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The echocardiographic assessment of diastolic function in the context of atrial fibrillation (AF) has been controversial and can be challenging and labor-intensive. We aimed to assess the actual practice of diastolic evaluation in AF in our community hospital echocardiography laboratory and to improve clinical performance by a quality improvement project.We reviewed 244 echocardiograms in patients with AF at the time of echocardiography from November 2019 to November 2020 (pre-intervention phase). We classified cases into a complete versus incomplete evaluation group according to the completeness of diastolic parameter measurement. After an educational intervention, we reviewed 68 echocardiograms in patients with AF from August 2021 to October 2021 (post-intervention phase).Our results demonstrated an improvement in a complete diastolic assessment from 69% to 91% after intervention (p .001). In the pre-intervention phase, the four parameters (mitral inflow pulsed wave Doppler image, left atrium volume index, mitral annular tissue Doppler image [TDI], and tricuspid regurgitation Vmax), mitral annular TDI was not acquired in 71 out of 244 cases (29.1%) and those cases were classified as incomplete evaluation group. Interestingly, in the pre-intervention phase, 57 out of 162 cases (35%) with preserved EF (≥50%) received significantly more incomplete diastolic evaluation than 14 out of 82 patients (17%) with reduced EF (50%) (p = .004). There were no statistically significant differences in age, BMI, the reason for requesting echocardiography, and patient level of care between the complete and incomplete evaluation groups. In the post-intervention phase, completeness of diastolic measurement in AF was significantly improved compared to the pre-intervention phase (29% vs. 9%, p .001, respectively).A quality improvement project effectively improved the clinical performance of diastolic evaluation in AF in our community echocardiography laboratory. After the intervention, we decreased an incomplete evaluation from 30% to 9%. More efforts should be needed to increase awareness and familiarity in evaluating diastolic function in AF.

To determine the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies.The charts of all pregnant people who delivered at Brockville General Hospital between September 2018 and December 2021 were retrospectively reviewed. Perinatal and maternal outcomes of low-risk nulliparous pregnant people who underwent elective induction at 39 weeks and over were extracted and compared with those of low-risk nulliparous pregnant people who underwent expectant management. Exclusion criteria included multiparous people, high-risk pregnancies, multiple gestations, deliveries at less than 39 weeks gestation, and elective cesarean deliveries. Univariate and multivariate analysis was performed.A total of 174 patients were included. Of these patients, 56 (32.2%) underwent elective induction of labour between 39Our results suggest that elective induction of labour at 39 weeks gestation and over in low-risk nulliparous people is associated with lower risks of cesarean delivery, composite adverse maternal outcomes, and composite adverse perinatal outcomes than expectant management.

biIntroduction:/i/bTeleneonatology (TN) allows remote neonatologists to provide real-time audio-video telemedicine support to community hospitals when neonates require advanced resuscitation or critical care. Currently, there are no published economic evaluations of U.S. TN programs.biObjective:/i/bTo evaluate the cost of TN from the perspective of the health care system.biMethods:/i/bWe constructed a decision tree comparing TN to usual care for neonates born in hospitals without a neonatal intensive care unit (NICU) who require consultation. Our outcome of interest was total cost per patient, which included the incremental cost of a TN program, the cost of medical transport, and the cost of NICU or non-NICU hospitalization. We performed threshold sensitivity analyses where we varied each parameter to determine whether the base-case finding reverted.biResults:/i/bFor neonates requiring consultation after birth in a hospital without a NICU, TN was less costly ($16,878) than usual care ($28,047), representing a cost-savings of $11,168 per patient. Sensitivity analyses demonstrated that at least one of the following conditions would need to be met for TN to no longer be cost saving compared to usual care: transfer rate with usual carelt;12% (base-case = 82%), TN reducing the odds of transfer bylt;8% (base-case = 52%), or TN cost exceeding $12,989 per patient (base-case = $1,821 per patient).biConclusions:/i/bEconomic modeling from the health system perspective demonstrated that TN was cost saving compared to usual care for neonates requiring consultation following delivery in a non-NICU hospital. Understanding the cost savings associated with TN may influence organizational decisions regarding implementation, diffusion, and retention of these programs.

Emergency department boarding and crowding lead to worse patient outcomes and patient satisfaction.We describe the implementation of a program to transfer patients requiring medical admission from an academic emergency department to a community hospital's medical floor and analyze its effects on patient outcomes.A prospective cohort study was performed. Data was collected on patient flow through the transfer program. Patient characteristics, boarding time in the emergency department, and hospital-based outcome measures were compared between patients in the transfer program who were successfully transferred to the community hospital and patients who were admitted to the academic medical center.79 patients were successfully transferred to the community hospital between November 23, 2020 and August 5, 2021, resulting in 279 bed days in the community hospital. Successfully transferred patients experienced a statistically shorter ED boarding time (5.7 vs. 10.9 h, p0.0001), ED length of stay (10.5 vs 16.1 h, p0.0001), and hospital length of stay (3.5 vs 5.7 days, p0.0001) compared to patients initially referred to the transfer program who were admitted to the academic medical center. There were no reported adverse events during transfer, upgrades to the ICU within 24 h of admission, or inpatient deaths for patients who were transferred.We implemented an academic emergency department to partner community hospital transfer program that safely level-loads medical patients in a healthcare system.

Context Vaccination status has been shown to be linked to patient-centered outcomes in those with COVID-19. However, minimal data have explored the relationship between vaccination status and representation rates after receiving monoclonal antibodies (MABs) the Delta strain of severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) in a community setting. Objectives The authors sought to determine if there was a difference in patient-centered outcomes between those who were vaccinated and unvaccinated after the administration of casirivimab/imdevimab for mild-to-moderate COVID-19 during the time when the Delta strain was most prevalent. Methods A convenience sample of consecutive adults given casirivimab/imdevimab at either an outpatient infusion center or within the emergency department (ED) were included in analysis. Patient demographics, authorized-use qualifiers from the emergency use authorization (EUA), baseline vital signs at the time of infusion, representation rates to a healthcare provider within the hospital’s network, and any admissions to the hospital following infusion were all collected from the patient’s electronic medical record. Vaccination status was confirmed in both the patient’s electronic medical record and the Arizona State Immunization Information System (ASIIS). Analysis was conducted utilizing descriptive statistics, the Mann–Whitney U test for continuous data, and the chi-squared analysis for nominal data. Results In total, 743 patients were included in the study, with 585 being unvaccinated and 158 being vaccinated at the time of administration. Those in the vaccinated group were more likely to be older (60.0 vs. 55.0 years; p Conclusions MAB therapy with casirivimab/imdevimab for the outpatient treatment of mild-to-moderate COVID-19 was associated with a low rate of hospitalization. However, those who were vaccinated were more likely to present for unexpected return care at either the ED or urgent care within 28 days of the initial infusion.

Nonprofit hospitals frequently partner with their local health department on developing community health needs assessments (CHNAs); yet, little is known about the role that such partnerships play in strengthening the alignment between needs identified in hospitals' assessments and the strategies adopted by hospitals to address identified needs. Using data for 486 hospitals from the third round of CHNAs (spanning the years 2018-2021), this study showed strong alignment between the health needs identified in the CHNAs and those addressed in hospitals' implementation strategies, independent of collaboration with the local health department. One noteworthy exception to this finding was that hospital-public health collaboration remained important for improved alignment of needs related to substance use. Involvement of the local health department may strengthen hospitals' capacity to address needs outside their traditional areas of expertise, such as substance use.

Evidence-based nursing practice supports the provision of high-quality patient care. This article shares how a contest at a community hospital promoted a culture of clinical inquiry and engaged nurses in evidence-based practice.

Purpose Interventions to improve the safety and efficiency of manual sterile compounding are needed. This study evaluated the impact of a technology-assisted workflow system (TAWS) on sterile compounding safety (checks, traceability, and error detection), and efficiency (task time). Methods Observations were conducted in an oncology pharmacy transitioning from a manual to a TAWS process for sterile compounding. Process maps were generated to compare manual and TAWS checks and traceability. The numbers and types of errors detected were collected, and task times were observed directly or via TAWS data logs. Results Analysis of safety outcomes showed that, depending on preparation type, 3 to 4 product checks occurred in the manual process, compared to 6 to 10 checks with TAWS use. TAWS checks (barcoding and gravimetric verification) produced better traceability (documentation). The rate of incorrect-drug errors decreased with technology-assisted compounding (from 0.4% [5 of 1,350 preparations] with the manual process to 0% [0 of 1,565 preparations] with TAWS use; P < 0.02). The TAWS increased detection of (1) errors in the amount of drug withdrawn from vials (manual vs TAWS, 0.4% [5/1,350] vs 1.2% [18/1565]; P < 0.02), and (2) errors in the amount of drug injected into the final container (manual vs TAWS, 0% [0/1,236] vs 0.9% [11/1,272]; P < 0.002). With regard to efficiency outcomes, TAWS use increased the mean mixing time (manual vs TAWS, 275 seconds vs 355 seconds; P < 0.001), had no significant impact on average visual checking time (manual vs TAWS, 21.4 seconds vs 21.6 seconds), and decreased average physical checking time (manual vs TAWS, 58.6 seconds vs 50.9 seconds; P < 0.001). Conclusion In comparison to manual sterile compounding, use of the TAWS improved safety through more frequent and rigorous checks, improved traceability (via superior documentation), and enhanced error detection. Results related to efficiency were mixed.

The authors describe a rural community hospital's approach to lung cancer screening using low-dose CT (LDCT) to address the high incidence of lung cancer mortality.An implementation project was conducted, documenting planning, education, and restructuring processes to implement a lung cancer screening program using LDCT in a rural community hospital (population 64,917, Rural-Urban Continuum Code 5) located in a region with the highest lung cancer mortality in Oregon. The hospital and community partners organized the implementation project around five recommendations for an efficient and effective lung cancer screening program that accurately identifies high-risk patients, facilitates timely access to screening, provides appropriate follow-up care, and offers smoking cessation support.Over a 3-year period (2018-2020), 567 LDCT scans were performed among a high-risk population. The result was a 4.8-fold increase in the number of LDCT scans from 2018 to 2019 and 54% growth from 2019 to 2020. The annual adherence rate increased from 51% in 2019 to 59.6% in 2020. Cancer was detected in 2.11% of persons scanned. Among the patients in whom lung cancer was detected, the majority of cancers (66.6%) were categorized as stage I or II.This rural community hospital's approach involved uniting primary care, specialty care, and community stakeholders around a single goal of improving lung cancer outcomes through early detection. The implementation strategy was intentionally organized around five recommendations for an effective and efficient lung cancer screening program and involved planning, education, and restructuring processes. Significant stakeholder involvement on three separate committees ensured that the program's design was relevant to local community contexts and patient centered. As a result, the screening program's reach and adherence increased each year of the 3-year pilot program.

Hospitals had to create new practices, training programs and roles due to the COVID-19 pandemic. An urban community hospital enacted written policies to cross-train nurses for supporting patients in an intensive care setting. This paper shares the planning, implementation, evaluation and revision of a support nurse training for a teambased intensive care unit model. Learning evaluations show that tailoring the education to the type of nurse is received more positively than a general skills training session. Leaders are encouraged to ensure that teams have role clarity and practice supports to be successful.

Among the myositis-specific antibodies (MSA), anti-transcriptional intermediary factor 1 (TIF1)-γ and anti-nuclear matrix protein 2 (NXP2) antibodies are reportedly associated with cancer-associated myositis (CAM). We aimed to investigate patient characteristics of CAM and the clinical role of cancer-associated MSA (caMSA) in a retrospective cohort from a city hospital. All patients visiting our department between April 2014 and October 2021 with newly diagnosed dermatomyositis, polymyositis, and clinically amyopathic dermatomyositis were included. Anti-TIF1-γ and anti-NXP2 antibodies were collectively considered as caMSA. First, we compared clinical characteristics in CAM, defined as cases showing onset or recurrence of malignancy within 5 years, versus non-CAM. Second, we investigated independent risk factors for CAM. Third, we compared clinical characteristics with and without caMSA within CAM. Finally, we investigated whether caMSA was predictive of poor prognosis. The cohort of 39 patients included 12 (30.7%) CAM cases. Compared with non-CAM, CAM had significantly more dermatomyositis and higher frequencies of dysphagia, anti-TIF1-γ antibody, and caMSA. Using logistic regression analysis, caMSA was an independent risk factor for CAM. In a comparison between caMSA and non-caMSA within CAM, caMSA was associated with higher frequencies of stage ≥ II. However, caMSA did not necessarily indicate a poor prognosis. Only caMSA represented an independent risk factor for CAM and showed a significant association with advanced cancer. Key Points • Cancer-associated MSA was an independent risk factor for cancer-associated myositis. • Cancer-associated MSA was associated with advanced cancer.

BACKGROUND: Hospitals are increasingly screening patients for social risk factors to help improve patient and population health. Intelligence gained from such screening can be used to inform social need interventions, the development of hospital-community collaborations, and community investment decisions. OBJECTIVE: We evaluated the frequency of admitted patients’ social risk factors and examined whether these factors differed between hospitals within a health system. A central goal was to determine if community-level social need interventions can be similar across hospitals. DESIGN AND PARTICIPANTS: We described the development, implementation, and results from Northwell Health’s social risk factor screening module. The statistical sample included patients admitted to 12 New York City/Long Island hospitals (except for maternity/pediatrics) who were clinically screened for social risk factors at admission from June 25, 2019, to January 24, 2020. MAIN MEASURES: We calculated frequencies of patients’ social needs across all hospitals and for each hospital. We used chi-square and Friedman tests to evaluate whether the hospital-level frequency and rank order of social risk factors differed across hospitals. RESULTS: Patients who screened positive for any social need (n = 5196; 6.6% of unique patients) had, on average, 2.3 of 13 evaluated social risk factors. Among these patients, the most documented social risk factor was challenges paying bills (29.4%). The frequency of 12 of the 13 social risk factors statistically differed across hospitals. Furthermore, a statistically significant variance in rank orders between the hospitals was identified (Friedman test statistic 30.8 > 19.6: χ2 critical, p = 0.05). However, the hospitals’ social need rank orders within their respective New York City/Long Island regions were similar in two of the three regions. CONCLUSIONS: Hospital patients’ social needs differed between hospitals within a metropolitan area. Patients at different hospitals have different needs. Local considerations are essential in formulating social need interventions and in developing hospital-community partnerships to address these needs. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06396-8.

Evaluate patient outcomes after endovascular aortic interventions performed for nonruptured aortic aneurysms by physician specialties.Endovascular aortic repair (EVAR), fenestrated or branched repair (F-BEVAR), and thoracic endovascular aortic repair (TEVAR) procedures were obtained from the Illinois Hospital Association Comparative Health Care and Hospital Data Reporting Services database from 2016 to 2019. Logistic and Poisson regression were used to determine outcomes by patient, physician, and hospital characteristics.A total of 4,935 procedures, 3,666 (74.3%) EVAR, 567 (11.5%) F-BEVAR, and 702 (14.2%) TEVAR were performed by vascular surgeons, interventional radiologists, interventional cardiologists, and cardiac surgeons. Vascular surgeons performed interventions equally between hospital types while interventional radiologists primarily performed interventions in teaching hospitals (68.1%) and interventional cardiologists and cardiac surgeons typically performed interventions in community hospitals (91.8% and 82.1%, respectively; P.001). No differences in inpatient mortality were noted between specialties. Patients treated by interventional radiologists had increased odds of staying in the hospital ≥8 days (odd ration [OR] 1.95, 95% confidence interval [CI] 1.19-3.19) and patients treated by interventional cardiologists had lower odds of being admitted to the intensive care unit [ICU] (OR 0.42, 95% CI 0.18-0.95).Differences in practice patterns among specialties performing endovascular aortic aneurysm repair for nonruptured aneurysms suggest opportunities for collaboration to optimize quality of care.

Background April 22nd, 2020, New York City (NYC) was the epicenter of the pandemic of Coronavirus disease 2019 (COVID-19) in the US with differences of death rates among its 5 boroughs. We aimed to investigate the difference in mortality associated with hospital factors (teaching versus community hospital) in NYC. Design Retrospective cohort study. Methods We obtained medical records of 6509 hospitalized patients with laboratory confirmed COVID-19 from the Mount Sinai Health System including 4 teaching hospitals in Manhattan and 2 community hospitals located outside of Manhattan (Queens and Brooklyn) retrospectively. Propensity score analysis using inverse probability of treatment weighting (IPTW) with stabilized weights was performed to adjust for differences in the baseline characteristics of patients initially presenting to teaching or community hospitals, and those who were transferred from community hospitals to teaching hospitals. Results Among 6509 patients, 4653 (72.6%) were admitted in teaching hospitals, 1462 (22.8%) were admitted in community hospitals, and 293 (4.6%) were originally admitted in community and then transferred into teaching hospitals. Patients in community hospitals had higher mortality (42.5%) than those in teaching hospitals (17.6%) or those transferred from community to teaching hospitals (23.5%, P Conclusions Patients admitted to community hospitals had higher mortality than those admitted to teaching hospitals.

Objectives The aim of this study was to determine the impact of the 2016 Canadian cardiovascular society guidelines for the management of dyslipidemia. More specifically, we assessed the use of 1) alternate lipid targets when triglyceride (TG) levels are high; and 2) nonfasting lipid testing. Methods Lipid profiles and pharmacy data were obtained from patients with a history of myocardial infarction and from patients ≥40 years of age with a diagnosis of diabetes. Results As TG increased to >1.5 mmol/L, percent within target for non–high-density lipoprotein cholesterol and apolipoprotein B 18 months after guideline release remained low in both patients with atherosclerotic cardiovascular disease (40%) and patients with diabetes in primary prevention (30%). Approximately 50% of patients were fasting when presenting for lipid testing. Use of high-intensity statin was suboptimal in both groups. Conclusions The concept of alternate lipid targets may not be well understood by many physicians, leading to undertreatment of patients. Progress was made in the promotion of routine nonfasting lipid testing.

Objective: We sought to create a novel physician assistant (PA) and physician hospital medicine co-management strategy, employing a 3:1 PA:physician structure, under which the physician oversees all PA patients, but without a separate independent panel. Methods: This is a retrospective cohort pre-post design, comparing metrics for a traditional physician-only hospitalist model with a PA-physician team model. Outcomes included length of stay (LOS), readmissions, discharge destination, patient satisfaction, and in-hospital mortality. Results: LOS for patients under the PA-physician model (74 hours) was lower than for the physician-only model (83 hours; P < .001). The PA-physician model team discharged more patients home than to another facility (PA-physician 77.6%, physician-only 74.3%; P = .03). Thirty-day readmissions were about 10% (P = .97) and patients reported respectful treatment in about 80% (P = .53) of cases in each cohort. Conclusions: Our 3:1 PA-physician model team showed equal to superior outcomes compared with the physician-only hospitalist model.

Background: For newborns requiring transfer to a higher level of care, stabilization before the arrival of the transport team is essential. Telemedicine consultations with a neonatologist may impro...

Background During the 2020 SARS-CoV-2 outbreak in New York City, hospitals canceled elective surgeries to increase capacity for critically ill patients. We present case volume data from our community hospital to demonstrate how this shutdown affected surgical care. Methods Between March 16 and June 14, 2020, all elective surgeries were canceled at our institution. All procedures performed during this operating room shutdown (ORS) were logged, as well as those 4 weeks before (PRE) and 4 weeks after (POST) for comparison. Results A total of 2,475 cases were included in our analysis, with 754 occurring during shutdown. Overall case numbers dropped significantly during ORS and increased during recovery (mean 245.0±28.4 PRE vs. 58.0±30.9 ORS vs. 186.0±19.4 POST cases/week, p

The aim of this article is to familiarize the reader with one system's approach to creating an aligned academic health system that facilitates delivery of academic health care in community hospitals.A wide variety of approaches to this challenge include viewing the community facilities as strictly feeders to the academic centers with no shared governance, to viewing them as branding opportunities with aligned governance, to a more integrated model such as ours, and to creating exclusive centers of excellence in the community facilities by consolidating services initially dispersed across competing hospitals into one center.We leveraged service lines and domains to standardize care across all hospital settings which facilitated delivery of complex tertiary care in community hospitals, thus increasing capacity in the Academic Medical Center for complex quarternary care.Through creating a more completely integrated, patient centric health system that leverages the community partners we minimized the need for people to travel from their community hospitals to the Academic Medical Center while still ensuring they received the expertise of a leading academic institution.

Background: Recently, a singular survey titled “Measure of Moral Distress—Healthcare Professionals,” which addresses shortcomings of previous instruments, has been validated. Aim: To determine how moral distress affects nurses and physicians differently across the various wards of a community hospital. Participant and research context: We distributed a self-administered, validated survey titled “Measure of Moral Distress—Healthcare Professionals” to all nurses and physicians in the medical/surgical ward, telemetry ward, intensive care units, and emergency rooms of a community hospital. Findings: A total of 101 surveys were included in the study. The mean Measure of Moral Distress—Healthcare Professionals score for all respondents was 143.0 (standard deviation = 79.8). The mean Measure of Moral Distress—Healthcare Professionals score was 1.75 greater for nurses than for physicians (92.5 vs 161.5, p < .001), and nurses were 2.52 times more likely to consider leaving their position due to moral distress (68% vs 27%). The mean Measure of Moral Distress—Healthcare Professionals score for moral distress was least prevalent in the medical/surgical ward (92.5, SD = 38.2) and highest in the telemetry ward (197.7, SD = 83.6). The intensive care unit ward had a mean Measure of Moral Distress—Healthcare Professionals score mildly greater than the emergency room. Ethical considerations: No participant identifying information or information connecting a survey response to an individual was collected. This study was approved by the Raritan Bay Medical Center’s Institutional Review Board. Discussion: This study provides insight into the level of moral distress in the community hospital setting. Telemetry nurses experience significantly more than nurses in other wards. Telemetry nurses typically manage patients sicker than medical/surgical wards, however do not have the resources of the critical care units. This scenario presents challenges for telemetry nurses and may explain their elevated moral distress. Conclusion: In community hospitals, telemetry nurses experience a considerably greater amount of moral distress compared to their colleagues in other wards. As measured by the Measure of Moral Distress—Healthcare Professionals questionnaire, moral distress continues to be higher among nurses compared to physicians.

Background Little is known regarding the impact of hospital academic status on outcomes following rectal cancer surgery. We compare these outcomes for nonmetastatic rectal adenocarcinoma at academic versus community institutions. Methods The National Cancer Database (2010–2016) was queried for patients with nonmetastatic rectal adenocarcinoma who underwent resection. Propensity score matching was performed across facility cohorts to balance confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival, other short and long-term outcomes were analyzed by way of logistic regression. Results After matching, 15,096 patients were included per cohort. Academic centers were associated with significantly decreased odds of conversion and positive margins with significantly increased odds of ≥12 regional nodes examined. Academic programs also had decreased odds of 30 and 90-day mortality and decreased 5-year mortality hazard. After matching for facility volume, no significant differences in outcomes between centers was seen. Conclusions No difference between academic and community centers in outcomes following surgery for non-metastatic rectal cancer was seen after matching for facility procedural volume.

Objectives Hantavirus is endemic in the Four Corners region of Arizona, Colorado, New Mexico, and Utah, and hantavirus cardiopulmonary syndrome (HCPS) disproportionately affects the Navajo Nation. We describe the application of a rapid screening tool for identification of HCPS. Methods A rapid screening tool for HCPS was implemented at Tséhootsooí Medical Center (TMC) in collaboration with academic partners. Results Since its implementation in 2016, 20 TMC staff members have been trained to perform this test, and 189 screens for HCPS have been reported. Although hantavirus infection is rare even in high-risk areas, use of this tool resulted in the identification of 4 acute cases of hantavirus infection. Conclusions The results demonstrate the successful implementation of a 5-point screening tool for hantavirus infection in an endemic setting by a laboratory in a small community hospital.

Study objective One proposed solution to prolonged emergency department (ED) wait times is a publicly available website that displays estimated ED wait times. This could provide information to patients so that they may choose sites with low wait times, which has the potential to smooth the overall wait times in EDs across a health system. We describe the effect of a novel city-wide ED wait time website on patient volume distributions throughout the city of Hamilton, Ontario, Canada. Methods We compared the number of new patients arriving every 15 minutes during 2 separate time periods—before and after a publicly viewable wait time website was made available. For each ED site, the effect of the posted wait time was measured by assessing its association with the total number of patient arrivals in the subsequent hour at the same site and at all other sites in Hamilton. Results Linear models showed clinically modest changes in patient volumes when wait times changed. However, nonlinear models showed that a 60-minute increase in wait time at a site was associated with 10% fewer patients presenting over the next hour. Larger negative associations were observed at community hospitals and urgent care centers. Increases in wait times at a given site were also associated with increased patient volumes at other sites in the system. Conclusion After the implementation of a public wait time website, elevated wait times led to fewer patients at the same site but more patient visits at other sites. This may be consistent with the wait time tracker inducing patients to avoid sites with high wait times and instead visit alternate sites in Hamilton, but only when wait times were very high.

Adrenocortical carcinoma is a rare but aggressive malignancy. While centralization of care to referral centers improves outcomes across common urological malignancies, there exists a paucity of data for low-incidence cancers. We sought to evaluate differences in practice patterns and overall survival in patients with adrenocortical carcinoma across types of treating facilities.We identified all patients diagnosed with adrenocortical carcinoma from 2004-2016 in the National Cancer Database. The Kaplan-Meier method was used to evaluate overall survival and multivariable Cox regression analysis was used to investigate independent predictors of overall survival. The chi-square test was used to analyze differences in practice patterns.We identified 2,886 patients with adrenocortical carcinoma. Median overall survival was 21.8 months (95% CI 19.8-23.8). Academic centers had improved overall survival versus community centers on unadjusted Kaplan-Meier analysis (p0.05) and had higher rates of adrenalectomy or radical en bloc resection (p0.001), performed more open surgery (p0.001), administered more systemic therapy (p0.001) and had lower rates of positive surgical margins (p=0.03). On multivariable analysis, controlling for treatment modality, academic centers were associated with significantly decreased risk of death (HR 0.779, 95% CI 0.631-0.963, p=0.021).Treatment of adrenocortical carcinoma at an academic center is associated with improved overall survival compared to community programs. There are significant differences in practice patterns, including more aggressive surgical treatment at academic facilities, but the survival benefit persists on multivariable analysis controlling for treatment modality. Further studies are needed to identify the most important predictors of survival in this at-risk population.

INTRODUCTION Chest pain is a common reason for emergency department (ED) visits. Evidence-based decision aids assessing risk for an adverse cardiac event are underused in community hospital emergency care. This study explored the acceptability, barriers, facilitators, and potential strategies for implementation of the HEART Score risk stratification tool, accelerated diagnostic pathway, and shared decision-making visual aid with physicians and chest pain patients ages >45 in a community hospital ED. METHODS Single center, mixed-methods study. (1) Physician semistructured interviews using The Consolidated Framework for Implementation Research for systematic analysis. (2) Patient and physician surveys. (3) 16-week intervention of physician training and pilot testing of decision aids with ED patients. RESULTS Physician interviews (n = 19); key facilitators: electronic medical record decision support, ease of use, risk stratification and disposition support, and shared decision-making training. Key barriers: time constraints, patient ability, and/or willingness to participate in shared decision-making, lack of integration with medical record and change in practice workflow. Patient study participants (n = 184) with a survey response rate of 92% (n = 170). Most patients (85%) were satisfied with the shared decision-making visual aid. Physicians surveyed (n = 84) with a response rate of 50% (n = 42). Most physicians, 95% (n = 40), support use of the HEART Score, with limited acceptance of the shared decision-making visual aid of 57% (n = 24). CONCLUSIONS Using evidence-based chest pain decision aids in a community hospital ED is feasible and acceptable. Key barriers and facilitators for implementation were identified. Further research in community hospitals is needed to verify findings, examine generalizability, and test implementation strategies.

Laparoscopic cholecystectomy is the gold standard for treatment of acute cholecystitis. Percutaneous cholecystostomy (PC) drains are alternatives to cholecystectomy in critically ill patients in whom surgery carries an unacceptably high risk. Recently, several studies demonstrated a significant increase in complications in patients undergoing PC in comparison to laparoscopic cholecystectomy. We conducted a retrospective analysis of patients who underwent PC drainage or cholecystectomy from 2014 through 2019 at our institution. We determined the rate of PC use and performed a linear regression analysis to evaluate PC utilization over time. After creating institutional guidelines and reeducating physicians on appropriate use of PC drainage in 2019, we compared PC utilization to prior years. A total of 146 PCs and 3163 cholecystectomies were performed over the study period. Of the cholecystectomies, 754 (23.8%) were performed in hospitalized patients under urgent or emergent conditions. Of the patients with acute cholecystitis, 16.2% were treated with PC. Linear regression analysis demonstrated a significant association between year and rate of PC procedures (p

Based on the experiences and lessons of its first COVID-19 patient surge in spring of 2020 (Wave 1), the New York hospital community recognized the importance of preparation and coordination for the anticipated winter 2020-2021 surge (Wave 2). This case study describes the coordination function of the Greater New York Hospital Association in downstate New York during the second wave, carried out using 4 key elements: enhanced situational awareness coupled with proactive outreach, partnerships between independent hospitals and health systems, frequent coordination meetings with hospitals, and routine coordination meetings with the Governor's Office and the New York State Department of Health. Given the existing relationships, functions, and support structures of hospital associations, this type of collaborative structure between state government and an association can be valuable in any situation that broadly impacts a state's healthcare community.

BackgroundChinese health insurance system faces resource distribution challenges. A patient-centric approach allows decision-makers to be keenly aware of optimized medical resource allocation.ObjectiveThis study aims to use the discrete choice model to determine the main factors affecting the healthcare preferences of the general Chinese population and their weights in the three scenarios (chronic non-communicable diseases, acute infectious diseases, and major diseases).MethodsThis study firstly identified the key factors affecting people's healthcare preferences through literature review and qualitative interviews, and then designed the DCE questionnaire. An online questionnaire produced by Lighthouse Studio (version 9.9.1) software was distributed to voluntary respondents recruited from mainland China's entire population from January 2021 to June 2021. Participants were required to answer a total of 21 questions of three scenarios in the questionnaire. The multinomial logit model and latent class model were used to analyze the collected data.ResultsA total of 4,156 participants from mainland China were included in this study. The multinomial logit and latent class model analyses showed that medical insurance reimbursement is the most important attribute in all three disease scenarios. In the scenario of “non-communicable diseases,” the attributes that participants valued were, from the most to the least, medical insurance reimbursement (45.0%), hospital-level (21.6%), distance (14.4%), cost (9.7%), waiting time (8.3%), and care provider (1.0%). As for willingness to pay (WTP), participants were willing to pay 204.5 yuan, or 1,743.8 yuan, to change from private hospitals or community hospitals to tertiary hospitals, respectively.ConclusionsThis study explores the healthcare preferences of Chinese residents from a new perspective, which can provide theoretical reference for the refinement of many disease medical reimbursement policies, such as developing different reimbursement ratios for various common diseases and realizing rational configuration of medical resources.

There is a national trend towards regionalizing complex hepatopancreaticobiliary (HPB) surgeries to high-volume institutions. Due to geographic and socioeconomic constraints, however, many patients in the United States continue to undergo HPB surgery at local community hospitals. This study evaluated complex HPB surgeries performed by a single surgeon at a low-volume community hospital from May 2007 to June 2021. A retrospective review of medical records (n=163) was done to collect data on patient demographics and outcomes. Surgical outcomes of HPB procedures were compared to published data from high-volume centers. Overall mortality within 30 days of the procedure was 1% (n=1). Using Clavien-Dindo classification, the major complication rate was 10%, including 8% grade III and 2% grade IV complications. Reoperation (2%) and readmission (3%) were rare in this population. Median length of stay was 7 days and median estimated blood loss was 500 milliliters. Surgical outcomes from the community hospital were comparable to high-volume centers. For pancreatic cancer patients treated at the community hospital, Kaplan-Meier curves revealed comparable 5-year survival time to national data. Complex HPB procedures can be safely performed at a low-volume hospital in Hawai‘i with outcomes comparable to large tertiary centers.

Objectives: Primary care physician-led community hospitals provide basic hospital care for older people in Finland. Yet little is known of the outcomes of the care. We investigated factors associated with discharge destination after hospitalization in a community hospital and the role of active rehabilitation during the stay. Design: Prospective observational study. Setting and Participants: Short-term community hospital stays of older adults (65 years) living in the Kuopio University Hospital district in central and eastern Finland. Methods: Data on short-term (1-31 days) hospital stays from 51 community hospitals were collected with an electronic survey between January and June 2016. Physicians, secretaries, and rehabilitation staff from each community hospital completed the data collection form. Discharge destination was defined as home, residential care or death, and active rehabilitation as frequency of rehabilitation at least once a day. Analyses were conducted using the Bayesian approach and the BayesiaLab 9.1 tool. Results: Data of 11,628 community hospital stays were analyzed. The patients’ mean age was 81.6 years (SD 7.9), and 57.5% were women. A younger age (65-74 years), a high number of rehabilitation staff (>2 per 10 patients), and receiving rehabilitation at least once a day were associated with discharging pa- tients to their own homes. Daily rehabilitation was associated with returning to home in all patient groups. Conclusions and Implications: Older patients admitted to a community hospital for any reason may benefit from active rehabilitation. The role of community hospitals in the acute care and rehabilitation of older patients is important in aging societies.

ImportanceDelays in screening programs and the reluctance of patients to seek medical attention because of the outbreak of SARS-CoV-2 could be associated with the risk of more advanced colorectal cancers at diagnosis.ObjectiveTo evaluate whether the SARS-CoV-2 pandemic was associated with more advanced oncologic stage and change in clinical presentation for patients with colorectal cancer.Design, Setting, and ParticipantsThis retrospective, multicenter cohort study included all 17 938 adult patients who underwent surgery for colorectal cancer from March 1, 2020, to December 31, 2021 (pandemic period), and from January 1, 2018, to February 29, 2020 (prepandemic period), in 81 participating centers in Italy, including tertiary centers and community hospitals. Follow-up was 30 days from surgery.ExposuresAny type of surgical procedure for colorectal cancer, including explorative surgery, palliative procedures, and atypical or segmental resections.Main Outcomes and MeasuresThe primary outcome was advanced stage of colorectal cancer at diagnosis. Secondary outcomes were distant metastasis, T4 stage, aggressive biology (defined as cancer with at least 1 of the following characteristics: signet ring cells, mucinous tumor, budding, lymphovascular invasion, perineural invasion, and lymphangitis), stenotic lesion, emergency surgery, and palliative surgery. The independent association between the pandemic period and the outcomes was assessed using multivariate random-effects logistic regression, with hospital as the cluster variable.ResultsA total of 17 938 patients (10 007 men [55.8%]; mean [SD] age, 70.6 [12.2] years) underwent surgery for colorectal cancer: 7796 (43.5%) during the pandemic period and 10 142 (56.5%) during the prepandemic period. Logistic regression indicated that the pandemic period was significantly associated with an increased rate of advanced-stage colorectal cancer (odds ratio [OR], 1.07; 95% CI, 1.01-1.13; P = .03), aggressive biology (OR, 1.32; 95% CI, 1.15-1.53; P P = .03).Conclusions and RelevanceThis cohort study suggests a significant association between the SARS-CoV-2 pandemic and the risk of a more advanced oncologic stage at diagnosis among patients undergoing surgery for colorectal cancer and might indicate a potential reduction of survival for these patients.

Pharmacists can provide a variety of discharge services that aid in transitions of care. The purpose of this study is to evaluate the impact of a pilot program implementing a unit-based clinical pharmacist at a community teaching hospital.This prospective study evaluated pharmacist-led discharge services on an adult medicine unit over a 5-week period. The control cohort received usual care, and the intervention cohort received additional pharmacy services (e.g., counseling, medication reconciliation, ensuring medication access, and overcoming discharge barriers). The primary outcome was 30-day all-cause hospital readmissions. Secondary outcomes included emergency department (ED) utilization, Hospital Consumer Assessment of Healthcare Providers and Systems scores, and patient satisfaction survey scores.Overall, 197 patients were included in the control group and 210 in the intervention group. Characteristics including previous hospital utilization, comorbidity count, and medication count at discharge were similar between groups. A reduction in 30-day all-cause hospital readmissions was observed in the cohort receiving pharmacist intervention, 13.3% versus 20.8% (p = 0.044). This study also demonstrated a significant decrease in ED utilization rates and improved patient satisfaction.This study adds to the growing body of literature supporting transition of care pharmacists in the hospital discharge model to improve patient care.

Leadership of a multispecialty group practice within a health system recognized in 2015 that population health management requires quality performance improvement and organizational culture change. While blueprints for building successful Accountable Care Organizations (ACOs) exist in the literature, few describe the journey to achieving both shared savings and high quality outcomes achieved by a medical group within an academic health system. Clinician education and engagement, prioritizing prevention and achieving benchmarks, developing supportive roles, more precise documentation of accurate diagnostic coding, and risk stratification constituted the approach. When first participating as an ACO, the medical group built programs and teams to improve quality, while CMS simultaneously changed quality measurements from pay-for-reporting to pay-for-performance. Quality scores initially dipped, though scores have since risen to 98.44% in 2020. Between 2015 and 2017, financial results were more than $10 million below the threshold, while in performance years 2018 to 2020, Northeast Medical Group achieved $24 million in aggregate in shared savings.

Background The optimal management for patients with low grade dysplasia (LGD) in Barrett’s esophagus (BE) is unclear. According to the Dutch national guideline, all patients with LGD with histological confirmation of the diagnosis by an expert pathologist (i. e. “confirmed LGD”), are referred for a dedicated re-staging endoscopy at an expert center. We aimed to assess the diagnostic value of re-staging endoscopy by an expert endoscopist for patients with confirmed LGD. Methods This retrospective cohort study included all patients with flat BE diagnosed in a community hospital who had confirmed LGD and were referred to one of the nine Barrett Expert Centers (BECs) in the Netherlands. The primary outcome was the proportion of patients with prevalent high grade dysplasia (HGD) or cancer during re-staging in a BEC. Results Of the 248 patients with confirmed LGD, re-staging in the BEC revealed HGD or cancer in 23 % (57/248). In 79 % (45/57), HGD or cancer in a newly detected visible lesion was diagnosed. Of the remaining patients, re-staging in the BEC showed a second diagnosis of confirmed LGD in 68 % (168/248), while the remaining 9 % (23/248) had nondysplastic BE. Conclusion One quarter of patients with apparent flat BE with confirmed LGD diagnosed in a community hospital had prevalent HGD or cancer after re-staging at an expert center. This endorses the advice to refer patients with confirmed LGD, including in the absence of visible lesions, to an expert center for re-staging endoscopy.

Background Recognition of precapillary pulmonary hypertension (PH) has significant implications for patient management. However, the low a priori chance to find this rare condition in community hospitals may create a barrier against performing a right heart catheterization (RHC). This could result in misclassification of PH and delayed diagnosis/treatment of precapillary PH. Therefore, we investigated patient characteristics and echocardiographic parameters associated with the decision whether to perform an RHC in patients with incident PH in 12 Dutch community hospitals. Methods and Results In total, 275 patients were included from the OPTICS (Optimizing PH Diagnostic Network in Community Hospitals) registry, a prospective cohort study with patients with incident PH; 157 patients were diagnosed with RHC (34 chronic thromboembolic PH, 38 pulmonary arterial hypertension, 81 postcapillary PH, 4 miscellaneous PH), while 118 patients were labeled as probable postcapillary PH without hemodynamic confirmation. Multivariable analysis showed that older age (>60 years), left ventricular diastolic dysfunction grade 2–3, left atrial dilatation were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilatation, and tricuspid regurgitation velocity ≥3.7 m/s favor an RHC performance. Conclusions Older age and echocardiographic parameters of left heart disease were independently associated with the decision to not perform an RHC, while presence of prior venous thromboembolic events or pulmonary arterial hypertension‐associated conditions, right atrial dilation, and severe PH on echocardiography favored an RHC performance. As such, especially elderly patients may be at an increased risk of diagnostic delays and missed diagnoses of treatable precapillary PH, which could lead to a worse prognosis.

This study aimed to clarify the details of outpatient oral antimicrobial use (AMU) at a Japanese community hospital and investigate the influence of the current inpatient-based antimicrobial stewardship (AS) on outpatients. A repeated cross-sectional study was conducted in Komaki City Hospital. Data on patients, physicians, and oral antibiotics were collected in October 2013, 2016, and 2019, and appropriateness of treatment and surgical antimicrobial prophylaxis (SAP) was evaluated. The percentage of patients receiving oral antibiotics increased significantly from 4.7% in 2013 (345/7338) to 5.9% in 2019 (365/6146), and the overall number of antimicrobial prescriptions per 1000 outpatients increased from 51.8 in 2013 to 68.0 in 2019. Prescriptions for third-generation cephalosporins per 1000 outpatients decreased (from 21.4 to 6.3), whereas the number of prescriptions for penicillin (from 3.8 to 15.3), fluoroquinolones (from 7.0 to 13.2), and co-trimoxazole (from 5.0 to 15.8) increased from 2013 to 2019. The appropriate AMU for overall infections significantly increased (from 68.4% in 2013 to 83.7% in 2019). The choice and duration of AMU significantly improved for SAP. However, even in 2019, only 29.3% of patients received antibiotics before surgery. The improved selection of antibiotics on outpatient prescription may be due to the influence of AS-which is focused on inpatients-while prescriptions for fluoroquinolones and prophylactics also increased. The challenges of antimicrobial administration after surgeries were also highlighted.

BACKGROUND Malnutrition is common and associated with adverse outcomes in geriatric patients with hip fractures. The study aims to evaluate the relationship between the nutritional status and rehabilitation efficiency and functional outcome on discharge in postoperative hip fracture patients. METHODS We prospectively evaluated 172 postoperative hip fracture patients who were admitted to the community hospital from November 2019 to November 2020. Nutritional status was assessed by the 7-point Subjective Global Assessment (SGA) within 48 h of admission. Patients were assessed for rehabilitation efficiency and functional outcome at the end of their inpatient stay. RESULTS There were 172 patients recruited with 100 (58.1%) malnourished and 72 (41.9%) well-nourished patients. Patients in the malnourished group were significantly older, needed walking aid assistance prior to sustaining hip fracture, cognitively impaired and had more comorbidities. Malnourished patients had lower rehabilitation efficiency scores (0.27, 95% CI -0.12 - 0.67 vs 1.32, 95% CI 0.88-1.76) and poorer functional outcomes on discharge (OR 21.5, 95% CI 2.45-188.7, p-value

Objective: To evaluate the prescribing practices and opioid consumption in an ambulatory setting to inform the development of evidence-based guidelines. Design: A prospective study of adults undergoing outpatient open and laparoscopic surgeries over 3 months. One week after discharge, a telephonic interview quantified the number of opioids prescribed and consumed, degree of pain control and satisfaction, and whether additional pain medication was requested. Setting: Community hospital ambulatory surgery center in Westchester County, New York. Participants: This study included 304 adults undergoing a variety of procedures by surgeons from multiple specialties. Main outcome measures: Quantify surgeons’ postoperative opioid prescribing compared with patient opioid consumption. Results: Eighty-one percent (N = 245) responded to the survey, of which 64 percent were prescribed opioids. Males and females were equally represented with the mean age of 59.4 years. Of those prescribed opioids, 92 percent filled the prescription. The most commonly prescribed opioids reported by the patients that filled their prescription (N = 145) were oxycodone (36.5 percent), oxycodone/acetaminophen (28.9 percent), and tramadol (22.7 percent). The mean number of opioid pills prescribed was 20 and the mean consumption was 6.7 pills, resulting in an average of 13 retained pills. Only 3.8 percent of the patients prescribed opioids at discharge called their provider for additional analgesia. Despite the low opioid consumption patients reported high satisfaction (4.5 on scale of 0-5) with pain control. Only 10.4 percent reported that the surgeon recommended an over the counter (OTC) analgesic option. There was variability in the amount of opioids prescribed within each surgical category. Conclusions: One week after outpatient surgery, patients consumed one-third of physician-prescribed opioids, yet they reported high pain management satisfaction. Our study will inform the development of a patient-centered interdisciplinary perioperative education program to more effectively tailor multimodal pain management in ambulatory surgical patients and collaterally reduce the number of retained opioids.

Patient satisfaction is gaining traction in the strategic direction and daily operations of hospital executives. The financial penalty/incentive tied to patient satisfaction scores creates a burning platform to accelerate progress. Previous studies have shown the effectiveness of various improvement strategies including leadership rounding and employee training, among others. There has not been a study utilizing an integrated model that incorporates known best practices into a holistic approach. The integrated model included service excellence training, nursing unit-specific action plans, and weekly leadership rounding. Implementation of the model led to significant and sustainable improvements in patient satisfaction in the community hospital setting. This approach can be leveraged and scaled in other organizations to accelerate the pace of change.

Purpose Small community hospitals often lack the human, financial, and technological resources necessary to implement and maintain successful antimicrobial stewardship programs now required by national regulatory and accrediting bodies. Creative solutions are needed to address this problem. Summary A 3-stage, quasi-experimental study including patients receiving antibiotics for pneumonia, skin and soft tissue infections, and urinary tract infections at a community hospital in Wisconsin from June 2013 to December 2015 was conducted. Remote telehealth prospective audit and feedback, guideline and order set management, and staff education targeting pharmacists, nurses, and physicians were provided during the 7-month intervention phase; these services were then removed for the postintervention period. Antimicrobial utilization (days of therapy [DOT] per 1,000 patient-days), hospital length of stay, and readmission and 30-day mortality rates were assessed to determine the impact of telehealth services on these outcomes. During the preintervention (baseline), intervention, and postintervention periods, 1,037 patients received antibiotics for the targeted infectious disease conditions. Patient demographics and rates of infectious disease conditions were similar among the different periods. Telehealth antimicrobial stewardship reduced broad-spectrum antibiotic use, including use of imipenem (from 83 to 31 DOT, P < 0.001), levofloxacin (from 123 to 99 DOT, P < 0.001), and vancomycin (from 104 to 85 DOT, P < 0.001), compared to utilization during the baseline period; mean (SD) length of stay also decreased (from 4.6 [2.8] days to 4.2 [2.6] days, P = 0.02). After nonrenewal of telehealth stewardship, vancomycin and piperacillin/tazobactam usage returned to or exceeded baseline levels. Conclusion The partnership between an academic medical center and a small community hospital improved antimicrobial utilization and clinical outcomes. Successful telehealth antimicrobial stewardship models should be explored further as a means to provide optimal patient care.

Objectives: This study aims to evaluate the clinical results and experiences in a community hospital regarding procedures for the replantation and revascularization of fingers. Patients and methods: Between June 2015 and December 2019, a total of 58 patients (51 males, 7 females; mean age: 33.4±6.3 years; range, 23 to 46 years) who were followed after total and/or subtotal amputation and replantation were retrospectively analyzed. The patients were evaluated at nine months in terms of cold intolerance, static two-point discrimination, and functional results using the range of motion (ROM) and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Results: The majority of the patients presented with work-related injuries (70%), most commonly by the mechanism of guillotine (64%), and to the dominant hand (76%) and the third finger (36%) most frequently. The overall success rate of digit salvage was 72.9% (n=51). Of 19 digits with unsuccessful surgical outcomes, seven were from total and 12 were from subtotal amputations. In the long-term, cold intolerance was observed in 14 patients (24.1%) according to the cold intolerance severity scale. The mean static two- point discrimination value was 6.0±0.7 mm and the mean QuickDASH score was 22.3±5.0. The mean ROM measured at nine months after surgery in the metacarpophalangeal and interphalangeal joints of the third and fourth digits was significantly lower than that in the others (p Conclusion: The predictors of survival of a replanted digit indicated in this study can be used as a guide and decision-making aid for any attempts for replantation.

RESUMO Mudanças epidemiológicas decorrentes do envelhecimento populacional motivaram transformações nos sistemas de saúde mundiais. Desde 1990, emergem discussões sobre Cuidados Intermediários (CI), visando diminuir hospitalizações, melhorar a coordenação do cuidado e estimular políticas públicas de cuidados próximos ao território. Este trabalho objetivou apresentar e analisar a literatura científica sobre CI, enfatizando serviços de Hospitais Comunitários. Realizou-se uma revisão integrativa, combinando os descritores “Intermediate Care”, “Community Hospitals”, “Intermediate Care Facilities”, “Long-Term Care”, “Hospitals Chronic Disease” e “Rehabilitation Services”, nos idiomas português, inglês e espanhol, nas bases Portal Regional da Biblioteca Virtual em Saúde, PubMed e Biblioteca Digital Brasileira de Teses e Dissertações. Após processo de busca e elegibilidade, foram incluídos 30 documentos para síntese qualitativa, provenientes de: Reino Unido, Noruega, Espanha, Dinamarca, Austrália e Itália. Resultados apontam para a eficácia, a efetividade e a eficiência dos CI, com boas avaliações por parte de profissionais e usuários. Os CI, como estratégia de fortalecimento da Atenção Primária à Saúde, redução de internações, favorecimento da independência funcional dos pacientes e seu retorno à comunidade, apresentam-se como uma inovação em saúde e aposta promissora. Entretanto, persistem lacunas na literatura que ensejam mais estudos sobre o tema, com vistas a subsidiar a tomada de decisão. ABSTRACT Epidemiological changes resulting from populational aging have led to changes in global health systems. Since 1990, discussions on Intermediate Care (IC) have emerged, with a view to reducing hospitalizations, improving care coordination, and stimulating public care policies close to the territory. This work aims to present and analyze the scientific literature on CI, emphasizing services from Community Hospitals. An integrative review was carried out, combining the descriptors “Intermediate Care”, “Community Hospitals”, “Intermediate Care Facilities”, “Long-Term Care”, “Hospitals Chronic Disease”, and “Rehabilitation Services”, in Portuguese, English and Spanish, in the Regional Portal of Virtual Health Library, PubMed and Digital Library of Thesis and Dissertations bases. After the search and eligibility process, 30 documents were included for qualitative synthesis, coming from: The United Kingdom, Norway, Spain, Denmark, Australia and Italy. Results point to the efficacy, effectiveness and efficiency of ICs, with good evaluations by professionals and users. ICs, as a strategy to strengthen Primary Health Care, reduce hospital admissions, favor patients’ functional independence and return to the community, are presented as a health innovation and promising bet. However, there are gaps in the literature that lead to more studies on the topic, with a view to supporting decision making.

Objective The establishment of a department of general internal medicine (GIM) has been shown to improve the clinical outcomes among patients treated in GIM departments but the effect on practice patterns in other departments remains unclear. We evaluated the association between the establishment of a GIM department and the use of blood cultures, an indicator of quality of care of infectious diseases, in other departments. Methods This study was conducted between 2013 and 2017 in a community hospital which established a new GIM department in 2015, with a mandate to improve the quality of care of the hospital including infectious disease management. The primary outcome was the change in the number of blood culture episodes per calendar month in other departments before and after establishment of the GIM department. The secondary outcome was the change in the blood culture episodes per month, indexed to 1,000 patient-days, during the same time. Using 2015 as the phase-in period, interrupted time series analyses were used to evaluate the change in the outcome variables. Results In departments other than GIM, there were 284 blood cultures prior to the establishment of the GIM department (2013-2014) and 853 afterwards (2016-2017). The number of blood culture episodes in other departments increased by 10.7 (95%CI: 0.39-21.0, p=0.042) per calendar month after the establishment of the GIM department; blood culture episodes / calendar month / 1,000 patient-days increased by 0.55 (95%CI: 0.03-1.07 p=0.037). Conclusion These results indicate that a GIM department in a community hospital can improve the quality of care in other departments.

Clostridioides difficile infection (CDI) is known for significant morbidity and mortality. Fecal microbiota transplantation (FMT) is an effective therapy for recurrent and resistant CDI. However, its impact on the mortality rate of patients with severe and fulminant CDI has not been rigorously studied yet. We aimed to evaluate the effectiveness of FMT on the mortality rate of patients with severe or fulminant CDI in a community hospital system.Our study included 106 inpatients with severe or fulminant CDI. Both standard-of-care (SOC) and FMT were provided to 14 (13.2%) patients (the FMT group). SOC antibiotics alone were provided to 92 (86.8%) patients, out of whom 28 patients were included via propensity score matching in a 2:1 ratio (the SOC group). The primary outcome was defined as the composite end-point of mortality during admission, within 30 and 90 days after discharge, and discharge with comfort measures only. Each component was a secondary end-point.The primary outcome rate in the FMT group was 7.1% (1/14) compared to 25.0% (7/28) in the SOC group. Univariate analysis demonstrated that FMT decreases mortality (odds ratio [OR] 0.08, 95% confidence interval [CI] 0.01-0.58, P = 0.01). However, multivariate regression did not show statistical significance (OR 0.15, 95% CI 0.01-2.53, P = 0.19), possibly due to the small sample size.FMT may decrease the mortality of patients with severe and fulminant CDI. Large studies are needed to validate these findings.

With the diversification of medical care and work reform, doctor clerks play a major role today and are recruited to mitigate the burden of doctors worldwide. Their recruitment can improve the working conditions of physicians, facilitate task shifting in rural community hospitals, improve patient care, and help address the lack of healthcare resources. This study used a qualitative method to investigate difficulties in the implementation of doctor clerks and ascertain the features of effective implementation by collecting ethnographic data through field notes and semi-structured interviews with workers. We observed and interviewed 4 doctor clerks, 10 physicians, 14 nurses, 2 pharmacists, 1 nutritionist, and 2 therapists for our study. We clarified the doctor clerk process in rural hospitals through four themes: initial challenge, balance between education and expansion, vision for work progression, and drive for quality of care. We further clarified effectiveness, difficulties, and enhancing factors in implementation. Doctor clerk recruitment and bridging of discrepancies among medical professionals can mitigate professional workloads and improve staff motivation, leading to better interprofessional collaboration and patient care.

IntroductionThe 500 community hospitals in the UK provide a range of services to their communities. The response of these small, mainly rural, hospitals to the COVID-19 pandemic has not yet been examined and so this study sought to address this gap.MethodAppreciative inquiry was used to understand staff perspectives of how community hospitals responded to the COVID-19 (SARS-CoV-2) pandemic. A total of 20 organisations participated, representing 168 (34%) community hospitals in the UK. Qualitative interviews were conducted, with a total of 85 staff members, using an online video platform. 30 case studies were developed from these interviews.ResultsStaff described positive changes that were made in the context of the fear and uncertainty experienced in the pandemic. Quality improvements were reported in a wide range of services and models of care such as the use of the inpatient beds, and the access and management of urgent care services. Rapid changes were made in the way that services were managed, such as communications and leadership. Programmes of accelerated training were offered for existing and redeployed staff. Attention to staff health and well-being was a feature and there were a variety of innovations designed to support patients and their families. The impact of the changes was viewed as strengthening of integrated working between staff and sectors, the ability to rapidly innovate and improve quality, and the scope to use local decision-making to make changes.ConclusionStaff of community hospitals described innovative and rapid quality improvements in their community hospitals in response to the pandemic. The case studies illustrated the features of community hospitals, showing that they can be resilient, flexible, responsive, creative, compassionate and integrated. The case studies of quality improvements are being used to encourage sharing and learning across community hospitals and beyond.

Introduction: There are limited studies exploring functional improvement in relation to characteristics of patients who, following acute hospital care, receive inpatient rehabilitation in community hospitals. We evaluated the association of acute hospital admission-related factors with functional improvement on community hospital discharge. Methods: We conducted a retrospective cohort study among patients who were transferred to community hospitals within 14-day post-discharge from acute hospital between 2016 and 2018. Modified Barthel Index (MBI) on a 100-point ordinal scale was used to assess functional status on admission to and discharge from the community hospital. We categorised MBI into 6 bands: 0–24, 25–49, 50–74, 75–90, 91–99 and 100. Multivariable logistic regression models were constructed to determine factors associated with categorical improvement in functional status, defined as an increase in at least one MBI band between admission and discharge. Results: A total of 5,641 patients (median age 77 years, interquartile range 69–84; 44.2% men) were included for analysis. After adjusting for potential confounders, factors associated with functional improvement were younger age, a higher MBI on admission, and musculoskeletal diagnosis for the acute hospital admission episode. In contrast, a history of dementia or stroke; lower estimated glomerular filtration rate; abnormal serum albumin or anaemia measured during the acute hospital episode; and diagnoses of stroke, cardiac disease, malignancy, falls or pneumonia; and other chronic respiratory diseases were associated with lower odds of functional improvement. Conclusion: Clinicians may want to take into account the presence of these high-risk factors in their patients when planning rehabilitation programmes, in order to maximise the likelihood of functional improvement. Keywords: Barthel Index, community hospitals, functional status, inpatients, rehabilitation, risk factors

Patients with suspected non-convulsive seizures are optimally evaluated with EEG. However, limited EEG infrastructure at community hospitals often necessitates transfer for long-term EEG monitoring (LTM). Novel point-of-care EEG systems could expedite management of nonconvulsive seizures and reduce unnecessary transfers. We aimed to describe the impact of rapid access to EEG using a novel EEG device with remote expert interpretation (tele-EEG) on rates of transfer for LTM.We retrospectively identified a cohort of patients who underwent Rapid-EEG (Ceribell Inc., Mountain View, CA) monitoring as part of a new standard-of-care at a community hospital. Rapid-EEGs were initially reviewed on-site by a community hospital neurologist before transitioning to tele-EEG review by epileptologists at an affiliated academic hospital. We compared the rate of transfer for LTM after Rapid-EEG/tele-EEG implementation to the expected rate if rapid access to EEG was unavailable.Seventy-four patients underwent a total of 118 Rapid-EEG studies (10 with seizure, 18 with highly epileptiform patterns, 90 with slow/normal activity). Eighty-one studies (69%), including 9 of 10 studies that detected seizures, occurred after-hours when EEG was previously unavailable. Based on historical practice patterns, we estimated that Rapid-EEG potentially obviated transfer for LTM in 31 of 33 patients (94%); both completed transfers occurred before the transition to tele-EEG review.Rapid access to EEG led to the detection of seizures that would otherwise have been missed and reduced inter-hospital transfers for LTM. We estimate that the reduction in inter-hospital transportation costs alone would be in excess of $39,000 ($1,274 per patient). Point-of-care EEG systems may support a hub-and-spoke model for managing non-convulsive seizures (similar to that utilized in this study and analogous to existing acute stroke infrastructures), with increased EEG capacity at community hospitals and tele-EEG interpretation by specialists at academic hospitals that can accept transfers for LTM.

Describe patient social needs in a large midwestern health care system. Health care systems are increasingly interested in addressing social needs in the clinical setting for improved health outcomes and lower costs. This retrospective cross-sectional analysis of health records data was a population health pilot project which tested a digital platform to screen and refer patients for social needs across three community hospitals serving Chicago and its South Suburbs. The analysis reports on social needs identified based on the referrals made. Electronic health record data were linked to the referral data to describe patient clinical and demographic characteristics. A total of 2909 patients had at least 1 social need identified. The mean age was 49 years ±21.7 and 65.7% were women. Only 33% of patients had 1 social need identified, indicating that if a social need is identified for patients, they most likely have social needs from other categories as well. Patients of color, specifically African American patients, were 14% more likely to have at least 3 social need categories identified (95% confidence interval of relative risk: 1.02-1.29). Financial stability was the most commonly reported social need (50.7%), followed by food and nutrition (43%). Transportation (22%) and housing (21%) were also commonly reported. This population health initiative reveals that many patients accessing health care have multiple social needs that can be identified at the point of care, and patterns of need-based referral vary by patient clinical and demographic characteristics.

Background There is limited research on individual patient characteristics, alone or in combination, that contribute to the higher levels of mortality in post-transfer patients. The purpose of this work is to identify significant combinations of diagnoses that identify subgroups of post-interhospital transfer patients experiencing the highest levels of mortality. Methods This was a retrospective cross-sectional study using structured electronic health record data from a regional health system between 2010–2017. We employed a machine learning approach, association rules mining using the Apriori algorithm to identify diagnosis combinations. The study population includes all patients aged 21 and older that were transferred within our health system from a community hospital to one of three main receiving hospitals. Results Overall, 8893 patients were included in the analysis. Patients experiencing mortality post-transfer were on average older (70.5 vs 62.6 years) and on average had more diagnoses in 5 of the 6 diagnostic subcategories. Within the diagnostic subcategories, most diagnoses were comorbidities and active medical problems, with hypertension, atrial fibrillation, and acute respiratory failure being the most common. Several combinations of diagnoses identified patients that exceeded 50% post-interhospital transfer mortality. Conclusions Comorbid burden, in combination with active medical problems, were most predictive for those experiencing the highest rates of mortality. Further improving patient level prognostication can facilitate informed decision making between providers and patients to shift the paradigm from transferring all patients to higher level care to only transferring those who will benefit or desire continued care, and reduce futile transfers.