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AimsTo highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic.BackgroundIn acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses.DesignDiscursive paper.FindingsNursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures.ConclusionCOVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive.Relevance to clinical practiceObjective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures.

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

Background Approximately 20% of all surgery performed in Canada is scheduled by allocation into emergency operating room time. There is currently no national standard for managing how this mixture of emergent, urgent, and semi urgent surgical cases should progress to the operating room. Methods We introduced a novel dynamic multi priority emergency surgery waitlist management system to a medium-sized Canadian acute care hospital from December 1, 2018 to February 28, 2019. Our hospitals critical incident reporting system was monitored before and during the study for any evidence of related adverse patient safety events. Internet-based user acceptance surveys were collected from users at 28 days and 89 days into the study. Results 703 operations were scheduled for 684 patients. The electronic system was reliable and had no outages or shutdowns over 89 days. There was no detectable change in the incidence of adverse patient safety events during the study. Overall, there were 54 system users enrolled in the study. The user acceptance survey results were not statistically significant but did show a preference for the new scheduling system in the surgeon user group, all other users preferred the original system. Discussion While there are evident efficiencies from the use of information systems in other industries the safe introduction of a such a system in the emergency surgery setting has never been fully realized. The authors relate the development of the novel multi-priority emergency surgery waitlist management system that was introduced in this study. The challenges of implementing this system and the limitations of the study are discussed. Conclusion The introduction of a novel emergency surgery waitlist management system into this active operating room setting for 89 days was not associated with a change in reported patient safety events. The tested system was reliable and was preferred by some surgeon users.

The 2014 outbreak of Ebola virus disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged U.S. emergency departments (EDs) to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to U.S. acute care facilities, ethical questions have been raised in both the press and medical literature as to how U.S. EDs, emergency physicians (EPs), emergency nurses, and other stakeholders in the health care system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association, and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to U.S. EPs, emergency nurses, and other stakeholders in the health care system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to U.S. EDs in how they approach preparation for and management of potential patients with EVD.

Purpose UNC Medical Center converted to an electronic health record (EHR) in 2014. This conversion allowed for the transition of paper chemotherapy orders to be managed electronically. This article describes the process for converting inpatient paper chemotherapy orders into the new EHR in a safe and effective manner. Summary A collaborative interdisciplinary approach to the EHR transition enabled our organization to move from using paper chemotherapy orders to fully electronic chemotherapy treatment plans in both ambulatory and acute care areas. Active chemotherapy orders for acute care inpatients were reviewed and transcribed by two oncology pharmacists in the cancer hospital prior to being signed by an attending physician. The newly input orders were independently verified by two pharmacists in the cancer hospital inpatient pharmacy. Nurse review of the signed and verified treatment plans, along with reconciliation of the medication administration record ensured a safe transition to the new EHR workflow. Providers benefit from the ability to review treatment plans remotely, track changes, and include supportive medications in one consolidated location. The coordinated team effort allowed for a smooth transition with minimal interruptions to patient care. Conclusion The pharmacist-led, multidisciplinary conversion to electronic chemotherapy orders was safe, accurate, and occurred ahead of schedule for the EHR go-live. Advance communication and planning around scheduled inpatient admissions helped to minimize the impact of the transition from paper to electronic treatment plans. Both pharmacist and physician engagement were necessary to ensure a smooth transition for active inpatient treatment plans.

The 2014 outbreak of Ebola Virus Disease (EVD) in West Africa has presented a significant public health crisis to the international health community and challenged US emergency departments to prepare for patients with a disease of exceeding rarity in developed nations. With the presentation of patients with Ebola to US acute care facilities, ethical questions have been raised in both the press and medical literature as to how US emergency departments, emergency physicians, emergency nurses and other stakeholders in the healthcare system should approach the current epidemic and its potential for spread in the domestic environment. To address these concerns, the American College of Emergency Physicians, the Emergency Nurses Association and the Society for Academic Emergency Medicine developed this joint position paper to provide guidance to US emergency physicians, emergency nurses and other stakeholders in the healthcare system on how to approach the ethical dilemmas posed by the outbreak of EVD. This paper will address areas of immediate and potential ethical concern to US emergency departments in how they approach preparation for and management of potential patients with EVD.

IntroductionHealth Data Research UK designated seven UK-based Hubs to facilitate health data use for research. PIONEER is the Hub in Acute Care. PIONEER delivered workshops where patients/public citizens agreed key principles to guide access to unconsented, anonymised, routinely collected health data. These were used to inform the protocol.MethodsThis paper describes the PIONEER infrastructure and data access processes. PIONEER is a research database and analytical environment that links routinely collected health data across community, ambulance and hospital healthcare providers. PIONEER aims ultimately to improve patient health and care, by making health data discoverable and accessible for research by National Health Service, academic and commercial organisations. The PIONEER protocol incorporates principles identified in the public/patient workshops. This includes all data access requests being reviewed by the Data Trust Committee, a group of public citizens who advise on whether requests should be supported prior to licensed access.Ethics and disseminationEast Midlands–Derby REC (20/EM/0158): Confidentiality Advisory Group (20/CAG/0084). www.PIONEERdatahub.co.uk

Aims A discussion of partnership in the context of family centered care in the acute paediatric setting, through a critical analysis of partnership models. Background Paediatric healthcare practitioners understand the importance of family centered care, but struggle with how to translate the core tenets into action and are confused by several rival terms. Partnering relationships are included in definitions of family centered care, yet less is known about strategies to fully engage or support parents in these partnerships. A rigorous examination of concepts embedded in family centered care such as partnership may provide a better understanding of how to implement the broader concept and support exemplary care in today's clinical practice environment. Design Discussion paper. Data Sources Electronic search (January 2000 - December 2014) performed on CINAHL, Medline, EMBASE, Sociological Abstracts and PsychINFO using keywords partnership, family centered care and conceptual framework. Eligible references were drawn from the databases, reference lists and expert sources. Eight models met inclusion criteria and had currency and relevance to the acute paediatric setting. Implications for Nursing Nurses should continue exploring partnership in various paediatric contexts given the wide-ranging definitions, lack of operational indicators and need for stronger relational statements in current models. An examination of key strategies, barriers and facilitators of partnership is recommended. Conclusion One partnership model had both high overall maturity and best fit with family centered care principles. All models originate from Western and developed countries, indicating that future partnership models should be more geographically, culturally and economically diverse. This article is protected by copyright. All rights reserved.

Effective team decision making has the potential to improve the quality of health care outcomes. Medical Emergency Teams (METs), a specific type of team led by either critical care nurses or physicians, must respond to and improve the outcomes of deteriorating patients. METs routinely make decisions under conditions of uncertainty and suboptimal care outcomes still occur. In response, the development and use of Shared Mental Models (SMMs), which have been shown to promote higher team performance under stress, may enhance patient outcomes. This discussion paper specifically focuses on the development and use of SMMs in the context of METs. Within this process, the psychological mechanisms promoting enhanced team performance are examined and the utility of this model is discussed through the narrative of six habits applied to MET interactions. A two stage, reciprocal model of both nonanalytic decision making within the acute care environment and analytic decision making during reflective action learning was developed. These habits are explored within the context of a MET, illustrating how applying SMMs and action learning processes may enhance team-based problem solving under stress. Based on this model, we make recommendations to enhance MET decision making under stress. It is suggested that the corresponding habits embedded within this model could be imparted to MET members and tested by health care researchers to assess the efficacy of this integrated decision making approach in respect to enhanced team performance and patient outcomes.

Introduction Catheter associated urinary tract infections are widely recognized as the most common health care associated infection in the acute care hospital setting. Methods Experts have reviewed the literature on catheter associated urinary tract infections in urological patients. Where the literature was lacking, expert opinion was used to build recommendations which may be useful to the urological community. Results In this white paper we address limitations surrounding how and when current definitions can be used to detect a catheter associated urinary tract infection in a urological patient, and propose alternative methods for diagnosing catheter associated urinary tract infection in specific populations, including geriatric, neurogenic bladder and lower urinary tract reconstruction. Techniques to avoid catheter associated urinary tract infections through proper urethral catheterization and alternatives to indwelling catheters for urological patients are also discussed. Conclusions Patients with urological disorders have specific concerns relating to catheter associated urinary tract infections. A review of the available literature as well as common clinical practice provides directives for the treatment of these patients in a specific and distinctive fashion to reduce the risk of infection. By understanding the needs and technical modifications necessary in these patients, hospital systems and practitioners can limit patient exposure to catheter associated urinary tract infections.

Rationale, Aims and Objectives:\ud Sharing aspects of the traditional medical record with patients has been successful in primary and antenatal care, but has not been investigated in the UK inpatient setting. Our aim was to evaluate the impact on patient and clinician experience of providing patients with a written lay summary of their care-plan in the acute care setting.\ud \ud Method:\ud We carried out a qualitative interview study on two acute medicine wards in an NHS University Teaching Hospital for a 4-week period in 2019. A summary record, designed in response to suggestions from doctors and patients from a previous study, was distributed to patients on the first ward round after admission. Eligible participants included all doctors and nurses working on and all patients and their families attending the acute medical units; patients were excluded if they lacked capacity to consent or were under 18. We interviewed 20 patients, 10 relatives, 10 doctors and 7 nurses.\ud \ud Results:\ud Patients felt that the summary improved their ability to remember details about their care so they could more accurately and easily update their relatives. They did not feel that the summary induced anxiety. Patient-doctor communication was improved: patients felt empowered to ask more questions and doctors felt that it solidified their plan and encouraged them to avoid medical jargon. Most patients felt the summary included the ‘right’ amount of information. Healthcare professionals were more concerned about the risk of breaching confidentiality than patients. Doctors felt that providing summaries was time-consuming; there were differing opinions about whether this was a worthwhile investment of time. Clinicians recognized that the traditional medical record has many roles.\ud \ud Conclusions:\ud A summary record could empower patients and improve patient-doctor communication but would require additional clinician and administrative time.

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

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.

Intoxicated persons showing challenging behavior (IPCBs) under influence of alcohol and/or drugs frequently have trouble finding appropriate acute care. Often IPCBs are stigmatized being unwilling or unable to accept help. Separated physical and mental healthcare systems hamper integrated acute care for IPCBs. This pilot aimed to substantiate the physical, psychiatric, and social health needs of IPCBs visiting the emergency room (ER) during a 3-month period. All ER visits were screened. After triage by the ER physician, indicated IPCBs were additionally assessed by the consultation–liaison–psychiatry physician. If needed, IPCBs were admitted to a complexity intervention unit for further examinations to provide integrated treatments and appropriate follow-up care. The INTERMED and Health of the Nation Outcome Scale (HoNOS) questionnaires were used to substantiate the complexity and needs. Field-relevant stakeholders were interviewed about this approach for acute integrated care. Alongside substance abuse, almost half of identified IPCBs suffered from comorbid psychiatric disturbances and one third showed substantial physical conditions requiring immediate medical intervention. Almost all IPCBs (96%) accepted the acute medical care voluntarily. IPCBs showed high mean initial scores of INTERMED (27.8 ± 10.0) and HoNOS (20.8 ± 6.9). At discharge from the complexity intervention unit, the mean HoNOS score decreased significantly (13.4 ± 8.6; P

To examine the association between nurse skill mix (the proportion of total hours provided by Registered Nurses) and patient outcomes in acute care hospitals.A quantitative systematic review included studies published in English between January 2000 - September 2018.Cochrane Library, CINAHL Plus with Full Text, MEDLINE, Scopus, Web of Science and Joanna Briggs Institute were searched. Observational and experimental study designs were included. Mix-methods designs were included if the quantitative component met the criteria.The Systematic Review guidelines of the Joanna Briggs Institute and its critical appraisal instrument were used. An inverse association was determined when seventy-five percent or more of studies with significant results found this association.Sixty-three articles were included. Twelve patient outcomes were inversely associated with nursing skill mix (i.e., higher nursing skill mix was significantly associated with improved patient outcomes). These were length of stay; ulcer, gastritis and upper gastrointestinal bleeds; acute myocardial infarction; restraint use; failure-to-rescue; pneumonia; sepsis; urinary tract infection; mortality/30-day mortality; pressure injury; infections and shock/cardiac arrest/heart failure.Nursing skill mix affected 12 patient outcomes. However, further investigation using experimental or longitudinal study designs are required to establish causal relationships. Consensus on the definition of skill mix is required to enable more robust evaluation of the impact of changes in skill mix on patient outcomes.Skill mix is perhaps more important than the number of nurses in reducing adverse patient outcomes such as mortality and failure to rescue, albeit the optimal staffing profile remains elusive in workforce planning.目的: 在于探讨护士技巧组合(注册护士提供的总时数比例)与急性护理医院患者结果之间的联系。 设计: 一项定量系统综述包括2000年1月至2018年9月期间以英语发表的各项研究。 资料来源: 搜索了Cochrane Library、CINAHL Plus with Full Text、MEDLINE、Scopus、Web of Science和Joanna Briggs Institute。纳入了观察性和实验性研究设计。如果定量成分符合标准,则纳入混合方法设计。 综述方法: 使用了Joanna Briggs Institute的系统综述指南及其关键评估工具。当75%或者更多具备显著结果的研究发现这种联系时,就确定了反向关联。 结果: 共纳入了63篇文章。12名患者的结果与护理技巧组合呈负相关(即,较高的护理技能组合与患者结果的改善显著相关)。这些是住院天数;溃疡、胃炎和上消化道出血;急性心肌梗死;约束使用;救援失败;肺炎;败血症;尿路感染;死亡率/30天死亡率;压力性损伤;感染和休克/心脏骤停/心力衰竭。 结论: 护理技巧组合影响了12例患者的结果。然而,需要使用实验性或纵向研究设计来进一步调查,从而建立因果关系。需要就技巧组合的定义达成共识,以便能够更有力地评估技巧组合变化对患者结果的影响。 影响: 在降低死亡率和救援失败等不良患者结果方面,技巧组合可能比护士人数更为重要,尽管最佳的人员配置在人力资源规划中仍然让人难懂。.

Background It is essential to identify factors that affect adherence to standard precautions, which could increase risk of occupational exposure to pathogens. Methods A descriptive cross-sectional study was conducted. Nurses (n = 241) in an acute care hospital completed the survey including the Factors Influencing Adherence to Standard Precautions Scale (FIASPS) (total possible scores in each domain ranged from 5 to 25) and the Compliance with Standard Precautions Scale (CSPS) (total possible scores ranged from 0 to 20). Results Results showed moderate influence of the judgement (mean = 14.04, SD = 4.04), leadership (M = 14.58, SD 3.78), and culture/practice (M = 12.61, SD = 3.18) factors; high score on contextual cues (M = 15.77, SD = 3.60); and low score on justification (M = 5.76, SD = 4.57). The overall mean CSPS score was 76.68% (SD 13.82). There was a significant negative relationship between justification for non-use of standard precautions and nurses' adherence with standard precautions (r = −0.24, p, Highlights • Poor adherence to standard precautions increases the risk of exposure to infections. • Regular training sessions can improve perception of risks of non-adherence. • Nurses can be encouraged to be role models in the practice of standard precautions. • Enforcement of policies is crucial to maintain adherence to standard precautions.

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.

Introduction: The Global Leadership Initiative on Malnutrition (GLIM) lacks reliable blood tests for evaluating the nutrition status. We retrospectively compared the GLIM criteria, Controlling Nutrition Status (CONUT) score, and Subjective Global Assessment (SGA) to establish effective malnutrition screening and provide appropriate nutritional interventions according to severity. Methods: We classified 177 patients into 3 malnutrition categories (normal/mild, moderate, and severe) according to the GLIM criteria, CONUT score, and SGA. We investigated the malnutrition prevalence, concordance of malnutrition severity, predictability of clinical outcome, concordance by etiology, and clinical outcome by inflammation. Results: The highest prevalence of malnutrition was found using the GLIM criteria (87.6%). Concordance of malnutrition severity was low between the GLIM criteria and CONUT score. Concordance by etiology was low in all groups but was the highest in the “acute disease” group. The area under the curve of clinical outcome and that of the “with inflammation group” were significantly higher when using the CONUT score versus using the other tools (0.679 and 0.683, respectively). Conclusion: The GLIM criteria have high sensitivity, while the CONUT score can effectively predict the clinical outcome of malnutrition. Their combined use can efficiently screen for malnutrition and patient severity in acute care hospitals.

We describe an innovative research protocol to: (a) examine patient-level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing.A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015-December 2019.Patients in the cohort will be followed from admission until 30-day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time-varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high-impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure-to-rescue; (b) in-hospital falls; (c) hospital-acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non-linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020.To our knowledge, this study is the first multisite patient-level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events.目的: 我们描述了一份创新的研究方案: (a) 检查急诊护理医院护士配置方法与不良事件风险之间的患者水平纵向关联; (b) 确定安全护士配置的可能阈值。 设计: 2015年1月至2019年12月期间, 魁北克省 (加拿大) 16家医院收治的成人医疗、外科和重症监护病房患者动态队列研究。 方法: 将从入院到出院后30天里, 对队列研究中的患者进行随访, 以评估与随后发生的不良事件相关的选定护士工作实践的暴露情况。将使用电子工资单数据, 测量住院期间各轮班的五种人员配置方法, 并采用以下时变指标: (a) 各患者的护理工作时间; (b) 技能混合; (c) 加班使用; (d) 教育混合和; 以及 (e) 经验。将从参与站点检索的电子健康记录数据中测量四个可能与护士配置方法相关的高影响不良事件: (a) 抢救失败; (b) 住院量下降; (c) 院内获得性肺炎和; 以及 (d)静脉血栓栓塞。为检测所选护士人员配置暴露与各种不良事件风险之间的关系, 将拟合单独的多变量Cox比例风险脆弱性回归模型, 同时调整患者、护理单位和医院特征, 并进行聚类分析。为评估可能的人员配置阈值, 将拟合灵活的非线性样条函数。我们于2019年10月, 获得该项研究的资助,于2020年2月获得研究伦理/机构的批准。 讨论: 据我们所知, 此项研究是第一次多地点患者水平的纵向调查, 其针对普通护士配置方法与不良事件风险之间的关联。希望我们的研究结果能帮助医院管理者最有效地利用稀缺的护理资源, 并找出减少不良事件发生的人员配置方法。.

The World Health Organization (WHO) declared the Coronavirus Disease (COVID‐19) a pandemic due to the huge upsurge in the number of reported cases worldwide. The COVID‐19 pandemic in India has become a public health threat, and if we go by the number of confirmed cases then the situation seems to be a matter of grave concern. According to real‐time data, the numbers of confirmed cases are growing exponentially. No doubt, substantial public health interventions both at the national and state levels are implemented immediately by the Government of India; there is a need for improved preparedness plans and mitigation strategies along with accurate forecasting. The present study aims to forecast the COVID‐19 outbreak infected cases in India. The data have been obtained from https://www.covid19india.org, https://www.worldometers.info/coronavirus, and ICMR reported publicly available information about COVID‐19 confirmation cases. We have used the double exponential smoothing method for forecasting the trends in terms of confirmed, active, recovered and death cases from COVID‐19 for emergency preparedness and future predictions. Findings reveal that the estimated value of point forecast is just 8.22% of the total number of confirmed cases reported on a daily basis across the country. It was observed that the deaths were lower for the states and union territories with a higher detection rate. It is suggested that by keeping in view the limited healthcare resources in the country, accurate forecasting, early detection, and avoidance of acute care for the majority of infected cases is indispensable.

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

Background In the UK, acute mental healthcare is provided by in-patient wards and crisis resolution teams. Readmission to acute care following discharge is common. Acute day units (ADUs) are also provided in some areas. Aims To assess predictors of readmission to acute mental healthcare following discharge in England, including availability of ADUs. Method We enrolled a national cohort of adults discharged from acute mental healthcare in the English National Health Service (NHS) between 2013 and 2015, determined the risk of readmission to either in-patient or crisis teams, and used multivariable, multilevel logistic models to evaluate predictors of readmission. Results Of a total of 231 998 eligible individuals discharged from acute mental healthcare, 49 547 (21.4%) were readmitted within 6 months, with a median time to readmission of 34 days (interquartile range 10–88 days). Most variation in readmission (98%) was attributable to individual patient-level rather than provider (trust)-level effects (2.0%). Risk of readmission was not associated with local availability of ADUs (adjusted odds ratio 0.96, 95% CI 0.80–1.15). Statistically significant elevated risks were identified for participants who were female, older, single, from Black or mixed ethnic groups, or from more deprived areas. Clinical predictors included shorter index admission, psychosis and being an in-patient at baseline. Conclusions Relapse and readmission to acute mental healthcare are common following discharge and occur early. Readmission was not influenced significantly by trust-level variables including availability of ADUs. More support for relapse prevention and symptom management may be required following discharge from acute mental healthcare.

Background The COVID-19 pandemic has necessitated a rapid increase of space in highly infectious disease intensive care units (ICUs). At Houston Methodist Hospital (HMH), a virtual intensive care unit (vICU) was used amid the COVID-19 outbreak. Objective The aim of this paper was to detail the novel adaptations and rapid expansion of the vICU that were applied to achieve patient-centric solutions while protecting staff and patients’ families during the pandemic. Methods The planned vICU implementation was redirected to meet the emerging needs of conversion of COVID-19 ICUs, including alterations to staged rollout timing, virtual and in-person staffing, and scope of application. With the majority of the hospital critical care physician workforce redirected to rapidly expanded COVID-19 ICUs, the non–COVID-19 ICUs were managed by cardiovascular surgeons, cardiologists, neurosurgeons, and acute care surgeons. HMH expanded the vICU program to fill the newly depleted critical care expertise in the non–COVID-19 units to provide urgent, emergent, and code blue support to all ICUs. Results Virtual family visitation via the Consultant Bridge application, palliative care delivery, and specialist consultation for patients with COVID-19 exemplify the successful adaptation of the vICU implementation. Patients with COVID-19, who were isolated and separated from their families to prevent the spread of infection, were able to virtually see and hear their loved ones, which bolstered the mental and emotional status of those patients. Many families expressed gratitude for the ability to see and speak with their loved ones. The vICU also protected medical staff and specialists assigned to COVID-19 units, reducing exposure and conserving personal protective equipment. Conclusions Telecritical care has been established as an advantageous mechanism for the delivery of critical care expertise during the expedited rollout of the vICU at Houston Methodist Hospital. Overall responses from patients, families, and physicians are in favor of continued vICU care; however, further research is required to examine the impact of innovative applications of telecritical care in the treatment of critically ill patients.

Background Hospital healthcare workers (HCW), in particular those involved in the clinical care of COVID-19 cases, are presumably exposed to a higher risk of acquiring the disease than the general population. Methods Between April 16 and 30, 2020 we conducted a prospective, SARS-CoV-2 seroprevalence study in HCWs in Southern Switzerland. Participants were hospital personnel with varying COVID-19 exposure risk depending on job function and working site. They provided personal information (including age, sex, occupation, and medical history) and self-reported COVID-19 symptoms. Odds ratio (OR) of seropositivity to IgG antibodies was estimated by univariate and multivariate logistic regressions. Findings Among 4726 participants, IgG antibodies to SARS-CoV-2 were detected in 9.6% of the HCWs. Seropositivity was higher among HCWs working on COVID-19 wards (14.1% (11.9–16.5)) compared to other hospital areas at medium (10.7% (7.6–14.6)) or low risk exposure (7.3% (6.4–8.3)). OR for high vs. medium wards risk exposure was 1.42 (0.91–2.22), P = 0.119, and 1.98 (1.55–2.53), P, The Lancet Regional Health - Europe, 1, ISSN:2666-7762

Background Coronavirus disease-2019 (COVID-19) has effected major changes to healthcare delivery within acute care settings. Rapid response calls (RRCs) in healthcare organisations have been effective at identifying and urgently managing acute clinical deterioration. Code-95 RRC were introduced to prewarn healthcare workers (HCWs) attending to patients suspected or confirmed with COVID-19 infection. Aims The primary aim of the study was to identify the personal impact of the COVID-19 pandemic on HCWs involved in attending Code-95 RRC. We sought to evaluate their perception of risks and effects on wellbeing and identify potential opportunities for improvement at organisational levels. Methods We undertook a detailed survey on HCWs attending Code-95 RRCs, including questions that sought to understand the impact of the pandemic as well as their perception of infection risk and emotional wellbeing. This was a substudy of the prospective cross-sectional single-centre survey of HCWs that was conducted over a 3-week period at Frankston Hospital, Victoria, Australia. We adopted a quantitative content analysis approach for free-text responses in this secondary analysis. Results Four hundred two free-text comments were received from 297 respondents and were analysed. More than two-thirds (68%, 223/297) were female. Of all comments, 39% (155/402) were related to organisational issues including communication, confusion due to constantly changing infection control policies, and insufficient training. Thirty-three percent of comments (133/402) raised issues regarding the adequacy of personal protective equipment. Anxiety was reported in 25% of comments (101/402) with concerns predominantly relating to emotional stress and fatigue, risks of virus exposure and transmitting the infection to others, and COVID-19 precautions impairing care delivery. Conclusion(s) Our study raises important issues that have relevance for all healthcare organisations in the management of patients with COVID-19. These include the importance of improving communication, especially when infection control policies are revised, optimising training, maintaining adequate personal protective equipment, and HCW support. Early recognition and management of these issues are crucial to maintain optimal healthcare delivery.

Background Electronic health records (EHRs) are a central feature of care delivery in acute care hospitals; however, the financial and quality outcomes associated with system performance remain unclear. Objective In this study, we aimed to evaluate the association between the top 3 EHR vendors and measures of hospital financial and quality performance. Methods This study evaluated 2667 hospitals with Cerner, Epic, or Meditech as their primary EHR and considered their performance with regard to net income, Hospital Value–Based Purchasing Total Performance Score (TPS), and the unweighted subdomains of efficiency and cost reduction; clinical care; patient- and caregiver-centered experience; and patient safety. We hypothesized that there would be a difference among the 3 vendors for each measure. Results None of the EHR systems were associated with a statistically significant financial relationship in our study. Epic was positively associated with TPS outcomes (R2=23.6%; β=.0159, SE 0.0079; P=.04) and higher patient perceptions of quality (R2=29.3%; β=.0292, SE 0.0099; P=.003) but was negatively associated with patient safety quality scores (R2=24.3%; β=−.0221, SE 0.0102; P=.03). Cerner and Epic were positively associated with improved efficiency (R2=31.9%; Cerner: β=.0330, SE 0.0135, P=.01; Epic: β=.0465, SE 0.0133, P Conclusions The results of this study provide evidence of a difference in clinical outcome performance among the top 3 EHR vendors and may serve as supportive evidence for health care leaders to target future capital investments to improve health care delivery.

Background For people in mental health crisis, acute day units (ADUs) provide daily structured sessions and peer support in non-residential settings, often as an addition or alternative to crisis resolution teams (CRTs). There is little recent evidence about outcomes for those using ADUs, particularly compared with those receiving CRT care alone. Aims We aimed to investigate readmission rates, satisfaction and well-being outcomes for people using ADUs and CRTs. Method We conducted a cohort study comparing readmission to acute mental healthcare during a 6-month period for ADU and CRT participants. Secondary outcomes included satisfaction (Client Satisfaction Questionnaire), well-being (Short Warwick–Edinburgh Mental Well-being Scale) and depression (Center for Epidemiologic Studies Depression Scale). Results We recruited 744 participants (ADU: n = 431, 58%; CRT: n = 312, 42%) across four National Health Service trusts/health regions. There was no statistically significant overall difference in readmissions: 21% of ADU participants and 23% of CRT participants were readmitted over 6 months (adjusted hazard ratio 0.78, 95% CI 0.54–1.14). However, readmission results varied substantially by setting. At follow-up, ADU participants had significantly higher Client Satisfaction Questionnaire scores (2.5, 95% CI 1.4–3.5, P < 0.001) and well-being scores (1.3, 95% CI 0.4–2.1, P = 0.004), and lower depression scores (−1.7, 95% CI −2.7 to −0.8, P < 0.001), than CRT participants. Conclusions Patients who accessed ADUs demonstrated better outcomes for satisfaction, well-being and depression, and no significant differences in risk of readmission, compared with those who only used CRTs. Given the positive outcomes for patients, and the fact that ADUs are inconsistently provided in the National Health Service, their value and place in the acute care pathway needs further consideration and research.

Background Current approaches to early detection of clinical deterioration in children have relied on intermittent track-and-trigger warning scores such as the Pediatric Early Warning Score (PEWS) that rely on periodic assessment and vital sign entry. There are limited data on the utility of these scores prior to events of decompensation leading to pediatric intensive care unit (PICU) transfer. Objective The purpose of our study was to determine the accuracy of recorded PEWS scores, assess clinical reasons for transfer, and describe the monitoring practices prior to PICU transfer involving acute decompensation. Methods We conducted a retrospective cohort study of patients ≤21 years of age transferred emergently from the acute care pediatric floor to the PICU due to clinical deterioration over an 8-year period. Clinical charts were abstracted to (1) determine the clinical reason for transfer, (2) quantify the frequency of physiological monitoring prior to transfer, and (3) assess the timing and accuracy of the PEWS scores 24 hours prior to transfer. Results During the 8-year period, 72 children and adolescents had an emergent PICU transfer due to clinical deterioration, most often due to acute respiratory distress. Only 35% (25/72) of the sample was on continuous telemetry or pulse oximetry monitoring prior to the transfer event, and 47% (34/72) had at least one incorrectly documented PEWS score in the 24 hours prior to the event, with a score underreporting the actual severity of illness. Conclusions This analysis provides support for the routine assessment of clinical deterioration and advocates for more research focused on the use and utility of continuous cardiorespiratory monitoring for patients at risk for emergent transfer.

Background As virtual reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR therapy as a novel means to manage behavioral and psychological symptoms of dementia, which are exacerbated during acute care hospitalization, with the goal of reducing the use of antipsychotics, sedatives, and physical restraints associated with negative adverse effects, increased length of stay, and caregiver burden. To date, no evaluations of immersive VR therapy have been reported for patients with dementia in acute care hospitals. Objective This study aimed to determine the feasibility (acceptance, comfort, and safety) of using immersive VR therapy for people living with dementia (mild, moderate, and advanced) during acute care hospitalization and explore its potential to manage behavioral and psychological symptoms of dementia. Methods A prospective, longitudinal pilot study was conducted at a community teaching hospital in Toronto. The study was nonrandomized and unblinded. A total of 10 patients aged >65 years (mean 86.5, SD 5.7) diagnosed with dementia participated in one or more research coordinator–facilitated sessions of viewing immersive 360° VR footage of nature scenes displayed on a Samsung Gear VR head-mounted display. This mixed-methods study included review of patient charts, standardized observations during the intervention, and pre- and postintervention semistructured interviews about the VR experience. Results All recruited participants (N=10) completed the study. Of the 10 participants, 7 (70%) displayed enjoyment or relaxation during the VR session, which averaged 6 minutes per view, and 1 (10%) experienced dizziness. No interference between the VR equipment and hearing aids or medical devices was reported. Conclusions It is feasible to expose older people with dementia of various degrees admitted to an acute care hospital to immersive VR therapy. VR therapy was found to be acceptable to and comfortable by most participants. This pilot study provides the basis for conducting the first randomized controlled trial to evaluate the impact of VR therapy on managing behavioral and psychological symptoms of dementia in acute care hospitals.

Background Tobacco use, physical inactivity, and poor diet are associated with morbidity and premature death. Health promotion and primary prevention counseling, advice, and support by a primary care provider lead to behavior change attempts among patients. However, although physicians consider preventative health important, there is often a larger focus on symptom presentation, acute care, and medication review. Objective This study evaluated the feasibility, adoption, and integration of the tablet-based Risk Factor Identification Tool (RFIT) that uses algorithmic information technology to support obtainment of patient risk factor information in primary care clinics. Methods This is a pragmatic developmental evaluation. Each clinic developed a site-specific implementation plan adapted to their workflow. The RFIT was implemented in 2 primary care clinics located in Manitoba. Perceptions of 10 clinic staff and 8 primary care clinicians informed this evaluation. Results Clinicians reported a smooth and fast transfer of RFIT responses to an electronic medical record encounter note. The RFIT was used by 207 patients, with a completion rate of 86%. Clinic staff reported that approximately 3%-5% of patients declined the use of the RFIT or required assistance to use the tablet. Among the 207 patients that used the RFIT, 22 (12.1%) smoked, 39 (21.2%) felt their diet could be improved, 20 (12.0%) reported high alcohol consumption, 103 (56.9%) reported less than 150 minutes of physical activity a week, and 6 (8.2%) patients lived in poverty. Clinicians suggested that although a wide variety of patients were able to use the tablet-based RFIT, implemented surveys should be tailored to patient subgroups. Conclusions Clinicians and clinic staff positively reviewed the use of information technology in primary care. Algorithmic information technology can collect, organize, and synthesize individual health information to inform and tailor primary care counseling to the patients’ context and readiness to change. The RFIT is a user-friendly tool that provides an effective method for obtaining risk factor information from patients. It is particularly useful for subsets of patients lacking continuity in the care they receive. When implemented within a context that can support practical interventions to address identified risk factors, the RFIT can inform brief interventions within primary care.

Key summary points Aim To assess impact of frailty screening and two markers of illness severity on survival following discharge from the hospital. Findings Independently of age, ward (acute geriatric and general medical) and comorbidity, both higher degree of frailty and illness severity associated with reduced survival probability following discharge. The impact of frailty on survival was higher in those experiencing high clinical and laboratory illness severity. Message The prognostic value of frailty screening increased when performed in conjunction with two markers of illness severity. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00555-8., Purpose Study associations between frailty, illness severity and post-discharge survival in older adults admitted to medical wards with acute clinical conditions. Methods Prospective cohort study of 195 individuals (mean age 86; 63% females) admitted to two medical wards with acute illness, followed up for all-cause mortality for 20 months after discharge. Ward physicians screened for frailty and quantified its degree from one to eight using Clinical Frailty Scale (CFS), while clinical illness severity was estimated by New Early Warning Score 2 (NEWS2) and laboratory illness severity was calculated by a frailty index (FI-lab) using routine blood tests. Results CFS, NEWS2 and FI-lab scores were independently associated with post-discharge survival in an adjusted Cox proportional hazards model with age, ward category (acute geriatric and general medical) and comorbidity as covariates. Adjusted hazard ratios and 95% confidence intervals were 1.54 (1.24–1.91) for CFS, 1.12 (1.03–1.23) for NEWS2, and 1.02 (1.00–1.05) for FI-lab. A frailty × illness severity category interaction effect (p = 0.003), suggested that the impact of frailty on survival was greater in those experiencing higher levels of illness severity. Among patients with at least moderate frailty (CFS six to eight) and high illness severity according to both NEWS2 and FI-lab, two (13%) were alive at follow-up. Conclusion Frailty screening aided prognostication of survival following discharge in older acutely ill persons admitted to medical wards. The prognostic value of frailty increased when combined with readily available illness severity markers acquired during admission. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00555-8.

This secondary analysis used a 10% random sample from the national Outcome and Assessment Information Set (OASIS) of Medicare beneficiaries ≥ 65 years old who received home health (HH) care in 2017 (N=646,109). We examined the risk of hospital admission during a 60-day HH episode among Medicare home health patients in different living arrangements, including living alone at home (23.8%), living with other at home (64.8%), and residing in assisted facility (AL) facilities (11.4%). At the start of the HH episode, AL residents were older, more likely to have cognitive impairment, depressive symptoms, and limitations in activities of daily living (ADL) than those living at home at home (alone/with others). In the multivariable logistic regression model of hospital admission adjusting for demographic status (age, sex, race/ethnicity, Medicaid status), cognitive impairment, depressive symptoms, and ADL limitations, when compared to HH patients living with others at home (reference), AL residents were 15% less likely to have hospital admission (Odds Ratio [OR]=0.85, 95% Confidence Interval [CI]: 0.84, 0.88, p

Background Diabetes affects more than 30 million patients across the United States. With such a large disease burden, even a small error in classification can be significant. Currently billing codes, assigned at the time of a medical encounter, are the “gold standard” reflecting the actual diseases present in an individual, and thus in aggregate reflect disease prevalence in the population. These codes are generated by highly trained coders and by health care providers but are not always accurate. Objective This work provides a scalable deep learning methodology to more accurately classify individuals with diabetes across multiple health care systems. Methods We leveraged a long short-term memory-dense neural network (LSTM-DNN) model to identify patients with or without diabetes using data from 5 acute care facilities with 187,187 patients and 275,407 encounters, incorporating data elements including laboratory test results, diagnostic/procedure codes, medications, demographic data, and admission information. Furthermore, a blinded physician panel reviewed discordant cases, providing an estimate of the total impact on the population. Results When predicting the documented diagnosis of diabetes, our model achieved an 84% F1 score, 96% area under the curve–receiver operating characteristic curve, and 91% average precision on a heterogeneous data set from 5 distinct health facilities. However, in 81% of cases where the model disagreed with the documented phenotype, a blinded physician panel agreed with the model. Taken together, this suggests that 4.3% of our studied population have either missing or improper diabetes diagnosis. Conclusions This study demonstrates that deep learning methods can improve clinical phenotyping even when patient data are noisy, sparse, and heterogeneous.

As the COVID-19 pandemic continues to escalate and place pressure on hospital system resources, a proper screening and risk stratification score is essential. We aimed to develop a risk score to identify patients with increased risk of COVID-19, allowing proper identification and allocation of limited resources. A retrospective study was conducted of 338 patients who were admitted to the hospital from the emergency room to regular floors and tested for COVID-19 at an acute care hospital in the Metropolitan Washington D.C. area. The dataset was split into development and validation sets with a ratio of 6:4. Demographics, presenting symptoms, sick contact, triage vital signs, initial laboratory and chest X-ray results were analysed to develop a prediction model for COVID-19 diagnosis. Multivariable logistic regression was performed in a stepwise fashion to develop a prediction model, and a scoring system was created based on the coefficients of the final model. Among 338 patients admitted to the hospital from the emergency room, 136 (40.2%) patients tested positive for COVID-19 and 202 (59.8%) patients tested negative. Sick contact with suspected or confirmed COVID-19 case (3 points), nursing facility residence (3 points), constitutional symptom (1 point), respiratory symptom (1 point), gastrointestinal symptom (1 point), obesity (1 point), hypoxia at triage (1 point) and leucocytosis (−1 point) were included in the prediction score. A risk score for COVID-19 diagnosis achieved area under the receiver operating characteristic curve of 0.87 (95% confidence interval (CI) 0.82–0.92) in the development dataset and 0.85 (95% CI 0.78–0.92) in the validation dataset. A risk prediction score for COVID-19 can be used as a supplemental tool to assist clinical decision to triage, test and quarantine patients admitted to the hospital from the emergency room.

Background Obtaining accurate clinical information about recent acute care visits is extremely important for outpatient providers. However, documents used to communicate this information are often difficult to use. This puts patients at risk of adverse events. Elderly patients who are seen by more providers and have more care transitions are especially vulnerable. Objective This study aimed to (1) identify the information about elderly patients’ recent acute care visits needed to coordinate their care, (2) use this information to assess discharge summaries, and (3) provide recommendations to help improve the quality of electronic health record (EHR)–generated discharge summaries, thereby increasing patient safety. Methods A literature review, clinician interviews, and a survey of outpatient providers were used to identify and categorize data needed to coordinate care for recently discharged elderly patients. Based upon those data, 2 guidelines for creating useful discharge summaries were created. The new guidelines, along with 17 previously developed medical documentation usability heuristics, were applied to assess 4 simulated elderly patient discharge summaries. Results The initial research effort yielded a list of 29 items that should always be included in elderly patient discharge summaries and a list of 7 “helpful, but not always necessary” items. Evaluation of 4 deidentified elderly patient discharge summaries revealed that none of the documents contained all 36 necessary items; between 14 and 18 were missing. The documents each had several other issues, and they differed significantly in organization, layout, and formatting. Conclusions Variations in content and structure of discharge summaries in the United States make them unnecessarily difficult to use. Standardization would benefit both patients, by lowering the risk of care transition–related adverse events, and outpatient providers, by helping reduce frustration that can contribute to burnout. In the short term, acute care providers can help improve the quality of their discharge summaries by working with EHR vendors to follow recommendations based upon this study. Meanwhile, additional human factors work should determine the most effective way to organize and present information in discharge summaries, to facilitate effective standardization.

Background Digital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective. Objective The aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending. Methods A retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or “weight” the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20. Results The NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, P=.047; £223, P Conclusions Patients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs.

Introduction The incidences and types of missed nursing care in the acute care and community sectors are both ubiquitous and quantifiable, however, there are few research studies relating to the type and frequency of missed maternity-based care for mothers and families. The aim of this study is to estimate the incidences and types of Australian missed midwifery care and to identify those factors that have causal links to it. Methods A non-experimental, descriptive method using a Likert developed MISSCARE scale was used to ascertain consensus estimates made by Australian midwives. Electronic invitations were extended to their membership using an inclusive link to the MISSCARE survey. Inclusion criteria were all ANMF members who were midwives and currently employed within the Australian public and private healthcare systems. Data analysis was undertaken using both Rasch analysis and Structural Equation Modelling. Results The type and frequency of missed Australian midwifery care can be quantified and several demographic factors are significant predictor variables for overall missed midwifery care. The most prevalent aspects of missed care in the Australian midwifery setting are midwives’ hand hygiene, supportive care, perinatal education, and surveillance type midwifery practices. Conclusions As the frequencies and types of missed midwifery care in Australia have been identified, it is possible for midwives to be mindful of minimising care omissions related to hand hygiene, providing supportive care and education to mothers as well as surveillance-type midwifery practices.

Background Patients with end-stage liver disease (ESLD) have limited treatment options and have a deteriorated quality of life with an uncertain prognosis. Early identification of ESLD patients with a poor prognosis is valuable, especially for palliative care. However, it is difficult to predict ESLD patients that require either acute care or palliative care. Objective We sought to create a machine-learning monitoring system that can predict mortality or classify ESLD patients. Several machine-learning models with visualized graphs, decision trees, ensemble learning, and clustering were assessed. Methods A retrospective cohort study was conducted using electronic medical records of patients from Wan Fang Hospital and Taipei Medical University Hospital. A total of 1214 patients from Wan Fang Hospital were used to establish a dataset for training and 689 patients from Taipei Medical University Hospital were used as a validation set. Results The overall mortality rate of patients in the training set and validation set was 28.3% (257/907) and 22.6% (145/643), respectively. In traditional clinical scoring models, prothrombin time-international normalized ratio, which was significant in the Cox regression (P Conclusions Medical artificial intelligence has become a cutting-edge tool in clinical medicine, as it has been found to have predictive ability in several diseases. The machine-learning monitoring system developed in this study involves multifaceted analyses, which include various aspects for evaluation and diagnosis. This strength makes the clinical results more objective and reliable. Moreover, the visualized interface in this system offers more intelligible outcomes. Therefore, this machine-learning monitoring system provides a comprehensive approach for assessing patient condition, and may help to classify acute death patients and palliative care patients. Upon further validation and improvement, the system may be used to help physicians in the management of ESLD patients.