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

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

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

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

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

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

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

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

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

BACKGROUND While previous studies have described the use of blood components in subsets of children, such as the critically ill, little is known about transfusion practices in hospitalized children across all departments and diagnostic categories. We sought to describe the utilization of red blood cell, platelet, plasma, and cryoprecipitate transfusions across hospital settings and diagnostic categories in a large cohort of hospitalized children. STUDY DESIGN AND METHODS The public datasets from 11 US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were accessed. All nonbirth inpatient encounters of children 0-18 years of age from 2013 to 2016 were included. RESULTS 61,770 inpatient encounters from 41,943 unique patients were analyzed. Nine percent of encounters involved the transfusion of at least one blood component. RBC transfusions were most common (7.5%), followed by platelets (3.9%), plasma (2.5%), and cryoprecipitate (0.9%). Children undergoing cardiopulmonary bypass were most likely to be transfused. For the entire cohort, the median (interquartile range) pretransfusion laboratory values were as follows: hemoglobin, 7.9 g/dl (7.1-10.4 g/dl); platelet count, 27 × 109 cells/L (14-54 × 109 cells/L); and international normalized ratio was 1.6 (1.4-2.0). Recipient age differences were observed in the frequency of RBC irradiation (95% in infants, 67% in children, p

Purpose: The purpose of this study was to compare how treatment with convalescent plasma (CP) monotherapy, remdesivir (RDV) monotherapy, and combination therapy (CP + RDV) in patients with COVID-19 affected clinical outcomes. Methods: Patients with COVID-19 infection who were admitted to the hospital received CP, RDV, or combination of both. Mortality, discharge disposition, hospital length of stay (LOS), intensive care unit (ICU) LOS, and total ventilation days were compared between each treatment group and stratified by ABO blood group. An exploratory analysis identified risk factors for mortality. Adverse effects were also evaluated. Results: RDV monotherapy showed an increased chance of survival compared to combination therapy or CP monotherapy (p = 0.052). There were 15, 3, and 6 deaths in the CP, RDV, and combination therapy groups, respectively. The combination therapy group had the longest median ICU LOS (8, IQR 4.5-15.5, p = 0.220) and hospital LOS (11, IQR 7-15.5, p = 0.175). Age (p = 0.036), initial SOFA score (p = 0.013), and intubation (p = 0.005) were statistically significant predictors of mortality. Patients with type O blood had decreased ventilation days, ICU LOS, and total LOS. Thirteen treatment-related adverse events occurred. Conclusion: No significant differences in clinical outcomes were observed between patients treated with RDV, CP, or combination therapy. Elderly patients, those with a high initial SOFA score, and those who require intubation are at increased risk of mortality associated with COVID-19. Blood type did not affect clinical outcomes.

OBJECTIVES: Mississippi recorded the first case of coronavirus disease 2019 (COVID-19) on March 11, 2020. This report describes the initial COVID-19 experience of the single healthcare system serving Jackson County, Mississippi. The intent of this retrospective review of COVID-19 hospitalized patients was to identify any characteristics or interventions amenable to improving care management and clinical outcomes for patients within our community hospital. METHODS: All hospitalized patients 18 years of age and older in our health system with positive tests for COVID-19 (severe acute respiratory syndrome-coronavirus-2 [SARS CoV-2]) by reverse transcriptase-polymerase chain reaction between March 15 and April 10, 2020 are included in this retrospective observational report. RESULTS: During the study period, 158 patients of the 1384 tested (11.4%) were positive for COVID-19 infection. Of the 158 patients, 41 (26%) were hospitalized, with 17 (41%) admitted to the intensive care unit (ICU). The remaining 24 patients did not require ICU admission. The mean age of the 158 COVID-19-positive patients was 55 years (range 2-103). Obesity was noted in 68% of the hospitalized patients, including 13 (54%) of the non-ICU patients and 15 (88%) of the ICU patients. All 9 deceased patients were obese. Twelve of 17 patients received invasive mechanical ventilation (IMV) and 3 patients received only high-flow nasal cannula oxygen. Only 25% (3 of 12) of the IMV patients were successfully extubated during the study period. The median duration on IMV was 17 days (range 4-35). The mortality in the 158 COVID-19-positive patients was 5.7% (9 of 158). None of the 24 non-ICU patients died. The ICU mortality rate was 53% (9 of 17). CONCLUSIONS: This report describes a community hospital experience with COVID-19. Patient outcome was comparable to that reported at larger centers. Obesity was a major comorbidity and correlated with adverse outcomes. Amidst the initial wave of COVID-19 with high demand for inpatient treatment, it is reassuring that appropriate care can be provided in a community health system.

BACKGROUND AND OBJECTIVES The aim of this study was to demonstrate whether academic thoracic surgeons could achieve morbidity and mortality rates in community hospitals equivalent to those seen in National Lung Screening Trial (NLST). METHODS This was a retrospective review of community hospital lung cancer procedures for clinical Stage I-III non-small-cell lung cancers from 2007 through 2014. Variables include age, comorbidities, computed tomography (CT) characterization, and operative techniques. RESULTS There were 177 patients who had lung cancers removed by a minimally invasive approach (79%), including lobectomy in 127 (72%), segmentectomy in 4 (2%), and wedge-resections in 46 (26%). The median patient age was 71 years (interquartile range [IQR], 63-76). The cohort was primarily female (58%), clinical Stage I (82%), with a median tumor size of 2.3 cm (IQR, 1.5-3.3). The median length of stay was 6 days (range: 1-35). Complications were experienced by 78 (44.1%) patients, most commonly atrial fibrillation in 20 (11.3%) followed by air-leak in 19 (10.7%). There were no in-hospital deaths. Tumor location and extent of resection were associated with complications, while larger tumor size, margin contour, and resection method were associated with air-leak (all p

As the nanoparticle albumin-bound paclitaxel (nab-PTX) is free of ethanol and premedication, the duration of administration is shorter and patients can drive themselves to and from the hospital. In the 2018 Japanese gastric cancer treatment guidelines, ramucirumab (RAM) plus weekly nab-PTX is conditionally recommended for previously treated patients with advanced gastric cancer. Here, we retrospectively analysed the efficacy and safety of RAM+nab-PTX for such patients in community hospitals. From January 2018 to December 2019, 43 patients with metastatic and recurrent gastric cancer received RAM+nab-PTX treatment. Six patients (13.9%) were older than 80 years and 9 patients (20.9%) showed ECOG-PS 2. Progression-free survival (PFS), overall survival (OS), overall response rate (ORR), disease control rate (DCR), and adverse events (AEs) were reviewed retrospectively. Median PFS was 114 days (95% confidence interval [CI]: 84-190) and median OS was 297 days (95% CI: 180-398). ORR and DCR were 32.4% and 72.2%, respectively. The incidence rates of ≥grade 3 neutropenia and febrile neutropenia were 53.5% and 2.3%, respectively. No treatment-related deaths occurred. RAM plus nab-PTX combination therapy demonstrated manageable toxicity even patients who were elderly or had an ECOG-PS 2. This treatment is useful in community hospital settings.

The number of medical graduates choosing surgical careers has been declining rapidly in Japan, likely because of surgeons' notoriously stressful working environments and inadequate compensation. We hypothesized that surgeons, in comparison to those in other specialties, have distinct perceptions of their job. To better understand the reasons for the decline in the number of surgeons, we conducted an email-based survey to characterize surgeons' and physicians' job perceptions.The study population, recruited via emailed invitations, completed a questionnaire primarily modeled after the Hackman and Oldham multidimensional tool. The survey contained seven dimensions: task significance, dealing with others, feedback from the job, autonomy, skill variety, task identity, and ethics. The response rate was 29.4%. Results were compared across specialty groups (surgery, internal medicine, and others) and-among surgeons-by hospital setting (university hospitals versus community hospitals).Responses from 415 Japanese physicians were included in this study. The mean scores for ethics, task significance, and dealing with others, and feedback from the job were significantly higher in the surgery group than in the internal medicine and other specialty groups (P 0.05). In contrast, the mean score for autonomy was lower in the surgery group than in the other groups, and the autonomy score was significantly lower in the university hospital surgery group than in the community hospital surgery group (P 0.05).There are clear differences in job perception between surgeons and other physicians, particularly in regard to ethics, task significance, dealing with others, and feedback from the job. Improvement of surgeons' working environments is an imminent need to avoid surgeons' burnout and mitigate the decline in the number of new surgical trainees in Japan.

Objective: To evaluate the use of tocilizumab in a community hospital setting for critically ill patients with severe COVID-19. Design: A retrospective case series Setting: Five community hospitals within 1 urban health system Patients: Adult patients whom received tocilizumab between March 27th, 2020 to April 30th, 2020 for severe COVID-19. Interventions: None. Measurements and Main Results Sixteen patients in total were evaluated from the 5 community hospitals. The mean (± SD) age of the patients was 53.9 ± 9.2 years, 56% were men, and the most common comorbidities present on admission were hypertension (31%) and diabetes mellitus (25%). All patients received at least 1 other treatment modality for COVID-19 (steroids, hydroxychloroquine, or convaslescent plasma). Additionally, all patients on admission to intensive care units had severe COVID-19 with 56% requiring mechanical ventilation with a pre-tocilizumab median (IQR) Pao2: Fio2 of 84 (69 – 108.6), 19% requiring vasopressor support, and inflammatory markers (CRP, LDH, ferritin, and IL-6) were elevated. The median (IQR) tocilizumab dose was 400 mg (400-600) which correlated with a weight-based mean (± SD) dose of 5.4 mg/kg ± 1.3. Of the 16 patients that received tocilizumab, 8 (50%) were discharged home, 7 (44%) died, and 1 (6%) was still hospitalized at the end of data collection. Patients who died were more likely to be older 62 ± 2 years, female (57%), had a higher rate of mechanical ventilation (86%) and vasopressors (43%) use at baseline, and had a higher median (IQR) IL-6 level prior to tocilizumab administration 550 pg/mL (IQR 83-1924). There were no reported adverse drug reactions reported after the administration of tocilizumab for any patient. Conclusions: Our findings do not support the effectiveness of tocilizumab in treatment of severe COVID-19 infection in critically ill patients.

Background/Aims: High-quality colonoscopy is essential to reduce colorectal cancer-related deaths. Little is known about colonoscopy quality in non-academic practice settings. We aimed to evaluate the quality of colonoscopies performed in community hospitals and nonhospital facilities. Methods: Colonoscopy data were collected from patients referred to six tertiary care centers after receiving colonoscopies at community hospitals and nonhospi tal facilities. Based on their photographs, we measured quality indicators includ ing cecal intubation rate, withdrawal time, adequacy of bowel preparation, and number of polyps. Results: Data from a total of 1,064 colonoscopies were analyzed. The overall ce cal intubation rate was 93.1%. The median withdrawal time was 8.3 minutes, but 31.3% of colonoscopies were withdrawn within 6 minutes. Community hospitals had longer withdrawal time and more polyps than nonhospital facilities (median withdrawal time: 9.9 minutes vs. 7.5 minutes, p < 0.001; mean number of polyps: 3.1 vs. 2.3, p = 0.001). Board-certified endoscopists had a higher rate of cecal intu bation than non-board-certified endoscopists (93.2% vs. 85.2%, p = 0.006). A total of 819 follow-up colonoscopies were performed at referral centers with a median interval of 28 days. In total, 2,546 polyps were detected at baseline, and 1,088 were newly identified (polyp miss rate, 29.9%). Multivariable analysis revealed that old er age (odds ratio [OR], 1.032; 95% confidence interval [CI], 1.020 to 1.044) and male sex (OR, 1.719; 95% CI, 1.281 to 2.308) were associated with increased risk of missed polyps. Conclusions: The quality of colonoscopies performed in community hospitals and nonhospital facilities was suboptimal. Systematic reporting, auditing, and feedback are needed for quality improvement.

This study compared the effectiveness of soft vs hard orthotics in treating heel pain and plantar fasciitis in adults. It also compared the level of function after orthotic use, cost, and number of visits for orthotics and explored whether age was a factor in orthotic effectiveness.Randomized controlled trial. Before randomization, patients were stratified by age (younger vs older adults) in blocks of 4 to ensure that there were an equal number of participants in each group (soft vs hard orthotics).An orthotic clinic in a community-based hospital and a private orthotic clinic.The participants were adults aged 18 years or older (N=44) with heel pain and plantar fasciitis.Participants received hard or soft customized orthotics.Participants rated their pain intensity and pain interference before and after orthotic use using subscales from the Brief Pain Inventory. Function was similarly measured using the Late Life Function and Disability Instrument: Function component. Analyses of age, cost, and number of visits were also compared.There was a reduction in pain intensity (P=.010) and pain interference (P.001) but no change in function over time (P=.333), and no difference between the groups who received hard vs soft orthotics. Age had no effect on orthotic effectiveness. Soft orthotics were less expensive (P.0001) and required fewer visits for fabrication (P.0001).Both soft and hard orthotics provided effective pain relief, but soft orthotics are less expensive.

Introduction Over the past several years there has been a dramatic increase in the implementation of telemedicine technology to aid in the delivery of care across community, inpatient, and emergency settings. This technology has proved valuable for acute life-threatening clinical scenarios. We aimed to pilot a novel neurosurgical telemedicine program within an academic tertiary care center to assist in consultation of patients with high-grade intracranial hemorrhage (ICH) (ICH score 4, 5). Methods A quality improvement conceptual framework was developed. Subsequently, a process map and improvement interventions were created. Patients in community hospitals with high-grade ICH or pre-existing Do Not Resuscitate/Do Not Intubate orders with an admitting diagnosis of ICH triggered a TeleNeurosurgery consultation. Patients who met the inclusion criteria, with consent of their decision makers, were enrolled in the study. Post-encounter physician surveys were used to evaluate overall satisfaction with the implementation. Results This 18-month pilot study proved feasible, with an enrollment of 63.6% (n = 14 of 22) of patients who met criteria. All patients who were enrolled in the study and participated in TeleNeurosurgery consultation remained at the presenting facility for end-of-life care and palliative medicine consultation. Both community emergency physicians and subspecialists who performed the consultations reported satisfaction with the TeleNeurosurgery consultation process and a perceived benefit both to patients, families, and emergency medicine physicians. Conclusions The program proved feasible and several areas in need of improvement within the health system were identified. Emergency physicians reported comfort with the process, program effectiveness, and improved access to care by implementation of this program.

BACKGROUND There has been a growing trend toward minimally invasive surgery (MIS) for colon cancer. Pathological analysis of a minimum of 12 lymph nodes (LNs) is a benchmark for adequate resection. Here, we present a comparison of surgical techniques in achieving a full oncologic resection. METHODS Patients undergoing surgery for Stage I-III colon cancer (2010-2016) were identified from the National Cancer Database. Cases were stratified by surgical approach. Trends in approach were assessed, including whether the 12-LN benchmark was met. Uni- and multivariate regression was used to assess overall survival (OS). RESULTS A total of 290,776 colectomies were analyzed. MIS increased from 32.8% to 57.2% from 2010 to 2016 (p

Importance: Although routine postoperative care for microvascular free flap reconstruction typically involves admission to the intensive care unit (ICU), few studies have investigated the effect of...

There is a strong association between hospital volume and surgical outcomes in resectable colorectal cancer. The purpose of our study was to investigate the association between hospital facility type and survival of patients with metastatic colorectal cancer.Adults from the National Cancer Database (2010-2015) with a primary diagnosis of colorectal metastases were included and stratified by facility type: community cancer program, comprehensive community cancer program, and academic/research program. The primary outcome was 5-year overall survival, analyzed using Kaplan-Meier survival curves, log-rank test, and the Cox proportional hazards regression model.Among the 52,958 included patients, 13.72% were treated at a community cancer program, 49.89% at a comprehensive community cancer program, and 36.29% at an academic/research program. A significant increase in the proportion of patients being treated in an academic/research program has been observed from 2010 to 2015. An academic/research program tended to use more chemotherapy with colorectal radical resection and liver or lung resection and immunotherapy with chemotherapy. In adjusted analysis, the academic/research program had decreased risk of mortality in comparison to the community cancer program and the comprehensive community cancer program (hazard ratio 0.90, 95% confidence interval 0.86-0.94; 0.87, 0.85-0.90; each P.001; respectively). Similar results were seen after stratifying by metastatic site and treatment type.The prognosis and overall survival of patients with metastatic disease is better in an academic/research program compared with a community cancer program or a comprehensive community cancer program, with this difference persisting across sites of metastatic disease and treatment types. Further studies are required to validate these results and investigate disparities in the management of metastatic colorectal cancer.

Respiratory tract infections (RTIs) are the most common diseases globally among children. This study aimed to assess the epidemiology of admission-requiring pediatric RTI cases and evaluate the effect of the pathogen type on the length of hospital stay (LOS) using the FilmArray® respiratory panel, a multiplex PCR test. The age-specific distribution and seasonality of viruses were investigated between March 26, 2018 and April 12, 2019. Multivariable linear regression analyses were performed to evaluate the effect of pathogen type and coinfection on LOS. Among 153 hospitalized RTI patients, respiratory syncytial virus was the leading cause of hospitalization in infants < 12 months of age (27.7%). Human metapneumovirus and parainfluenza virus were also major causes of hospitalization in patients aged 2-3 years (22.6% and 22.6%, respectively). In the multivariable linear regression model excluding rhinovirus/enterovirus, there was a significant association between viral coinfection and longer LOS (p = 0.012), while single viral infection of any type was not positively correlated with LOS. This study revealed the epidemiology of admission-requiring pediatric RTIs.

BACKGROUND Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. STUDY DESIGN AND METHODS A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. RESULTS Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P

Objective Patients in Sweden’s rural community hospitals have not been clinically characterised. We compared characteristics of patients in general practitioner-led community hospitals in northern Sweden with those admitted to general hospitals. Design Retrospective register study. Setting Community and general hospitals in Västerbotten and Norrbotten counties, Sweden. Patients Patients enrolled at community hospitals and hospitalised in community and general hospitals between 1 January 2010 and 31 December 2014. Outcome measures Age, sex, number of admissions, main, secondary and total number of diagnoses. Results We recorded 16,133 admissions to community hospitals and 60,704 admissions to general hospitals. Mean age was 76.8 and 61.2 years for community and general hospital patients (p

OBJECTIVE: To determine the impact of telemedicine visits, compared to in-person visits, on patient satisfaction in an established community hospital-based multidisciplinary central nervous system (CNS) clinic. METHODS: Telemedicine options – virtual visits and teleconferencing – were introduced in July 2020. Both radiation oncologist and neurosurgeon were simultaneously present for the telemedicine visit. Descriptive patient demographics, survey responses, and travel time and distance calculations were analyzed. Satisfaction score was compared to previously published data. RESULTS: A total of twenty-five telemedicine visits (n=22 video; n=3 phone) were completed since July 2020. Patient demographics are as follows: mean age was 59 years (range=22–81), women (9) and men (16), repeat telemedicine visits n=10, malignant CNS disease (17) and benign disease (5). Mean one-way distance traveled was 165.07 miles (median=114; range=0.8–358). Mean roundtrip travel time was estimated at 5h 5min. Mean telemedicine visit duration was 15.3 mins (range=4–46). Mean patient satisfaction score for telemedicine visits was 4.84. CONCLUSION: Patients who opted for the telemedicine visits found them just as effective as in-person visits, saving time and travel costs as well as ensuring patient safety during the current COVID-19 pandemic. The telemedicine visit platform facilitates the multidisciplinary clinic model and should be considered for more widespread utilization (Tab. 3, Fig. 1, Ref. 18). Text in PDF www.elis.sk.

Due to the COVID-19 pandemic, nursing programs were challenged to continue educating students at practice sites, and educational institutions limited or eliminated face-to-face education. The purpose of this article is to report on a university and community college nursing program and an academic medical center that implemented an academic-practice partnership with the goal of creating opportunities to continue clinical experiences for nursing students during the pandemic. Principles and implementation of this successful partnership provide direction for other nursing programs and practice settings that may continue to have challenges in returning students to clinical and keeping them in clinical as the pandemic continues., Highlights • Clinical education is necessary to maintain a pipeline of nurses in the workforce. • Academic-practice partnerships are essential to nurse education during a pandemic. • Our experience is shared planning and implementing a practice/academic partnership. • Principles and strategies to maintain clinical education during crises are provided.

Studies have shown that the incidence of postoperative delirium, the hospital length of stay and time to surgery are reduced when older adults with a hip fracture are cared for by a multidisciplinary team providing comprehensive geriatric assessments. Most of these studies have been conducted in academic centres. We sought to determine if implementation of an orthogeriatric collaborative care model would improve key quality of care metrics in a community hospital setting.This retrospective pre- and postintervention single-site study was conducted in a community hospital in Ontario, Canada. We included consecutive patients aged 65 years or older who were admitted for a hip fracture between June 2015 and June 2017. In the intervention period, a new postoperative order set included a referral to a geriatrician for comprehensive geriatric assessment, with direct implementation of recommendations. Primary outcomes were the incidence of postoperative delirium and length of stay. Secondary outcomes included Health Quality Ontario's quality standards for hip fracture.A total of 212 consecutive patients (95 in the preintervention group and 117 in the postintervention group) were included in the study. The incidence of postoperative delirium (26.3% v. 26.5%, p = 0.98) and length of stay (interquartile range 4-10 v. 5-10 d, p = 0.32) were similar in the preintervention and postintervention groups. There were improvements (p0.001) in the rates of asssessment of mental status, falls and bone health; identification of delirium prevention strategies; prescription of vitamin D or calcium or both; and recommendations for antiresorptive therapy. Despite systemic implementation of the orthogeriatric model, only 74.4% of patients in the postintervention group were seen by a geriatric medicine consultant.Although the implementation of an orthogeriatric collaborative care model for older adults with a hip fracture did not reduce the incidence of postoperative delirium or length of stay, there were improvements in the rates at which several other key quality standards for hip fracture care were met. Earlier proactive, comprehensive geriatric assessment in a community hospital setting will be the target for further quality improvement initiatives.Des études ont montré que l’incidence du délire postopératoire, la durée du séjour à l’hôpital et le temps d’attente avant la chirurgie sont réduits lorsque les personnes âgées présentant une fracture de la hanche reçoivent les soins d’une équipe multidisciplinaire qui réalise une évaluation gériatrique complète. La plupart de ces études ont été effectuées dans des centres universitaires. Nous souhaitions donc déterminer si l’intégration d’un modèle de soins orthogériatriques collaboratif améliorerait les principaux indicateurs de la qualité des soins dans les hôpitaux communautaires.Cette étude rétrospective comparant 2 groupes de patients avant et après la mise en oeuvre d’une intervention a été menée dans un seul hôpital communautaire en Ontario, au Canada. Nous avons inclus les patients consécutifs de 65 ans et plus admis pour une fracture de la hanche entre juin 2015 et juin 2017. Pendant la période d’intervention, un nouvel ensemble d’ordonnances postopératoires a été ajouté. Il comprenait l’aiguillage vers un gériatre pour une évaluation gériatrique complète et l’application directe des recommandations. Les principales issues à l’étude étaient l’incidence du délire postopératoire et la durée de l’hospitalisation. Les issues secondaires comprenaient le respect des normes de qualité relatives à la fracture de la hanche de Qualité des services de santé Ontario.Au total, 212 patients consécutifs (95 dans le groupe préintervention et 117 dans le groupe postintervention) ont été inclus dans l’étude. L’incidence du délire postopératoire (26,3 % c. 26,5 %, p = 0,98) et la durée de l’hospitalisation (écart interquartile 4–10 jours c. 5–10 jours, p = 0,32) étaient similaires dans les 2 groupes. Il y a eu des améliorations (p0,001) dans le taux d'évaluation de l'état mental, des chutes et de la santé des os; dans l'intégration de stratégies de prévention du délire; dans la prescription de vitamine D ou de calcium, ou des deux; et dans les recommandations de traitement antirésorptif. Malgré l'adoption du modèle orthogériatrique dans l'ensemble du centre, seulement 74,4 % des patients du groupe postintervention ont eu une consultation en gériatrie.Bien que la mise en œuvre d’un modèle de soins orthogériatriques collaboratif chez les personnes âgées présentant une fracture de la hanche n’ait pas réduit l’incidence du délire postopératoire ou la durée de l’hospitalisation, il y a eu une amélioration du respect de plusieurs normes de qualité importantes relatives à ce type de fracture. L’évaluation gériatrique complète réalisée tôt, de manière proactive, dans les hôpitaux communautaires sera la cible d’initiatives d’amélioration de la qualité à venir.

Highlights • The current COVID-19 pandemic has stretched advanced health systems beyond their capacities. • Previous pneumonia severity scores have been promoted as useful tools to help clinicians predict outcomes and guide clinical decisions. • The CURB-65 and Quick COVID-19 Severity Index scoring systems showed a good performance for predicting in-hospital mortality. • The Quick COVID-19 Severity Index score and the Brescia-COVID Respiratory Severity Scale prediction rule showed a good performance for predicting intensive care unit admission., Objective To evaluate the performance of the Quick COVID-19 Severity Index (qCSI) and the Brescia-COVID Respiratory Severity Scale (BCRSS) in predicting intensive care unit (ICU) admissions and in-hospital mortality in patients with coronavirus disease 2019 (COVID-19) pneumonia. Methods This was a retrospective cohort study of 313 consecutive hospitalized adult patients (18 years or older) with confirmed COVID-19. The area under the receiver operating characteristic curve (AUC) was used to assess the discriminatory power of the qCSI score and BCRSS prediction rule compared to the CURB-65 score for predicting mortality and intensive care unit admission. Results The overall in-hospital fatality rate was 32.3%, and the ICU admission rate was 31.3%. The CURB-65 score had the highest numerical AUC to predict in-hospital mortality (AUC 0.781) compared to the qCSI score (AUC 0.711) and the BCRSS prediction rule (AUC 0.663). For ICU admission, the qCSI score had the highest numerical AUC (AUC 0.761) compared to the BCRSS prediction rule (AUC 0.735) and the CURB-65 score (AUC 0.629). Conclusions The CURB-65 and qCSI scoring systems showed a good performance for predicting in-hospital mortality. The qCSI score and the BCRSS prediction rule showed a good performance for predicting ICU admission.

Objective: Laparoscopic surgery is an alternative procedure for colorectal cancers. However, high-level supporting evidence has been derived from high-volume centers in developed countries. During the early phase of applying the laparoscopic approach, we evaluated the procedure’s short-term outcomes in our regional middle-volume hospital in a developing country. Methods: We retrospectively analyzed data for a cohort of 223 colorectal cancer patients who underwent elective surgery from October 2017 to September 2019. We compared 165 patients undergoing open surgery (OS group) with 58 undergoing laparoscopic surgery (LS group) using a propensity score-matched analysis. Results: After matching, each group contained 58 patients for evaluating outcomes. The LS group had more harvested mesenteric lymph nodes (5.0 nodes, 95% confidence interval (CI): 1.8–8.1; p-value

Uncertainty surrounding the COVID-19 epidemic exists, partly driven by the difficulty in prognostication and understanding risk factors that portend worse outcomes. This study examines whether differences in clinical characteristics on admission result in the need for intensive care unit (ICU)–level care and demonstrates few differences among patients needing ICU care and those that did not. Furthermore, patients admitted to the ICU generally have poor outcomes., Objectives The severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) epidemic is characterized by a global sense of uncertainty, partly driven by the paucity of real-life clinical data. This study assessed whether admission patient characteristics were associated with need for intensive care unit (ICU) care. Methods The observational study included consecutive patients admitted to a large community teaching hospital with a diagnosis of SARS-CoV-2 between March 6, 2020 and March 31, 2020. Comparisons were made based on the need for ICU admission. Results A total of 156 patients were admitted, 42 of whom (26.9%) required ICU admission and 114 (73.1%) did not. No difference in age (61.9 years vs 60.5 years, P = 0.67), race/ethnicity, or comorbidities were noted, except that patients requiring ICU care had lower serum albumin levels and lymphocyte counts and higher liver function tests, white blood cell count, and absolute neutrophil count on admission. The average time from admission to death was similar (10 days in an ICU subset vs 9.2 days in a non-ICU subset, P = 0.78), yet patients necessitating ICU care had longer hospital lengths of stay (10.2 vs 5.1 days, P = 0.0002). At the time of data extraction, 15 patients in the ICU had died, 7 were discharged from the hospital, and 20 were still admitted while 5 patients died in the non-ICU cohort with 97 discharged and 12 patients admitted. Conclusions This is the largest study assessing clinical differences based on the need for ICU admission in inpatients with SARS-CoV-2. It found few major differences in clinical variables between subsets. Among patients admitted to the ICU, outcomes were generally poor.

Introduction Monoclonal antibodies received an Emergency Use Authorization (EUA) from the U.S. Food & Drug Administration for the outpatient treatment of mild to moderate coronavirus disease 2019 (COVID-19). REGN-COV2, casirivimab and imdevimab, has been shown to decrease the viral load and healthcare visits of those with mild to moderate COVID-19 who are treated in the outpatient setting. Objective To determine 7- and 14-day emergency department (ED) and hospitalization rates of adult patients given REGN-COV2 for the outpatient treatment of COVID-19 at a community hospital. Methods A convenience sample of consecutive adult patients given REGN-COV2 from January 18, 2021 through March 31, 2021 for the outpatient treatment of mild to moderate COVID-19. Abstracted data included patient demographics, allergic reactions, ED presentations and hospitalizations at 7 and 14 days, and in-hospital mortality. Results A total of 68 patients with a medain age of 69 years (IQR 57–75.5) and 58.3% being female were given REGEN-COV2 during the study period. No allergic reactions were noted during infusion. Of those infused, 18% (12/68) were infused in the ED and had a median length of stay of 477 min. Following infusion, 10% (7/68) of patients re-presented to the ED and 2% (1/68) were hospitalized for COVID-19 at 14 days. In those aged 65 years or greater, 12% (5/42) of patients re-presented to the ED following infusion. Of those who re-presented to the emergency department, the median age was 72.5 years and the median time from infusion to re-presentation was 2.0 days. No patients suffered in-hospital mortality during the study period. Conclusion There was a significant length of stay associated with REGN-COV2 infusion in the emergency department. Following REGN-COV2 infusion, few patients under the age of 65 re-presented to the emergency department at seven and 14 days. However, a large number of patients aged over 65 years re-presented to the ED following infusion.

Background: Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens. Methods: A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups. Results: 698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD. Conclusion: Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.

Background Vascular prosthetic graft infections are rare but associated with high morbidity and mortality. Treatment involves removal of the infected graft requiring arteriotomy closure. Previously this was performed with autologous graft, but bovine tissue has increasingly been used. The objective of this paper is to review the community hospital experience with bovine tissue repair in an infected vascular field. Materials and Methods A retrospective review of all cases performed by a single surgeon in a community hospital for infected prosthetic grafts was completed. Sixteen cases were included where bovine tissue was used for repair. Presentation, location of graft, and causative organism were reviewed, and outcomes including reoperation and mortality were recorded. Results Of the 16 patients, 15 (94%) had positive cultures of the graft. Methicillin-Resistant Staph Aureus was the most commonly isolated organism (50%). There were 3 unplanned reoperations including a revision from below to above knee amputation, drainage of a hematoma, and a wound debridement within the first year. Over the 1 year follow up period, 3 patients died for a mortality of 19%. There were no reinfections during follow-up. Discussion Prosthetic graft infection is a rare but serious vascular surgery complication. The causative organism has shifted in the last few years to become increasingly drug resistant. Treatment requires excision, and bovine tissue has been demonstrated to provide a safe and durable method of repair.

Objective The aim of the study was to examine the ability of overreading of computed tomography (CT) and right lower quadrant ultrasound (RLQ US) to diagnose appendicitis for children with suspected appendicitis with equivocal CTs at community hospitals. Methods This was a retrospective chart review of all children transferred to a children's hospital from community emergency departments with suspected appendicitis over 2 years for whom both CT and RLQ US were performed. Results One hundred eighty-four children were included with a median age of 10.8 years, and 57.6% were female. Community hospitals documented that CTs were equivocal for appendicitis in 110 (59.8%), positive in 63 (34.2%), and negative in 11 (6.0%). Ninety-seven CTs (88.1%) designated equivocal at community hospitals were later deemed interpretable by pediatric radiologists: 21 (19.1%) as appendicitis and 76 (69.1%) as normal. In 13 children (11.8%), both the community and children's hospital CT interpretations were equivocal. In equivocal cases, RLQ US was consistent with appendicitis in 6 (46.2%), normal in 5 (41.7%), and nondiagnostic in 2. κ value between CT interpretations at community versus children's hospital was 0.13 (95% confidence interval, 0.05-0.22), and κ value between CT interpretation at the children's hospital and RLQ US was 0.59 (95% confidence interval, 0.48-0.70). Conclusions Most CTs deemed equivocal for appendicitis at community hospitals were interpretable by pediatric radiologists. In a few children for whom CTs were designated nondiagnostic, RLQ US provided a definitive diagnosis in almost 90% of cases. The first step in evaluation of children with suspected appendicitis for whom outside CTs are deemed equivocal should be to have the study reinterpreted by a pediatric radiologist.

Introduction The severe acute respiratory syndrome related coronavirus 2 (SARS-CoV-2) has infected more than 20 million people worldwide, and the spread is most prevalent in the USA, where California had accounted over 240,000 cases in the initial 5 months of the pandemic. To estimate the number of infected persons in our community, we conducted a cross-sectional study to estimate seroprevalence of SARS-CoV-2 infection. Methods This cross-sectional study evaluated the presence of immunoglobulin G, antibody for SARS-CoV-2 during the time period of July 15, 2020, to July 27, 2020. Testing was done on serum samples from patients who had visited affiliated outpatient clinics or our emergency department. Additionally, we collected age, gender, ethnicity, race, and location of testing. Results Eight hundred sixty-five tests were included in the study. The outpatient clinics cohort accounted for 56% of results and emergency department (ED) contributed 44%. The positive percentage of SARS-CoV-2 test was 9.4% (95% CI: 0.08–0.12). The positivity rates of the outpatient (5.6%) and ED (14.2%) setting differed. The prevalence of SARS-CoV-2 IgG was greatest in those that identified as Hispanic/Latino, 18.1% versus 13.4% in other groups. Specifically compared to the non-Hispanic/Latino population, the prevalence was significantly higher, with a relative risk of 2.73 (95% CI: 1.8–4.1), p

Background and PurposeThe Japanese Nurse Association (JNA) has established the JNA ladder to assess competency in various clinical nursing settings in Japan. This study developed and tested a specific Japanese community hospital's Nurse Competency Scale (the Unnan ladder).MethodsUsing the Delphi method, the contents of the Unnan ladder were identified and validated in a four-step approach. A 28-nurse panel approved 66 items; 112 community nurses assessed the content, construct concurrent validity, and internal consistency of the Unnan ladder competency scale.ResultsThe Unnan ladder data were normally distributed. Higher scores on it correlated with higher scores on the Nurse Competency Scale. The Unnan ladder categories showed good internal consistency.ConclusionsThis ladder's application may lead to improved nursing skills and better patient care.

BACKGROUND Falls are the leading cause of traumatic brain injury (TBI) and TBI-related deaths for older persons (age, ≥65 years). Antiplatelet and/or anticoagulant therapy (antithrombotics [ATs]) is generally felt to increase this risk, but the literature is inconsistent. The purpose of this study was to determine the impact of AT use on the rate, severity, and outcomes of TBI in older patients following ground level falls. METHODS Ground level fall patients from 90 hospitals' trauma registries were selected. Patients were excluded if younger than 65 years or had an Abbreviated Injury Scale score of >2 in a region other than head. Electronic medical record data for preinjury AT therapy were obtained. Patients were grouped by regimen for no AT, single, or multiple agents. Groups were compared on rates of diagnosed TBI, TBI surgery, and mortality. RESULTS There were 33,710 patients (35% male; mean age, 80.5 years; mean Glasgow Coma Scale, 14.6), with 47.6% on single or combination AT therapy. The proportion of patients with TBI diagnoses did not differ between those on no AT (21.25%) versus AT (21.61%; p = 0.418). Apixaban (15.7%; p < 0.001) and rivaroxaban (13.19%; p = 0.011) were associated with lower rates of TBI, and acetylsalicylic acid-clopidogrel was associated with a higher TBI rate (24.34%; p = 0.002) versus no AT. acetylsalicylic acid-clopidogrel was associated with a higher cranial surgery rate (2.9%; p = 0.006) versus no AT (1.96%), but surgery rates were similar for all other regimens. No regimen was associated with higher mortality. CONCLUSION In this large multicenter study, the intake of ATs in older patients with ground level falls was associated with inconsistent effects on risk of TBI and no significant increases in mortality, indicating that AT use may have negligible impact on patient clinical management. A large, confirmatory, prospective study is needed because the commonly held belief that ATs uniformly increase the risk of traumatic intracranial bleeding and mortality is not supported. LEVEL OF EVIDENCE Therapeutic/care management, level II.

Background There is limited data on the clinical presentation and predictors of mortality in the African‐American(AA) patients hospitalized with COVID‐19 despite the disproportionately higher burden and mortality. The aim of this study is to report on the clinical characteristics and the predictors of mortality in hospitalized AA patients with COVID‐19 infection. Methods In this retrospective cohort review, we included all AA patients with confirmed COVID‐19 infection admitted to an inner‐city teaching community hospital in New York City. Demographics, clinical presentation, baseline co‐morbidities, and laboratory data were compared between survivors and non‐survivors. The predictors of mortality were assessed using multivariate logistic regression analysis. Results Of the 408 (median age, 67years) patients included, 276(66.65%, median age 63years) survived while 132(33.35%, median age 71years) died. The most common presenting symptoms were cough, myalgia, fever/chills, shortness of breath, and gastrointestinal symptoms (nausea, vomiting, diarrhea, and abdominal pain), with a prevalence of 62.50%, 43.87%, 53.68%, and 27.21%, respectively. Age (OR 1.06, CI 1.04‐1.08, P‐

BACKGROUND AND OBJECTIVES The benefit of tissue plasminogen activator (tPA) in acute ischemic stroke is time dependent. A 15-minute decrease in door-to-needle (DTN) time has been associated with increased odds of ambulating independently, faster discharge, and decreased odds of death. We investigated common causes of delay in DTN times in a community hospital setting in order to identify areas for improvement. METHODS A retrospective medical record review was conducted at a 574-bed community hospital. This included 100 patients who received tPA from 2016 to 2019. Time segments were classified a priori to reflect key work elements from the time between hospital arrival to tPA and recorded for each chart. Linear regression models were used to identify work elements associated with increased DTN time. RESULTS Median DTN time was 54:29 minutes. Linear regression analyses determined that differences in NIHSS score (P = .030), triage to computed tomography (CT) start (P = .017), triage to stroke physician page (P = .016), and CT report to tPA administration (P < .001) were associated with increased DTN time. CT report to tPA administration was most strongly associated with a Pearson coefficient of 0.868 (P < .001) with increased DTN time. CONCLUSIONS The DTN time at our institution was above the recommended target. Our findings suggest that reducing the CT report time interval may decrease DTN time.

Highlights • Telemedicine is an emerging field with diverse applications. • Mild TBI patients may be candidates for screening before inter-facility transfer. • Avoiding unnecessary hospital transfers can better optimize resource utilization., We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14–15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In “screened” patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the “unscreened” group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38). In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14–15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.

Supplemental Digital Content is available in the text., Background and Purpose: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. Methods: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. Results: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92–104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130–136]; P

Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization.A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization.Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%,Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.Les protocoles de récupération optimisée après une chirurgie (ou ERAS, pour enhanced recovery after surgery) utilisent des pratiques périopératoires fondées sur des données probantes pour réduire la morbidité, abréger la durée des séjours hospitaliers et améliorer la satisfaction des patients. Les protocoles ERAS sont considérés comme une norme thérapeutique; toutefois, leur utilisation reste faible et on note une importante variation dans leur application. Le but de cette étude était de caractériser dans les faits les variations des pratiques en chirurgie colorectale et d’identifier les prédicteurs de l’utilisation des protocoles ERAS.Un sondage a été effectué auprès des chirurgiens généraux de la base de données du Collège des médecins et chirurgiens de l’Ontario. On a recueilli des données sur les caractéristiques démographiques de base, l’utilisation des protocoles ERAS et les prédicteurs de leur déploiement. Neuf pratiques ERAS ont été analysées. L’analyse multivariée a permis de déterminer les effets des covariables démographiques, hospitalières et celles des chirurgiens sur le recours aux protocoles ERAS.Nous avons invité 797 chirurgiens généraux à participer au sondage, et 235 d’entre eux représentant 84 hôpitaux ontariens y ont répondu (taux de réponse 30 %). Les chirurgiens des établissements universitaires et des grands hôpitaux communautaires ont représenté respectivement 30 % et 47 % des répondants. En tout, 20 % des répondants ont déclaré appliquer les 9 pratiques ERAS de manière constante. L’alimentation précoce au Jour 0 postopératoire, la restriction des liquides intraveineux et les directives concernant les cathéters et les sondes étaient significativement mieux observées chez les répondants qui adhéraient aux protocoles ERAS que chez ceux qui n’y adhéraient pas (74 % c. 54 %,On continue d’observer une importante variation des pratiques en chirurgie colorectale. Les principes ERAS individuels sont généralement suivis, mais ils ne sont pas formellement intégrés aux protocoles hospitaliers.

The Department of Veterans Affairs (VA) has established and maintained the largest integrated health care system in the United States. Previous research has shown that this system provides high-quality health care but has been limited by concerns regarding patient access ([1][1],[2][2]). Because of

Surveys confirm risk factors for the incarceration of patients with psychosis including homelessness and comorbidity. There is also agreement that severe psychosis can lead to violence. Data describing prisoners with psychosis in Germany are scarce. We aimed to compare patients with psychosis in a prison hospital and patients with psychosis in a community hospital. Demographic data were collected, as well as comorbidity in the form of substance dependence and a psychiatric assessment using the German version of the 18-item Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative Syndrome Scale (PANSS). In the prison hospital group more patients were homeless (17 versus 2%) and non-German (36 versus 4%). There were also more patients with substance dependence or abuse in the prison hospital group. The total scores of BPRS and PANSS were lower in the prison hospital group (BPRS, 43.8 versus 51.2; PANSS, 71.5 versus 83.7). We assume that social disintegration for mentally disturbed offenders prior to incarceration hindered effective treatment. To avoid further social disintegration and possible further deterioration of mental health status of released offenders, which may lead to reoffending after imprisonment, discharge management after release from prison should be improved.

Procalcitonin (PCT) is a biomarker that may help providers optimize antibiotic (AB) therapy. Numerous clinical trials have demonstrated the utility of PCT-guided decision algorithms in treating lower respiratory tract infections and sepsis, but evidence from real-world studies is limited. This study sought to evaluate the effects of PCT on select clinical outcomes in community hospitals.An observational, retrospective, case-control study was conducted. Hospitals from a large US hospital system were categorized into "treatment" and "control" hospitals. Treatment hospitals were those with in-house PCT testing, a pharmacy team tasked with PCT testing follow-up and results in the patient's electronic medical records alongside a recommendation on AB treatment. Control hospitals either did not have PCT testing available in house or sent out tests to a laboratory or neighboring facility. Patients from treatment hospitals were matched 1:1 to patients from control hospitals based on admission diagnosis code, sex, age and whether an intensive care unit admission was observed. Clinical outcomes included number of days of AB treatment, length of stay, 30 day readmissions, mortality and acute kidney injury. Comparisons were conducted using multivariable regressions accounting for clustering at the hospital level.Patients from treatment hospitals had significantly shorter hospital stays (-0.68 days, 95% CI: -1.26, -0.09;These findings suggest that PCT, along with specific treatment recommendations, may lead to shortened hospital stays with no adverse outcome on patient safety.

Objectives:The objective of this study was to evaluate the effectiveness of a 911 trauma re-triage protocol implemented at a new community hospital in a region with a high volume of trauma and frequent transports by private vehicle.Methods:This retrospective cohort study included all trauma patients ≥15 years old transferred via 911 trauma re-triage from a new community hospital over a 10-month period from August 2015 through April 2016. Criteria for 911 trauma re-triage were developed with input from local Emergency Medical Services (EMS) and trauma experts. An educational module, along with the criteria and implementation steps, was distributed to the emergency department (ED) personnel at the community hospital. Data were abstracted from the regional trauma registry, and the EMS patient care records were reviewed. Primary outcomes were: (1) median total transport time; and (2) proportion of patients who met the 911 re-triage criteria.Results:During the study period, 32 patients with traumatic injuries were transferred via 911 re-triage to the closest trauma center (TC). The median age of patients was 31 years (IQR 24-45 years) with 78% male and 66% suffering from a penetrating mechanism. The median prehospital provider scene time was 10 minutes (IQR 8-12 minutes) and transport time was seven minutes (IQR 6-9 minutes). Median total transport time was 17 minutes (IQR 15-20 minutes). Seventeen patients (53%) met 911 re-triage criteria as determined by study investigators. The most common criteria met was “penetrating injury to the head, neck, or torso” in 14 cases.Conclusion:This study demonstrated that 911 re-triage was a feasible strategy to expeditiously transfer critical trauma patients to a TC within a mature trauma system in an urban-suburban setting with a median total transport time of 17 minutes.

Despite efforts to improve access to palliative care services, a significant number of patients still have unmet needs throughout their continuum of care. As such, this project was conducted to increase recognition of patients who could benefit from palliative care, increase referrals, and connect regional sites. This study utilized Plan-Do-Study-Act cycles through a quality improvement approach to develop and test the Palliative Care Screening Tool and aimed to screen 100% of patients within 24 hours who were admitted to selected units by February 2017. The intervention was implemented in 3 different units, each within community hospitals. Patients 18 years or older were screened if they were admitted to one of the selected units for the project, regardless of their diagnosis, age, or comorbidities. The percentage of newly admitted patients who were screened and the total number of palliative care consults were assessed as outcome measures. The tool was met with varying compliance among the 3 sites. However, there was an overall increase in consults across all hospital sites, and an increase in the proportion of noncancer patients was demonstrated. Although the aim was not reached, the tool helped to create a shift in the demographic of patients identified as palliative.

BACKGROUND: Patient safety during the post-discharge period is a major public health concern. Racial differences on incidence and risk factors associated with post-discharge adverse events (AEs) are understudied. The aim of the study was to examine the differences on the incidence of post-discharge AEs and the associated risk factors between African American and Caucasian patients. METHODS: This was a prospective cohort study of patients at risk for post-discharge AEs from December 2011 through October 2012. We included 589 patients who were African American or Caucasian and discharged home from an urban community hospital. The patients spoke English and could be contacted after discharge for evaluation. Two nurses performed 30-day post-discharge telephone interviews, and two physicians adjudicated health records to determine AEs using a previously established methodology. RESULTS: African American patients had a slightly higher incidence of post-discharge AEs than Caucasian patients (30.6% vs. 29.9%), although the difference did not show statistical significance. The multivariable logistic regression model indicated that post-discharge AEs were associated with timely follow-up and the number of secondary discharge diagnoses. In subgroup analyses of the risk factors in each racial group separately, only timely follow-up ambulatory visits were associated with post-discharge AEs. CONCLUSION: Post-discharge AEs were experienced by a large proportion of both African American and Caucasian patients, and there was no statistically significant difference in these proportions by race.

Background and Objective Endoscopic endonasal surgery (EES) for the management of sellar, suprasellar, and anterior skull base lesions is gaining popularity. Our aim was to analyze and present the clinical outcomes of EES for the management of these lesions in a community hospital setting. Methods We retrospectively reviewed the charts of 56 patients with sellar, suprasellar, and anterior skull base lesions who underwent EES between 2010 and 2018. Results There was male predominance (53.6%) with a mean age of 54.9 ± 13.7 years. Lesions were 45 pituitary adenomas, 5 meningiomas, 3 metastatic, 1 craniopharyngioma, 1 Rathke cyst, and 1 mucocele. Gross total excision was achieved in 57.1%, subtotal excision occurred in 37.5%, and decompression and biopsy were achieved in 5.4% patients. Postoperative vision normalized or improved in 27 patients (86.1%) and was stable in 4 patients (13.9%). Recovery of a preexisting hormonal deficit occurred in 13 (23.2%) patients, and a new hormonal deficit occurred in 9 patients (16.1%). The mean hospital stay was 6.1 ± 4.9 days. Postoperative complications included cerebrospinal fluid leak in 8 patients (14.3%). Four patients (7.1%) had meningitis. Diabetes insipidus was present in 19 patients (33.9%), and postoperative intracranial hematoma requiring evacuation was necessary in 2 patients (3.6%). The mean follow-up duration was 47.5 ± 25.8 months. Lesion progression or recurrence requiring redo surgery occurred in 5 patients (8.9%). Regarding the learning curve, the postoperative cerebrospinal fluid leak, meningitis, new hormonal deficits, and diabetes insipidus decreased in the second half of the patients. Conclusions EES provides an effective and safe surgical option with low morbidity and mortality for the treatment of sellar, suprasellar, and anterior skull base lesions in a community hospital setting.