the characteristics and main findings of longitudinal studies available in the literature that investigated the role of the SPPB in predicting mortality in older adults. The studies (n = 40) are from North America, South America, Europe, and Asia; the majority (n = 16) were conducted with community-dwelling older adults and reported an association between lower SPPB scores and a higher risk of mortality, and between higher SPPB scores and higher survival. Nevertheless, few studies have analyzed the accuracy of the instrument to predict mortality. The only study that established cut-off points was conducted with older adults discharged from an acute care hospital. Although an SPPB score lower than 10 seems to predict all-cause mortality, further studies showing cut-off points in specific settings and loco-regional specificities are still necessary.

Purpose of review Disease-related treatment action plans for acute exacerbations providing information that may be helpful for self-management for patients and caregivers are commonly used for chronic conditions such as asthma and diabetes. However, among patients with epilepsy, a review of the literature suggested that the majority did not have an action plan in place for acute seizure treatment. Recent findings Currently, there is a lack of unified guidance on seizure action plans (SAPs) in the literature. In the authors’ opinion, available formats have limitations for practical use and may not be easily customizable to individual patients, and they are not often designed to provide simple-to-follow steps for rapid immediate steps to determine and initiate appropriate treatment of seizure emergencies. Our group reviewed current examples of SAPs and provided guidance on the development of acute seizure action plans (ASAPs) designed to facilitate rapid, appropriate acute care in the community and to be as useful as possible for a wide range of care partners, including those with limited experience. Summary This paper provides agreed upon expert opinion recommendations and considerations for goals, development process, types of content, and format for an ASAP.

Introduction: The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial. Methods: A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost. Results: A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group. Conclusion: The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in health-related quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program.