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Despite universal healthcare, immigrants often face unique challenges accessing healthcare. Employing an interpretative phenomenological analysis approach, four focus groups were conducted with 29 women and eight men from 15 different countries attending English language classes hosted at a non-governmental organization in Regina, Saskatchewan, Canada in 2016 and 2017. Personal factors such as language barrier, lack of transportation, childcare and others interacted with systemic factors such as lack of appointment, long wait times, etc. delaying access at each point of contact with the healthcare system. Participants expressed dissatisfaction with the potency of medications, time spent in appointments and the way healthcare professionals communicated health information. The referral process and wait times were viewed as barriers to accessing specialist, diagnostic and acute care services. Participants were concerned that appropriate healthcare will be unavailable when needed. Strategies addressing systemic and person-specific barriers are needed to provide equitable client-centered care.

The goal of this study is to provide empirical evidence of the impact of nurse staffing levels on seven nursing-sensitive patient outcomes (NSPOs) at the hospital unit level. Combining a very large set of claims data from a German health insurer with mandatory quality reports published by every hospital in Germany, our data set comprises approximately 3.2 million hospital stays in more than 900 hospitals over a period of 5 years. Accounting for the grouping structure of our data (i.e., patients grouped in unit types), we estimate cross-sectional, two-level generalized linear mixed models (GLMMs) with inpatient cases at level 1 and units types (e.g., internal medicine, geriatrics) at level 2. Our regressions yield 32 significant results in the expected direction. We find that differentiating between unit types using a multilevel regression approach and including postdischarge NSPOs adds important insights to our understanding of the relationship between nurse staffing levels and NSPOs. Extending our main model by categorizing inpatient cases according to their clinical complexity, we are able to rule out hidden effects beyond the level of unit types. Supplementary Information The online version contains supplementary material available at 10.1007/s10198-021-01292-2.

BACKGROUND: Patients are frequently discharged from the hospital before all test results have been finalized. Thirty to 40% of tests pending at discharge (TPADs) return potentially actionable results that could necessitate change in the patients’ management, often unbeknownst to their physicians. Delayed follow-up of TPADs can lead to patient harm. We sought to synthesize the existing literature on interventions intended to improve the management of TPADs, including interventions designed to enhance documentation of TPADs, increase physician awareness when TPAD results finalize post-discharge, decrease adverse events related to missed TPADs, and increase physician satisfaction with TPAD management. METHODS: We searched Medline, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Database of Controlled Clinical Trials and Medline (January 1, 2000–November 10, 2016) for randomized controlled trials and prospective, controlled observational studies that evaluated interventions to improve follow-up of TPADs for adult patients discharged from acute care hospitals or emergency department settings. From each study we extracted characteristics of the intervention being evaluated and its impact on TPAD management. RESULTS: Nine studies met the criteria for inclusion. Six studies evaluated electronic discharge summary templates with a designated field for documenting TPADs, and three of six of these studies reported a significant improvement in documentation of TPADs in discharge summaries in pre- and post-intervention analysis. One study reported that auditing discharge summaries and providing feedback to physicians were associated with improved TPAD documentation in discharge summaries. Two studies found that email alerts when TPADs were finalized improved physicians' awareness of the results and documentation of their follow-up actions. Of the four studies that assessed patient morbidity, two showed a positive effect; however, none specifically measured the impact of their interventions on downstream patient harm due to delayed follow-up of TPADs. Three studies surveyed physicians’ attitudes towards the interventions, of which two studies reported improved physician satisfaction with TPAD management with the implementation of an enhanced discharge template and a notification system when TPADs finalize. DISCUSSION: Discharge summary templates, educational interventions for discharging physicians, and email alerts when TPAD results are finalized show promise in improving management of TPADs. Given the complexity of the processes necessary to ensure follow-up of TPADs, rigorous evaluations of multifaceted interventions (e.g., improved discharge documentation of TPADs combined with email alerts when results become available) is needed. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-017-4290-9) contains supplementary material, which is available to authorized users.

T his literature review by Luu et al. 1 examines the results of 20 studies about provider-to-provider communication for the transfer of persons from outpatient to inpatient care settings. The authors narrowed their results from 4009 initial citations by including only original articles written in English, involving human subjects, and that were clearly about transitions of care or direct provider-to-provider communication. The result is a small cohort of studies from the US, the UK, and Australia, through which the authors explore the frequency and type of communication methods used during transitions of care from outpatient to inpatient settings. They found that most of these studies themselves were small and presented statistically insignificant data about communication outcomes, and thus conclude that the existing evidence regarding outpatient-to-inpatient provider-to-provider communication is insufficient. The authors attempt to address and evaluate what is known about provider-to-provider communication during outpatient-to-inpatient care transitions and the potential effects of direct provider-to-provider communication on certain outcomes, including mortality, readmissions, length of stay, patient and provider satisfaction, and utilization. Unfortunately, the study’s size and approach limit its overall value, except to note in the conclusion that more robust studies about outpatient-to-inpatient provider-to-provider communication are needed. It is also unclear how the noted outcome measures were identified, or that they are capable of defining ideal communication methods for optimizing patient care and minimizing potential medical errors during outpatient-to-inpatient transitions. Many variables that occur after an outpatient-to-inpatient transition, and that are unrelated to the initial communication, can affect all the identified outcome measures. Other unexamined pieces would have been helpful to address, such as to what degree provider communication plays a role in determining whether transitions from outpatient to inpatient care settings align with patient wishes, and whether such communications affect treatment decision-making at the moment of inpatient admission. At least mentioning the potential influences of macroand micro-systematic differences in the provision of health care between the US, the UK, and Australia would also be helpful in contextualizing the importance and impact of communication with outpatient-toinpatient care transitions. Future work should also study how the reasons for outpatient-to-inpatient transfers are communicated between providers.

Day hospital mental health programs provide alternate care to individuals of high acuity that do not require an inpatient psychiatric stay. Ensuring provision of best practice within these programs is essential for patient stabilization and recovery. However, there is scant literature to review when creating such a program. This paper provides an overview of the steps an acute care hospital took when designing and implementing new programming within a day hospital program. Qualitative data was collected following initial program rollout. This data helped to inform the ongoing modification of groups offered, group scheduling and content, as well as ensuring patient satisfaction and adequate skill delivery during the rollout period and beyond. The goal of this paper is to inform health service delivery for other programs when attempting to build or re-design a day hospital program.

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.

Coronavirus disease 2019 (COVID-19) is a severe, novel virus that has spread globally. The implementation of a combination of public health interventions is required to reduce viral spread and avoid overwhelming acute care systems. Once available, an effective vaccination will further mitigate the impact of the COVID-19 pandemic. However, decision makers will initially need to prioritise access to limited vaccine stockpiles as these will be insufficient to vaccine the whole population. The aim of this study is to identify optimal vaccine allocation strategies defined by age and risk target groups, coverage, effectiveness, and cost of vaccine, within a dynamic context where other public health responses and population behaviour change. In this study we use an epidemiological model of COVID-19 that has been enhanced to produce expected costs and Quality Adjusted Life Year results as well as total cases, hospitalisations, deaths, and net monetary benefit. We use the model to simulate hypothetical scenarios where vaccine is allocated beginning on October 15, 2020 with vaccine assumptions ranging from moderately optimistic to ‘worst-case scenario’. Net monetary benefit is used as the objective for optimisation. In a scenario with a sterilizing vaccine that is 80% effective, a stockpile sufficient for 40% population coverage, and prioritisation of those over the age of 60 at high risk of poor outcomes, active cases are reduced by 29.2% and net monetary benefit increased by $297 million dollars, relative to an identical scenario with no vaccine. The relative impact of prioritisation strategies varies greatly depending on concurrent public health interventions, for example, polices such as school closures and senior contact reductions have similar impacts on incremental net monetary benefit when there is no prioritisation given to any age or risk group (147 vs. 120 million, respectively), but when older and high risk groups are given priority, the benefit of school closures is much larger than reducing contacts for seniors (iNB 122 vs. 79 million, respectively). Results demonstrated that rank ordering of different prioritisation options varied greatly by prioritisation criteria, with different vaccine effectiveness and coverage, and by concurrently implemented policies. The results of this paper have three key policy implications: (i) that optimal vaccine allocation will depend on the public health policies, and human behaviours in place at the time of allocation; (ii) the outcomes of vaccine allocation policies can be greatly supported with interventions targeting contact reduction in critical sub-populations; and (iii) the identification of the optimal strategy depends on which outcomes are prioritised.

Qualitative study. The purpose of this study is to understand the patient perspective after diagnosis of an acute traumatic spinal cord injury (tSCI). Discussing the diagnosis and prognosis of a tSCI with a patient can be a challenging experience for both the patient and the physician. As such, this paper attempts to better understand the patient experience to improve communication when discussing this life-altering injury. Vancouver General Hospital, Vancouver, British Columbia, Canada. This study is a qualitative study utilizing grounded theory and semi-structured interviews. The interview transcripts were manually coded using manifest and latent content analysis. Major and minor codes were identified and discussed. In total, 17 interviews were conducted, fifteen individuals with tSCI who received acute care at Vancouver General Hospital (VGH) and eleven family members were interviewed. Patient participants were interviewed individually or in a paired interview with a participating family member. Patient participants had varying spinal cord injuries from AIS A-D. Two major themes were identified from the interviews. The first major theme was physician demeanor (general approach and attitude towards patients) and the second major theme was delivery of information (content, timing, and source). This study summarizes the preferences of patients who sustained a tSCI discussions regarding their diagnosis and prognosis in the acute care setting. The goal of this study is to help guide physician interactions at this difficult and vulnerable time for patients with hopes to improve patient care through effective communication.

Whether practiced by ethics committees or clinical ethicists, medical ethics enjoys a solid foundation in acute care hospitals. However, medical ethics fails to have a strong presence in the primary care setting. Recently, some ethicists have argued that the reason for this disparity between ethics in the acute and primary care setting is that primary care ethics is distinct from acute care ethics: the failure to translate ethics to the primary care setting stems from the incorrect belief that acute care ethics can be applied to the primary care setting. In this paper, I argue that primary care ethics and acute care ethics are species of the same ethical genus, and that the ethical differences are not ones of kind but of circumstance. I do this by appealing to the role obligations that underlie acute care and primary care clinicians' medical ethical obligations and the shared institutions that ground those obligations.

Early detection of clinical deterioration and timely escalation are critical for improving patient safety and preventing subsequent events in hospitals/acute care settings. This paper reviewed existing Rapid Response Systems (RRS) and their applications that incorporate Early Warning Score (EWS) for escalating patient deterioration and rapid response. We identified and analysed response applications and key factors impacting on ward nurses’ ability to recognise and respond to patients deterioration. The literature reports comprise of adoption of various EWS protocols, communication policies, and educational strategies to the specialised healthcare team that have been introduced in the acute care settings to improve patient deterioration workflow. It was found that there are gaps and limitations at different stages of RRS from vital signs collection to escalation and response. Currently, there is no single solution available for clinicians to adopt an efficient escalation workflow. Therefore, there is a clear need for a connected, integrated, user-friendly and effective solution for collection of vital signs to timely escalation and response. Finally, we discussed key gaps and limitations of RRS with future direction and recommendations.

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.

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.

The core competency of the healthcare system is to provide treatment and care to the patient. The prime focus has always been towards appointing specialized physicians, well-trained nurses and medical staffs, well-established infrastructure with advanced medical equipment, and good quality pharmacy items. But, of late, the focus is driven towards management side of healthcare systems which include proper capacity planning, optimal resource allocation, and utilization, effective and efficient inventory management, accurate demand forecasting, proper scheduling, etc. and may be dealt with a number of operations research tools and techniques. In this paper, a Markov decision process inventory model is developed for a hospital pharmacy considering the information of bed occupancy in the hospital. One of the major findings of this research is the significant reduction in the inventory level and total inventory cost of pharmacy items when the demand for the items is considered to be correlated with the number of beds of each type occupied by the patients in the healthcare system. It is observed that around 53.8% of inventory cost is reduced when the bed occupancy state is acute care, 63.9% when it is rehabilitative care, and 55.4% when long-term care. This may help and support the healthcare managers in better functioning of the overall healthcare system.

Pharmacists working in community and primary care are increasingly developing advanced skills to provide enhanced services, particularly in dealing with minor acute illness. These services can potentially free-up primary care physicians’ time; however, it is not clear whether they are sufficiently cost effective to be recommended for wider provision in the UK. The aim of this study was to review published economic evaluations of enhanced pharmacy services in the community and primary care settings. We undertook a systematic review of economic evaluations of enhanced pharmacy services to inform NICE guidelines for emergency and acute care. The review protocol was developed and agreed with the guideline committee. The National Health Service Economic Evaluation Database, Health Technology Assessment Database, Health Economic Evaluations Database, MEDLINE and EMBASE were searched in December 2016 and the search was updated in March 2018. Studies were assessed for applicability and methodological quality using the NICE Economic Evaluation Checklist. Of 3124 records, 13 studies published in 14 papers were included. The studies were conducted in the UK, Spain, The Netherlands, Australia, Italy and Canada. Settings included community pharmacies, primary care/general practice surgeries and patients’ homes. Most of the studies were assessed as partially applicable with potentially serious limitations. Services provided in community and primary care settings were found to be either dominant or cost effective, at a £20,000 per quality-adjusted life-year threshold, compared with usual care. Those delivered in the patient’s home were not found to be cost effective. Advanced pharmacy services appear to be cost effective when delivered in community and primary care settings, but not in domiciliary settings. Expansion in the provision of these services in community and primary care can be recommended for wider implementation.

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.

An amendment to this paper has been published and can be accessed via the original article.

The International Classification of Functioning, Disability and Health (ICF) provides a standardized language of almost 1500 ICF categories for coding information about functioning and contextual factors. Short lists (ICF Core Sets) are helpful tools to support the implementation of the ICF in clinical routine. In this paper we report on the implementation of ICF Core Sets in clinical routine using the "ICF Core Sets for Hand Conditions" and the "Lighthouse Project Hand" as an example. Based on the ICF categories of the "Brief ICF Core Set for Hand Conditions", the ICF-based assessment tool (ICF HandA) was developed aiming to guide the assessment and treatment of patients with injuries and diseases located at the hand. The ICF HandA facilitates the standardized assessment of functioning - taking into consideration of a holistic view of the patients - along the continuum of care ranging from acute care to rehabilitation and return to work. Reference points for the assessment of the ICF HandA are determined in treatment guidelines for selected injuries and diseases of the hand along with recommendations for acute treatment and care, procedures and interventions of subsequent treatment and rehabilitation. The assessment of the ICF HandA according to the defined reference points can be done using electronic clinical assessment tools and allows for an automatic generation of a timely medical report of a patient's functioning. In the future, the ICF HandA can be used to inform the coding of functioning in ICD-11.

Undergraduate clinical education follows the "bedside" tradition that exposes students to inpatients. However, the hospital learning environment has two main limitations. First, most inpatients require acute care, and students may complete their training without seeing patients with frequent non-emergent and chronic diseases that are managed in outpatient settings. Second, students rarely cope with diagnostic problems, because most inpatients are diagnosed in the community or the emergency room. These limitations have led some medical schools to offer longitudinal integrated clerkships in community settings instead of hospital block clerkship rotations. In this paper, I propose the hypothesis that the hospital learning environment has a third limitation: it causes students' distress and delays their development of reflectivity and medical professionalism. This hypothesis is supported by evidence that (a) the clinical learning environment, rather than students' personality traits, is the major driver of students' distress, and (b) the development of attributes, such as moral reasoning, empathy, emotional intelligence and tolerance of uncertainty that are included in the definitions of both reflectivity and medical professionalism, is arrested during undergraduate medical training. Future research may test the proposed hypothesis by comparing students' development of these attributes during clerkships in hospital wards with that during longitudinal clerkships in community settings.

Nursing is recognized as a stressful occupation where the incidence of negative outcomes such as burnout and high attrition has been well documented. Studies have consistently found that a higher level of resilience is related to retention in the nursing workforce. Mindfulness has been shown to lower levels of burnout and may play an important role in resilience to vicarious trauma. A brief mindful self-care and resiliency (MSCR) program aimed specifically at reducing compassion fatigue, and enhancing nurses’ resilience was piloted in a tertiary acute care hospital in Australia. This paper reports findings from the qualitative component of a mixed methods study which aimed to explore nurses’ responses to the MSCR program including its perceived feasibility, acceptability, and applicability. A sample of 20 nurses completed the MSCR program, of which 16 nurses (80% response) participated in individual unstructured interviews. Verbatim transcripts of the audio recorded interviews were subjected to thematic analysis. Five themes emerged that described participants’ perceptions of how the program benefitted nurses and its applicability in routine practice: Gaining perspective and insight; developing feelings of inner calm; taking time to care for self; feasibility and acceptability of the MSCR program; and using self-care strategies. The MSCR program was found to be feasible and acceptable from the perspective of nurse participants working in this acute care hospital. Fifteen nurses (94%) reported using mindful awareness and self-regulation after completing the program indicating that the strategies offered were practicable in this work setting.

Background Assessment of the current situation is crucial before introducing innovative infection prevention measures. According to the literature, hospital managers should take on the role of “power promoters” in adopting infection prevention measures due to their position and decision-making authority. However, there is no empirical evidence for whether or not this assumption is valid. This paper reports German hospital managers’ perceptions of current challenges in infection prevention and control and innovative prevention measures. We analysed the managerial promoters and barriers of adopting innovations in order to derive recommendations for improving the innovation process in hospitals using the novel AHOI-approach to actively involve patients and their relatives in anti-infection measures. Methods All 3877 medical, nursing and administrative managers of German hospitals were invited to participate in an online survey. The first set of questions intended to determine their perception of problems of hygiene management in their institution and in particular in the interaction with patients and their relatives. The second set of questions was asked to identify potential challenges and barriers to combating nosocomial infections and involving patients and their relatives in infection prevention. Results Two hundred six managers from German hospitals participated in the survey. Transmission of pathogens was seen as the main problem in the inpatient area, especially in acute care hospitals and stationary geriatric care. Barriers to the implementation of novel infection prevention concepts were primarily perceived as lack of time and refinancing by health insurance providers. The surveyed hospital managers assessed that the active involvement of patients and their relatives in infection prevention could strengthen the infection prevention of their institution. Conclusions Hospital managers are open to innovative hygiene interventions. In particular, they welcome the active involvement of patients and their relatives in infection prevention. Therefore, financial and institutional barriers, such as insufficient funding of hygiene management, must be overcome.

Background Involving link nurses in infection prevention and control is a strategy to improve clinical practice that has been implemented in hospitals worldwide. However, little is known about the use, the range and benefits of this strategy. We aimed to identify key concepts of infection control link nurses (ICLN) and ICLN programs, to evaluate the effect of such programs, and to identify gaps in the evidence base. Methods In a scoping review, we searched PubMed, CINAHL, Google and Google Scholar for manuscripts on ICLN in acute care hospitals. We included research- and opinion-based papers, abstracts, reports and guidelines. Results We included 29 publications and identified three key concepts: the profile of ICLN, strategies to support ICLN, and the implementation of ICLN programs. The majority of included studies delineates the ICLN profile with accompanying roles, tasks and strategies to support ICLN, without a thorough evaluation of the implementation process or effects. Few studies report on the effect of ICLN programs in terms of patient outcomes or guideline adherence, with positive short term effects. Conclusion This scoping review reveals a lack of robust evidence on the effectiveness of ICLN programs. Current best practice for an ICLN program includes a clear description of the ICLN profile, education on infection prevention topics as well as training in implementation skills, and support from the management at the ward and hospital level. Future research is needed to evaluate the effects of ICLN on clinical practice and to further develop ICLN programs for maximal impact. Electronic supplementary material The online version of this article (10.1186/s13756-019-0476-8) contains supplementary material, which is available to authorized users.

The need for supportive and palliative care services in patients with cancer is well established. However, the emerging unique challenges of acutely unwell patients with cancer necessitate the need for research into the optimal strategies and pathways for their management. The clinical challenges of emergency oncology alongside its increasing financial burden have led to an interest as to the best strategies for delivering this care. In the USA and UK, varying models of emergency and acute care are developing. There is a clear need for non-oncology physicians with an interest in the management of oncological emergencies to be at the heart of this work. This paper considers the current situation in the USA and UK and the future directions for the delivery of this care.

Background Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It is hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Main body Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Conclusion Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system.

Within the current healthcare system, individuals recognized to be at imminent risk for suicide are likely to be referred for inpatient psychiatric care. The hospitalization setting provides a safe and supportive environment for specialty acute care services and stabilization. However, the majority of current interventions that are delivered to suicidal patients during this sensitive timeframe do not directly target suicide risk. Cognitive Behavior Therapy (CBT) is an evidence-based psychotherapeutic intervention that can easily be adapted for use in psychiatric inpatient settings. A specialized outpatient CBT protocol for suicide prevention has been developed and empirically evaluated by Drs. Aaron Beck and Gregory Brown at the University of Pennsylvania. This brief and targeted outpatient CBT program has been found to be efficacious in reducing the likelihood of subsequent suicide attempts by 50 %. Post-Admission Cognitive Therapy (PACT) is an inpatient adaptation of the CBT protocol for suicide prevention, developed by Dr. Marjan Ghahramanlou-Holloway at the Uniformed Services University of the Health Sciences. PACT is currently undergoing empirical validation, but it is important to note that the components of PACT are all cognitive behavioral practices recognized to reduce suicide risk. PACT is a promising inpatient CBT program that can be delivered in individual format to suicidal patients during their hospital stays. This intervention provides an opportunity to collaboratively review the suicide narrative, to conceptualize underdeveloped and overdeveloped skills directly tied to suicide risk, and to plan for safety and relapse prevention. Moreover, based on their conceptualization of the suicide mode activation for each patient, PACT clinicians choose cognitive behavioral strategies to modify thoughts, emotions, and/or behaviors that are most likely to result in a recurrence of suicidal behaviors. This paper provides a brief review of inpatient-based CBT options, introduces providers to the PACT inpatient protocol, and describes several promising alternate interventions.

This paper is an examination of hospital 30-day readmission costs using data from 119 acute care hospitals operated by the U.S. Veterans Administration (VA) in fiscal year 2011. We applied a two-part model that linked readmission probability to readmission cost to obtain patient level estimates of expected readmission cost for VA patients overall, and for patients discharged for three prevalent conditions with relatively high readmission rates. Our focus was on the variable component of direct patient cost. Overall, managers could expect to save $2140 for the average 30-day readmission avoided. For heart attack, heart failure, and pneumonia patients, expected readmission cost estimates were $3432, $2488 and $2278. Patient risk of illness was the dominant driver of readmission cost in all cases. The VA experience has implications for private sector hospitals that treat a high proportion of chronically ill and/or low income patients, or that are contemplating adopting bundled payment mechanisms.

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.

Background The Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) is an international collaborative project with the overall objective of standardizing the approach to the evaluation and treatment of critically ill patients world-wide, in accordance with best-practice principles. One of CERTAIN’s key features is clinical decision support providing point-of-care information about common acute illness syndromes, procedures, and medications in an index card format. Methods This paper describes 1) the process of developing and validating the content for point-of-care decision support, and 2) the content management system that facilitates frequent peer-review and allows rapid updates of content across different platforms (CERTAIN software, mobile apps, pdf-booklet) and different languages. Results Content was created based on survey results of acute care providers and validated using an open peer-review process. Over a 3 year period, CERTAIN content expanded to include 67 syndrome cards, 30 procedure cards, and 117 medication cards. 127 (59 %) cards have been peer-reviewed so far. Initially MS Word® and Dropbox® were used to create, store, and share content for peer-review. Recently Google Docs® was used to make the peer-review process more efficient. However, neither of these approaches met our security requirements nor has the capacity to instantly update the different CERTAIN platforms. Conclusion Although we were able to successfully develop and validate a large inventory of clinical decision support cards in a short period of time, commercially available software solutions for content management are suboptimal. Novel custom solutions are necessary for efficient global point of care content system management. Electronic supplementary material The online version of this article (doi:10.1186/s12911-016-0367-3) contains supplementary material, which is available to authorized users.

In April 2015, Oregon Health & Science University (OHSU) deployed a web-based, electronic medical record-embedded application created by third party vendor Vynca Inc. to allow real-time education, and completion of Physician Orders for Life Sustaining Treatment (POLST). Forms are automatically linked to the Epic Systems™ electronic health record (EHR) patient header and submitted to a state Registry, improving efficiency, accuracy, and rapid access to and retrieval of these important medical orders. POLST Forms, implemented in Oregon in 1992, are standardized portable medical orders used to document patient treatment goals for end-of-life care. In 2009, Oregon developed the first POLST-only statewide registry with a legislative mandate requiring POLST form signers to register the form unless the patient opts out. The Registry offers 24/7 emergency access to POLST Forms for Emergency Medical Services, Emergency Departments, and Acute Care Units. Because POLST is intended for those nearing end of life, immediate access to these forms at the time of an emergency is critical. Delays in registering a POLST Form may result in unwanted treatment if the paper form is not immediately available. An electronic POLST Form completion system (ePOLST) was implemented to support direct Registry submission. Other benefits of the system include single-sign-on, transmission of HL7 data for patient demographics and other relevant information, elimination of potential errors in form completion using internalized logic, built-in real-time video and text-based education materials for both patients and health care professionals, and mobile linkage for signature capture.

The benefit of exercise training in congestive heart failure (CHF) has become widely appreciated over the past 20 years. It is now clear that exercise exerts a number of beneficial effects in CHF, including an improvement of skeletal muscle perfusion, and metabolism, breathing efficiency, and neurohumoral activation [1]. More recent evidence indicates that exercise training in patients with CHF also improves cardiac function [2], which is in agreement with observations in animal models of CHF and appears mediated by exercise-induced amelioration of CHF-associated interstitial fibrosis and cardiomyocyte dysfunction and apoptosis [3]. These beneficial effects of exercise are the consequence of the activation of different molecular signalling pathways that drive the transcriptional control of cardiac remodelling in exercise training versus CHF [1, 3, 4]. In this issue of the Netherlands Heart Journal the Dutch Royal Society for Physiotherapy (KNGF) presents practical guidelines for exercise-based cardiac rehabilitation of patients with CHF [5]. Interestingly, the number of national guidelines in clinical cardiology in most European countries is currently declining, which is due to a number of reasons. First, scientific collaboration among national cardiology societies in Europe has become very close within the European Society of Cardiology (ESC) and even large countries such as Germany now no longer produce national guidelines, e.g. for myocardial revascularisation, but issue a German translation of the ESC pocket guideline accompanied by a ‘commentary’ that puts ESC recommendations into a national perspective. Second, the scientific standards to produce guidelines have been continually raised over the last two decades: To assess the evidence base a large and continually increasing number of published studies need to be assessed for quality in order to be included in meta-analyses. This process can only be accomplished with professional bibliographic and statistical help and requires significant resources. So why did the Dutch Royal Society for Physiotherapy engage in the painstaking task of producing national guidelines for exercise-based cardiac rehabilitation (CR) of patients with chronic CHF? In contrast to most areas of acute care, the financing, infrastructure, and medical quality of the CR program differ significantly between European countries. It may therefore make sense to develop a practical guideline particularly targeted to the clinical situation in the Netherlands. Additionally, the Dutch Royal Society for Physiotherapy represents physiotherapists rather than clinical cardiologists and therefore takes a different perspective of allied health personnel on how to implement the treatment strategies that cardiologists or rehabilitation physicians may have recommended. Consequently, it is much more detailed than usual cardiology guidelines in the practical aspects of patient functional assessment, patient education and empowerment, and the actual training program [5, 6]. The key messages of these guidelines are: (i) Aerobic endurance training at 50–80 % of VO2 peak remains the training intervention of choice for most CHF patients, especially those in advanced stages of functional impairment. High-intensity interval training (HIT) can be recommended in relatively low-risk CHF patients to achieve higher training effectiveness. (ii) Objective assessment of maximal functional capacity by cardiopulmonary exercise testing is a precondition for optimal individual determination of recommended training intensities. (iii) Useful optional components of the training programme may comprise inspiratory muscle training, strength training, and relaxation therapy. Patient assessment can help to identify patients who benefit from these program components (i.e. Pimax < 70 % predicted, significant muscle wasting, high anxiety levels). (iv) Exercise training is only effective as long as it is maintained. Therefore, continuation of regular physical activity and training after the cardiac rehabilitation phase needs to be encouraged and - if possible - monitored. However, because this is a guideline for physiotherapists it does not address several important issues, which are relevant for the general clinical cardiologist, including: (i) How can we identify CHF patients who may particularly benefit from training therapy? (ii) How to assess the patient’s individual risk before the initiation of training therapy? (iii) What are the inclusion and exclusion criteria for training interventions in CHF? (iv) What invasive/non-invasive diagnostic testing should be performed prior to transferral for training therapy? For all these questions, physicians should consult the position paper from the European Association of Cardiovascular Prevention and Rehabilitation [7]. In the setting of chronic CHF, peak exercise capacity should be determined by maximal symptom-limited cardiopulmonary exercise testing with small 5 to 10 W/min increments. In known ischaemic heart disease exercise-induced myocardial ischaemia should be determined and exercise levels should be below the ischaemic threshold. If cardiopulmonary exercise-testing equipment is not available, submaximal tests, such as the 6-min walk test, should be considered [8]. A baseline echocardiogram is recommended to assess left ventricular systolic function, and to exclude potentially correctable conditions such as high-grade mitral regurgitation prior to the initiation of training therapy. Notwithstanding the medical conditions required to qualify for training therapy, it is essential for physicians not to withhold the benefits of rehabilitation from their patients. Thus, current referral rates for cardiac rehabilitation range between 12 % in US Medicare patients and 70 % in middle European countries with well-developed rehabilitation systems [9, 10]. In large reviews on referral strategies and enrolment rates in cardiac rehabilitation, automatic referral orders and liaison methods have been identified as the most useful strategies to improve referral rates [11]. In the end, however, it comes down to the patient’s and the physician’s conviction that cardiac rehabilitation is needed to achieve optimal clinical outcome [12]. Hence, it is up to us to educate all patients with CHF that there is a clear dose–response relation between training intensity (as measured by MET-hours per week) and outcome improvement indicating significant reductions in adjusted hazard ratios for all cause/cardiac mortality or all-cause/cardiac hospitalisation between 3 and 7 MET-hours per week [13].