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Background: Patients with language barriers encounter healthcare disparities, which may be alleviated by leveraging interpreter skills to reduce cultural, language, and literacy barriers through improved bidirectional communication. Evidence supports the use of in-person interpreters, especially for interactions involving patients with complex care needs. Unfortunately, due to interpreter shortages and clinician underuse of interpreters, patients with language barriers frequently do not get the language services they need or are entitled to. Health information technologies (HIT), including artificial intelligence (AI), have the potential to streamline processes, prompt clinicians to utilize in-person interpreters, and support prioritization. Methods: From May 1, 2023, to June 21, 2024, a single-center stepped wedge cluster randomized trial will be conducted within 35 units of Saint Marys Hospital & Methodist Hospital at Mayo Clinic in Rochester, Minnesota. The units include medical, surgical, trauma, and mixed ICUs and hospital floors that admit acute medical and surgical care patients as well as the emergency department (ED). The transitions between study phases will be initiated at 60-day intervals resulting in a 12-month study period. Units in the control group will receive standard care and rely on clinician initiative to request interpreter services. In the intervention group, the study team will generate a daily list of adult inpatients with language barriers, order the list based on their complexity scores (from highest to lowest), and share it with interpreter services, who will send a secure chat message to the bedside nurse. This engagement will be triggered by a predictive machine-learning algorithm based on a palliative care score, supplemented by other predictors of complexity including length of stay and level of care as well as procedures, events, and clinical notes. Discussion: This pragmatic clinical trial approach will integrate a predictive machine-learning algorithm into a workflow process and evaluate the effectiveness of the intervention. We will compare the use of in-person interpreters and time to first interpreter use between the control and intervention groups. Trial registration: NCT05860777. May 16, 2023. [ABSTRACT FROM AUTHOR]

The article presents a study which explored the utilization rate of transitional care management (TCM) service by beneficiaries' characteristics associated with a higher risk of readmission. Topics discussed include patient characteristics and use of TCM service among random sample of medicare fee-for-service beneficiaries in 2015-2019, factors for readmission as well as barriers to TCM access, and limitations of the study.

In the article, the authors discuss their process of developing and implementing ambulation safety checklists for hemodynamically-stable patients with pulmonary artery catheters (PAC) in the step-down unit. Also cited are the qualified staff like primary nurse, charge nurse, and resource nurse, and the potential benefits of said checklists like reducing nurse burnout, increasing physical activity in patients, and preventing deconditioning.

Background: There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease‐related dementias (AD/ADRD) is unknown. Methods: Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH‐), no AD/ADRD residing in NH (AD/ADRD‐ NH+), and no AD/ADRD not residing in NH (AD/ADRD‐ NH‐). Results: Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77–0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59–0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD‐ NH‐ population, but the AD/ADRD+ NH‐ group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0–15.7). Conclusions: Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation. [ABSTRACT FROM AUTHOR]

In Iran, the Elburz and Zagros Mountain ranges include substantial karst regions housing numerous aquifers and groundwater resources. Niphargus Schiødte, 1849, a diverse subterranean amphipod genus, inhabits Western Palearctic groundwater environments, with Iran marking the eastern limit of its distribution. This study examined specimens collected from springs along the Elburz and Zagros Mountains, revealing two distinct taxonomic units through a combination of morphological observations and molecular analyses, utilizing COI and 28S rDNA genes. N. elburzensis sp. nov. is characterized by produced epimeral plates I to III; a telson lobe with five distal, two lateral, and one mesial spine each, a rectangular shape of gnathopod II propodi with two L-setae on palmar corner and maxilla I outer plate spines with 2-2-1-1-3-0-1 denticles. N. zagrosensis sp. nov. is distinguished by a triangular shape gnathopod II propodi, pereopod VI longer than pereopod VII, maxilliped outer plate less than half of palp article 2, and uropod III distal article exceeding 80% of the proximal article. Pairwise genetic distances between N. elburzensis sp. nov. and other species ranged from 10.70% (N. fiseri) to 23.48% (N. daniali) for COI gene and 1.56% (N. urmiensis) to 10.98% (N. daniali) for 28S gene. Also, N. zagrosensis sp. nov. exhibited COI gene distances from 5.73% (N. alisadri) to 20.66% (N. daniali) and from 0.13% (N. alisadri) to 11.36% (N. daniali) for 28S gene distances. Bayesian analysis suggests that the two newly discovered species are part of the expansive local Iranian clade. These species are supported phylogenetically by separate and independent lineages, as indicated by high bootstrapping values. [ABSTRACT FROM AUTHOR]

BACKGROUND: There have been studies on the use of cognitive behavioral nursing intervention (CBNI) but the main subjects were patients with secondary glaucoma and there are fewer studies on the care of congenital glaucoma. OBJECTIVE: To explore the clinical value of cognitive behavioral nursing model in patients with congenital glaucoma. METHODS: One hundred and fifty-three postoperative patients with congenital glaucoma treated in our hospital between January 2021 and December 2022 were prospectively selected for the study and randomly divided into a control group (n = 77) and an observation group (n = 76). The control group was given routine nursing, and the observation group was given cognitive behavioral nursing mode on the basis of the control group. Anxiety self-assessment scale (SAS), depression self-assessment scale (SDS), Connor-Davidson toughness scale, and treatment adherence evaluation scale were used to evaluate the psychological state, mental toughness, treatment adherence, treatment effect and nursing care satisfaction in the two groups before and after 2 weeks of intervention. The efficacy of the treatment was also assessed by determining the visual acuity (VA), intraocular pressure (IOP), and mean defective (MD) value of the visual field of the two groups of patients. RESULTS: After nursing, the SDS score (46.33 ± 6.16 versus 53.21 ± 5.94) and SAS score (44.41 ± 5.6 versus 52.82 ± 6.31) in the observation group were lower than those in the control group (P < 0.05). The scores of optimism (11.55 ± 1.90 versus 8.20 ± 1.95), self-improvement (22.05 ± 3.60 versus 17.60 ± 4.30), tenacity (37.45 ± 3.10 versus 28.90 ± 4.55) and total score (71.35 ± 8.00 versus 56.85 ± 8.50) in the observation group were higher than those in the control group (P < 0.05). After care, the VA of the observation group (0.95 ± 0.22) was greater than that of the control group (0.84 ± 0.16), and the IOP (14.25 ± 0.58 versus 15.89 ± 0.67) and the MD (5.42 ± 0.46 versus 6.68 ± 0.49) of the observation group were less than that of the control group. The difference between the two groups was statistically significant (P < 0.05). The compliance (96.05% versus 85.71%) and nursing satisfaction (96.10% versus 85.71%) of the observation group were higher than those of the control group (P < 0.05). CONCLUSION: Cognitive-behavioural nursing care for glaucoma patients can improve patients' mental toughness, improve visual acuity, reduce intraocular pressure and mean visual field defect values, and have a positive effect on enhancing patients' treatment adherence and nursing satisfaction. [ABSTRACT FROM AUTHOR]

Asthma is the most common chronic disease in children, disproportionately affects families with lower incomes, and is a leading reason for acute care visits and hospitalizations. This retrospective cohort study used the Massachusetts All Payer Claims Database (2014–2018) to examine differences in acute care utilization and quality of care for asthma between Medicaid- and privately insured children in Massachusetts. Outcomes included acute care use (emergency department [ED] or hospitalization), ED visits with asthma, routine asthma visits, and filled prescriptions for asthma medications. Multivariable logistic regression was used to account for differences in demographics, ZIP codes, health status, and asthma severity. Overall, 10.0% of Medicaid-insured children and 5.6% of privately insured were classified as having asthma. Among 317,596 child-year observations for children with asthma, 64.4% were insured by Medicaid. Medicaid-insured children had higher rates of any acute care use (50.4% vs. 30.0%) and ED visits with an asthma diagnosis (27.2% vs. 13.3%) compared to privately insured children. Only 65.4% of Medicaid enrollees had at least one routine asthma visit compared to 74.3% of privately insured children. Most children received at least one asthma medication (88.6% Medicaid vs. 83.3% privately insured), but a higher percentage of Medicaid-insured children received at least one rescue medication (84.0% vs. 73.7%), and a lower percentage of Medicaid-insured (46.1% vs. 49.2%) received a controller medication. These results suggest that opportunities for improvement in childhood asthma persist, particularly for children insured by Medicaid. [ABSTRACT FROM AUTHOR]

Aims: We aim to examine and understand the work processes of antimicrobial stewardship (AMS) teams across 2 hospitals that use the same digital intervention, and to identify the barriers and enablers to effective AMS in each setting. Methods: Employing a contextual inquiry approach informed by the Systems Engineering Initiative for Patient Safety (SEIPS) model, observations and semistructured interviews were conducted with AMS team members (n = 15) in 2 Australian hospitals. Qualitative data analysis was conducted, mapping themes to the SEIPS framework. Results: Both hospitals utilized similar systems, however, they displayed variations in AMS processes, particularly in postprescription review, interdepartmental AMS meetings and the utilization of digital tools. An antimicrobial dashboard was available at both hospitals but was utilized more at the hospital where the AMS team members were involved in the dashboard's development, and there were user champions. At the hospital where the dashboard was utilized less, participants were unaware of key features, and interoperability issues were observed. Establishing strong relationships between the AMS team and prescribers emerged as key to effective AMS at both hospitals. However, organizational and cultural differences were found, with 1 hospital reporting insufficient support from executive leadership, increased prescriber autonomy and resource constraints. Conclusion: Organizational and cultural elements, such as executive support, resource allocation and interdepartmental relationships, played a crucial role in achieving AMS goals. System interoperability and user champions further promoted the adoption of digital tools, potentially improving AMS outcomes through increased user engagement and acceptance. [ABSTRACT FROM AUTHOR]

Introduction: The study aimed to explore feasibility and effect of hospital‐community online management on the medication management of elderly peritoneal dialysis (PD) patients with end‐stage renal disease (ESRD) during COVID‐19. Methods: A total of 160 patients receiving PD were randomly divided into the control (n = 80, outpatient follow‐up management mode) and observation (n = 80, hospital‐community online management mode) groups. The self‐efficacy (General Self‐Efficacy Scale [GSES]), medication adherence (8‐item Morisky medication adherence scale [MMAS‐8]), quality of life (kidney disease quality of life short form [KDQOL‐SF]), and degree of depression (beck depression inventory [BDI]) before and after the intervention were compared. Results: After the intervention, the scores of GSES (4.20 ± 0.46 vs. 3.09 ± 0.33), MMAS‐8 (5.82 ± 0.92 vs. 5.13 ± 1.25), and KDQOL‐SF were significantly higher, whereas the BDI score (9.50 ± 2.86 vs. 12.08 ± 2.95) was significantly lower in the observation group than in the control group (p < 0.05). Conclusion: Hospital‐community online management presents good effects in the medication management of PD patients with ESRD. [ABSTRACT FROM AUTHOR]

Background: The clinical outcomes of diabetes can be influenced by primary care providers' (PCP) treatment approaches. This study explores the association between PCP approaches to management and performance measured by established diabetes metrics and related costs. Methods: In phase one, Electronic Medical Records were used to extract diabetes related metrics using Healthcare Effectiveness Data and Information Set (HEDIS), for patients with diabetes who had office visits to 44 PCP practices from April 2019 to March 2020. Using those metrics and scoring system, PCP practices were ranked and then categorized into high- and low-performing groups (top and bottom 25%, n = 11 each), with a total of 19,059 clinic visits by patients with a diagnosis of diabetes. Then extensive analysis was performed to evaluate a correlation between treatment approaches and diabetes outcomes across the top and bottom performing practices. In phase 2, patients with diabetes who were attributed to the aforementioned PCP practices were identified in a local health plan claims data base (a total of 3,221 patients), and the allowed amounts from their claims were used to evaluate differences in total and diabetes-related healthcare costs by providers' performance. Results: Comparing 10,834 visits in high-performing practices to 8,235 visits in low-performing practices, referrals to certified diabetes care and education specialists and provider-to-provider electronic consults (e-consults) were higher in high-performing practices (Z = 6.06, p <.0001), while traditional referrals were higher in low-performing practices (Z = -6.94, p <.0001). The patient-to-provider ratio was higher in the low-performing group (M = 235.23) than in the high-performing group (M = 153.26) (Z = -2.82, p =.0048). Claims data analysis included 1,825 and 1,396 patients from high- and low-performing providers, respectively. The patient-to-provider ratio was again higher in the low-performing group (p =.009, V = 0.62). Patients receiving care from lower-performing practices were more likely to have had a diabetes-related hospital observation (5.7% vs. 3.9%, p =.02; V = 0.04) and higher diabetes-related care costs (p =.002; d = − 0.07); these differences by performance status persisted when controlling for differences in patient and physician characteristics. Patients seeing low-performing providers had higher Charlson Comorbidity Index scores (Mdn = 3) than those seeing high-performing providers (Mdn = 2). Conclusions: Referrals to the CDCES and e-Consult were associated with better measured diabetes outcomes, as were certain aspects of cost and types of hospital utilization. Higher patients to providers ratio and patients with more comorbidities were observed in low performing group. [ABSTRACT FROM AUTHOR]

Background: Malnutrition and poor functional reserves place patients at risk for negative surgical outcomes. In this prospective study we aimed to measure preoperative nutritional and sarcopenia risk and evaluate their impact on postoperative outcomes. Methods: Adults scheduled to undergo elective general and gastrointestinal surgery were screened for nutrition risk using the Malnutrition Universal Screening Tool screening tool. Sarcopenia risk was measured using the SARC‐F tool and hand‐grip strength. Patients were followed postoperatively. Incidence of complications, length of stay (LOS), readmission rates, and need for step‐down care were recorded. Results: One hundred and twenty‐two patients were included. Mean age was 53.8 years (standard deviation [SD] 16.44). Sixty‐six (54%) were scheduled for day‐case procedures, and 56 (46%) for nonday‐case procedures. About 18.9% (n = 23) were at nutritional risk preoperatively. Ten patients (8.2%) had probable sarcopenia based on SARC‐F, whereas seven (5.7%) had measurably reduced HG. Incidence of postoperative complications was 23.8% (n = 29). Nutrition risk was associated with the development of complications (p = 0.018). In the nonday‐case group, nutritional risk was associated with greater LOS (p = 0.013). Older age was associated with need for step‐down care (p = 0.002) as was SARC‐F (p = 0.003). Conclusions: Preoperative nutritional screening can predict postoperative complications and LOS, whereas sarcopenia screening is predictive of the need for step‐down care after discharge. Screening tools are quick and inexpensive and could provide valuable information to clinicians and allow patients the opportunity to enhance their physical preparedness for surgery thereby mitigating their risk for negative surgical outcomes. Key points: Simple, inexpensive preoperative screening tools can predict postoperative outcomes: nutritional risk as measured by the Malnutrition Universal Screening Tool (MUST) was associated with increased incidence of postoperative complications and length of stay (LOS), whereas the SARC‐F screening tool for sarcopenia was predictive of the need for step‐down care postoperatively.Routine use of nutritional and sarcopenia screening tools in a preoperative surgical outpatient setting tools can provide clinically relevant information to clinicians and allow patients the opportunity to enhance their physical preparedness for surgery thereby mitigating their risk for negative surgical outcomes. [ABSTRACT FROM AUTHOR]

The evaluation and management of young infants presenting with fever remains an area of significant practice variation. While most well-appearing febrile young infants have a viral illness, identifying those at risk for invasive bacterial infections, specifically bacteremia and bacterial meningitis, is critical. This statement considers infants aged ≤90 days who present with a rectal temperature ≥38.0°C but appear well otherwise. Applying recent risk-stratification criteria to guide management and incorporating diagnostic testing with procalcitonin are advised. Management decisions for infants meeting low-risk criteria should reflect the probability of disease, consider the balance of risks and potential harm, and include parents/caregivers in shared decision-making when options exist. Optimal management may also be influenced by pragmatic considerations, such as access to diagnostic investigations, observation units, tertiary care, and follow-up. Special considerations such as temperature measurement, risk for invasive herpes simplex infection, and post-immunization fever are also discussed. [ABSTRACT FROM AUTHOR]

Objective To understand the characteristics of patients in the emergency observation room, analyze the factors influencing death, and provide orientation for improving the level of emergency treatment in the hospital. Methods The data of all patients discharged from the emergency observation room in a tertiary hospital in Shanghai from January 1 to December 31, 2019 were collected. The patients were divided into the death group and the survival group based on their outcome. The clinical data of two groups were compared, and the characteristics of death cases were analyzed. Results In 2019, there were 2 211 patients discharged from the emergency observation room, including 125 deaths and 2 086 survivors. Among the surviving patients, 1 183 were discharged (accounting for 56.71%), and 903 were admitted to specialized departments for further treatment (accounting for 43.28%). The median (25th, 75th percentile) observation time was 2.50 (1.00, 9.00) days, and 1 076 patients (accounting for 48.67%) had an observation time longer than 72 h. The average age was (67.81 ± 18.87) years, and males accounted for 57.98% (1 282 cases). The death group had a higher incidence of respiratory system diseases and malignant tumors than the survival group, while the survival group had a higher incidence of nervous system diseases (P < 0.01). The frequencies of using non-invasive ventilators and electrocardiogram monitoring in the death group were higher than those in the survival group (P < 0.01). The peak period of death occurrence was mainly in the winter. The multivariate logistic regression analysis showed that the risk of death increased to 1 . 057 and 1 . 013 times for every 1 year increment of age and every 1 day increment of staying in observation time, respectively (P < 0.001); the risk of death for patients with two or more diagnosed diseases was 3.873 times that of patients with one diagnosis (P < 0.001); compared with patients from the clinic, the risk of death for patients from the rescue room increased to 2.877 times (P < 0.001). Conclusions The hospital should standardize the triage and treatment of critically ill and complicated patients, allocate and distribute emergency resources reasonably, and strengthen the observation of the condition. Effective prevention and treatment strategies should be formulated based on high-risk factors such as old age, respiratory system diseases, tumors, and seasonal variations to improve the efficiency and quality of emergency treatment. [ABSTRACT FROM AUTHOR]

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OBJECTIVES: To explore the usefulness of the Violent Event Severity Tool (VEST). BACKGROUND: The Joint Commission and many governing bodies require establishing workplace violence prevention programs in hospitals. Inconsistent processes have hampered the efficacy evaluation of such programs for collecting and reporting violence. The VEST was developed as a standardized tool for capturing violence data. METHODS: Ninety-six healthcare workers attending the 2022 Magnet® conference completed the survey. The VEST includes 6 types and 4 intensities of violent incidents. RESULTS: Most participants reported that the VEST is easy to use (79%), relevant (85%), and useful (85%). Fewer than half were satisfied with their incident report filing processes. Only 38% of participants experiencing grade 1 physical assault filed an incident report, whereas 70% and 100% experiencing grades 3 and 4 physical assaults filed. CONCLUSIONS: The VEST appears to be a useful and relevant tool for consistent collection and reporting of various violence types and severities. [ABSTRACT FROM AUTHOR]

When physicians admit patients to a hospital, their decisions about where--and to whose professional stewardship and services--those patients belong are influenced by federal policies, of which many clinicians are not aware. The distinction between observation and admission has clinical and ethical implications for patients and practices. The evolution of "observation status" from a clinical tool to a catchall of vague and imprecise meaning has been driven by changes to physician payment and compensation structures, particularly Current Procedural Terminology codes and Centers for Medicare and Medicaid Services regulations, and its current value to clinicians and patients is questionable. This article contextualizes clinicians' admission and observation practices and considers how metrics influence patient costs and how clinicians and organizations are compensated. [ABSTRACT FROM AUTHOR]

This article delves into the significance of workplace reflection and its influence on organizational health. It investigates the vital role of introspection, evaluation, and improvement within professional settings. The study outlines the definition of workplace reflection as a process that critically analyzes an individual's thoughts, actions, and experiences to enhance personal and organizational growth. Scientific insights are presented, highlighting the impact of reflection on individual learning and development, continuous improvement, enhanced problem-solving, learning from success and failure, employee well-being and satisfaction, organizational learning, and fostering innovation and creativity. The findings emphasize the importance of cultivating a culture of reflection within organizations to foster growth, adaptability, and long-term success. Methodology: In line with the study's overall objectives and methodology, the research sample consisted of doctors and Nurses employed at Saudi hospitals in the Eastern Province. The appropriate sample size of 320 doctors and Nurses was determined to represent the target population in this study. Results: the data suggests that there is some level of meditation practices, both mindfulness and transcendental, present in the workplace according to the perceptions of the doctors and nurses in the sampled Saudi hospitals in the Eastern Province. However, further analysis and interpretation would be necessary to draw more comprehensive conclusions about the impact of these meditation practices on organizational health. Also, the data suggest that the participants have varying perceptions of different dimensions of organizational health, with some dimensions being perceived more positively than others. Further analysis and interpretation would be necessary to gain a comprehensive understanding of the strengths and areas for improvement in organizational health based on these perceptions. Recommendations: aim to improve the well-being of doctors, enhance their performance, and contribute to the overall organizational health of Saudi hospitals in the Eastern Province. By implementing these suggestions, hospitals can create a supportive and conducive environment that promotes the physical, mental, and professional well-being of their doctors, ultimately leading to improved healthcare outcomes and patient satisfaction. [ABSTRACT FROM AUTHOR]

With the recent change to value-based care, institutions have struggled with the appropriate management of patients under observation. Observation status can have a huge impact on hospital and patient expenses. Institutions have implemented specialized observation units to provide better care for these patients. Starting in January 2020, coinciding with the initiation of daily multidisciplinary rounds, our study focused on patients aged 18 and older admitted to our hospital under observation status. Efforts were built upon prior initiatives at Jersey Shore University Medical Center (JSUMC) to optimize patient care and length of stay (LOS) reduction. The central intervention revolved around the establishment of daily "Observation Huddles"—succinct rounds led by hospital leaders to harmonize care for patients under observation. The primary aim was to assess the impact of daily multidisciplinary rounds (MDR) on LOS, while our secondary aim involved identifying specific barriers and interventions that contributed to the observed reduction. Our study revealed a 9-h reduction in observation time, resulting in approximately USD 187.50 saved per patient. When accounting for the period spanning 2020 to 2022, potential savings totaled USD 828,187.50 in 2020, USD 1,046,062.50 in 2021, and USD 1,243,562.50 in 2022. MDR for observation patients led to a reduction in LOS from 29 h to 20 h (p < 0.001). [ABSTRACT FROM AUTHOR]

Objectives: Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). Methods: This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. Results: The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P <.00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P =.01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P =.01). Conclusion: The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected. [ABSTRACT FROM AUTHOR]

Equitable access to quality surgical care and low-cost healthcare services for all segments of the population remains a big problem in many African health systems. In Cameroon, it is very common to find medically discharged patients who have received surgical treatment and are unable to pay the resulting bills. These patients can be held in detention in hospitals until payments are complete. Even the corpses of patients who die with unpaid medical bills can be withheld until their family members pay off the debt. While this practice has been ongoing for many y, there remains very little scholarship on the issue reported in the literature. The main objective of this study was to uncover the lived experiences of discharged patients residing in hospital detention for being unable to pay their medical bills. In-depth interviews, focus group discussions, and observations were conducted with purposefully selected patients living in detention in 2 rural private hospitals in the Fundong Health District in Cameroon. A thematic framework technique was used to analyze the transcribed data. The study was ethically approved by the Cameroon Bioethics Initiative, and informed consent was obtained from all participants. Living in hospital detention after receiving treatment constitutes an economic, social, and psychological burden for patients. Economically, it exacerbated poverty for the patients unable to purchase food, medications, and clothing due to lack of jobs and financial support. Socially, many of these individuals suffered from isolation, loneliness, shame, stigma, risk of contracting other diseases, and precarious sleeping conditions. The psychological burden was comprised of stress, depression, trauma, nightmares, and suicidal thoughts. The experiences of discharged patients in hospital detention suggest that they live in very deplorable conditions. There is a need for a functional healthcare protection mechanism, such as universal health coverage, to reduce the cost of healthcare services and surgical operations. Alternative payment mechanisms should also be considered. [ABSTRACT FROM AUTHOR]

BACKGROUND: In recent years, the incidence of viral keratitis has been on the rise. OBJECTIVE: This study explored the application effect of continuous care for patients with viral keratitis. METHODS: A total of 148 patients with viral keratitis admitted to the ophthalmology department of the authors' hospital from January 2019 to December 2020 were selected and divided into the observation group and the control group via the random number table method, with 74 cases in each group. Continuous care was conducted following routine discharge guidance for patients in the observation group, while routine discharge guidance only was provided for the control group. The patients in both groups were continuously observed for one year. The medication compliance, return visit rate, recurrence rate, nursing satisfaction, and quality of life between the two groups were compared and analyzed after one year. RESULTS: The medication compliance was higher in the observation than in the control group and the difference was statistically significant (P < 0.05). The rate of return visits at 1 week, 1 month, 3 months, 6 months, and 1 year in the observation group were higher than those in the control group and the differences were statistically significant (P < 0.05). The difference in the recurrence rate between the two groups at 1 week was not statistically significant (P > 0.05), while the recurrence rate at 1, 3, and 6 months, and 1 year in the observation group were higher than those in the control group, and the difference was statistically significant (P < 0.05). The total score of the quality of life in the observation group was higher than in the control group and the difference was statistically significant (P < 0.05). CONCLUSION: Continuous care had a good application effect on patients with viral keratitis, which could potentially effectively improve medication compliance and the rate of return visits, reduce recurrence rate, and improve patient satisfaction and their quality of life. Accordingly, the results of this study present high clinical value. [ABSTRACT FROM AUTHOR]

BACKGROUND: Nationally, the volume of geriatric falls with intracranial hemorrhage is increasing. Our institution began observing patients with intracranial hemorrhage, Glasgow Coma Scale of 14 or greater, and no midline shift or intraventricular hemorrhage with hourly neurologic examinations outside of the ICU in a high observation trauma (HOT) protocol. We first excluded patients on anticoagulants or antiplatelets (HOT I), then included antiplatelets and warfarin (HOT II), and finally, included direct oral anticoagulants (HOT III). Our hypothesis is that HOT protocol safely reduces ICU use and creates cost savings in this patient population. STUDY DESIGN: Our institutional trauma registry was retrospectively queried for all patients on HOT protocol. Patients were stratified based on date of admission (HOT I [2008-2014], HOT II [2015-2018], and HOT III [2019-2021]), and were compared for demographics, anticoagulant use, injury characteristics, lengths of stay, incidence of neurointervention, and mortality. RESULTS: During the study period, 2,343 patients were admitted: 939 stratified to HOT I, 794 to HOT II, and 610 to HOT III. Of these patients, 331 (35%), 554 (70%), and 495 (81%) were admitted to the floor under HOT protocol, respectively. HOT protocol patients required neurointervention in 3.0%, 0.5%, and 0.4% of cases in HOT I, II, and III, respectively. Mortality among HOT protocol patients was found to be 0.6% in HOT I, 0.9% in HOT II, and 0.2% in the HOT III cohort (p = 0.33). CONCLUSIONS: Throughout the study period ICU use decreased without an increase in neurosurgical intervention or mortality, indicating the efficacy of the HOT selection criteria in identifying appropriate candidates for stepdown admission and HOT protocol. [ABSTRACT FROM AUTHOR]

Medical facilities, such as hospitals, clinics, and locations where diagnosis and treatment are administered, create dangerous waste that predisposes individuals to deadly infections. Medical waste management aims to improve health and prevent public health and environmental threats. Questionnaires, interviews, site visitations, and observations were utilized to determine the management strategies implemented in the three hospitals and evaluate the efficacy of waste management. The hospitals under review are Afe Babalola University Multi-system Hospital (AMSH), Ekiti State University Teaching Hospital (EKSUTH), and Federal Teaching Hospital Ido-Ekiti (FETHI). Statistical Package for the Social Sciences (SPSS) was utilized for the statistical analysis of the questionnaires, and the mean assessment was utilized to compute the waste per bed each day. The results revealed that the three hospitals' sharp, infectious, and pharmaceutical waste is the most sorted. All hospitals burn their medical waste in incinerators but dispose of the ashes in dumpsites. The mean evaluation of all hospitals' medical waste was weighed to establish the overall amount generated. The total amount of medical waste created at AMSH, EKSUTH, and FETHI is 31.5 kg, 53.6 kg, and 135.1 kg, respectively. The medical waste generated per bed per day in AMSH, EKSUTH, and FETHI is 0.61 kg, 0.74 kg, and 0.73 kg, respectively. It was determined that the proper management and disposal of waste is a critical obligation of healthcare facilities. There should be a provision for educating personnel about the consequences of inappropriately disposing of medical waste. [ABSTRACT FROM AUTHOR]

Introduction: The number of emergency department observation units (EDOU) and observation stays has continued to increase. Despite this, there is limited data on the characteristics of patients who return unexpectedly to the ED after EDOU discharge. Methods: We identified the charts of all patients who were admitted to the EDOU of an academic medical center between January 2018–June 2020 and had a return to the ED within 14 days of discharge from the EDOU. Patients were excluded if they were admitted to the hospital from the EDOU, left against medical advice, or died in the EDOU. We manually extracted selected demographic factors, comorbidities, and healthcare utilization data from the charts. Physician reviewers identified return visits thought to be related to the index visit or potentially avoidable. Results: During the study period, there were 176,471 ED visits, 4,179 admissions to the EDOU, and 333 return visits to the ED within 14 days from discharge from the EDOU, representing 9.4% of all patients discharged from the EDOU. We identified a higher rate of return for patients treated for asthma and lower rates of return for patients treated for chest pain or syncope than the overall return rate. Physician reviewers determined that 64.6% of unplanned returns were related to the index visit, and 4.5% were potentially avoidable. Of potentially avoidable visits, 53.3% occurred within 48 hours of discharge, supporting the use of this period as a potential quality metric. While there was no significant difference in the percentage of related return visits between males and females, there was a higher rate of potentially avoidable visits for male patients. Conclusion: This study adds to the limited body of literature on EDOU returns, finding an overall return rate of under 10%, with about two-thirds of returns determined to be related to the index visit and <5% considered to be potentially avoidable. [ABSTRACT FROM AUTHOR]

Objective: Designing practical decision support tools and other health care technology in health services research relies on a clear understanding of the cognitive processes that underlie the use of these tools. Unfortunately, methods to explore cognitive processes are rarely used in health services research. Thus, the objective of this manuscript is to introduce cognitive task analysis (CTA), a family of methods to study cognitive processes involved in completing a task, to a health services research audience. This methods article describes CTA procedures, proposes a framework for their use in health services research studies, and provides an example of its application in a pilot study. Data Sources and Study Setting: Observations and interviews of health care providers involved in discharge planning at six hospitals in the Veterans Health Administration. Study Design: Qualitative study of discharge planning using CTA. Data Collection/Extraction Methods: Data were collected from structured observations and semi‐structured interviews using the Critical Decision Method and analyzed using thematic analysis. Principal Findings: We developed an adaptation of CTA that could be used in a clinical environment to describe clinical decision‐making and other cognitive processes. The adapted CTA framework guides the user through four steps: (1) Planning, (2) Environmental Analysis, (3) Knowledge Elicitation, and (4) Analyses and Results. This adapted CTA framework provides an iterative and systematic approach to identifying and describing the knowledge, expertise, thought processes, procedures, actors, goals, and mental strategies that underlie completing a clinical task. Conclusions: A better understanding of the cognitive processes that underly clinical tasks is key to developing health care technology and decision‐support tools that will have a meaningful impact on processes of care and patient outcomes. Our adapted framework offers a more rigorous and detailed method for identifying task‐related cognitive processes in implementation studies and quality improvement. Our adaptation of this underutilized qualitative research method may be helpful to other researchers and inform future research in health services research. [ABSTRACT FROM AUTHOR]

Background: In Italy, the State Regions Conference on 1st August 2019 approved the Guidelines for Short-Stay Observation (SSO). At the beginning of 2022, the main Scientific Societies of the pediatric hospital emergency-urgency area launched a national survey to identify the extent to which these national guidelines had been adopted in the emergency rooms and pediatric wards of the Italian Regions. Methods: A survey has been widespread, among Pediatric Wards and Pediatric Emergency Departments (EDs), using both a paper questionnaire and a link to a database on Google Drive, for those who preferred to fill it directly online. Those who did not spontaneously answer, where directly contacted, via email and/or through a phone call and invited to participate. The data collected have been: age of managed children, presence of triage, presence of Sub-intensive Care Unit and Intensive Care Unit and special questions about Pediatric SSO, availability of training courses for workers, number of ED access in the last 4 years. Results: This survey is still ongoing, without a definite deadline, so we presented the preliminary data. Currently, 8/20 Regions have not yet adopted the Guidelines. Till 02 January 2023, data from 253 hospitals were collected. There are currently 180/253 active Pediatric SSO (71.03% of the Hospitals). There are not active SSO in 33.27% of first level ED, in 19.35% of second level ED and in 33.66% of General Hospitals with Pediatric Wards. Active SSO are located mainly (75.97%) within Pediatric Wards. At the moment, the survey has been completed in 16 Regions: in the 8 Regions which are using guidelines, pediatric SSOs are active in all the second level ED (compared to 60.87% of the other 8 regions), in the 91.66% of first level ED (compared to the 33.3%), and in the 97.1% of General Hospitals (compared to 33.3%), with a statistically significance (p < 0.0001). The territorial analysis of these 16 regions highlighted geographical differences in the percentage of SSOs active: 35.22% are active in hospitals in Southern Italy, 88.64% in Central Italy and 91.67% in those of the North. Conclusions: The delay in adopting specific guidelines negatively influences activation of pediatric SSOs in hospital system and prevents the adjustment of welfare level to new needs. To facilitate the activation of SSOs in hospitals, it is also necessary to guarantee adequate economic recognition. It is essential to implement public interventions to overcome the current inequalities in the interest of children and their families: the current delay seriously penalizes emergency pediatric hospital care, especially in the southern Italian Regions. [ABSTRACT FROM AUTHOR]

Background: Chimeric antigen receptor T cell infusion (CAR T) therapy has revolutionized the treatment of hematologic malignancies, but treatmentrelated toxicities are of concern. Understanding the timing and reasons for which patients present to the emergency department (ED) after CAR T therapy can assist with the early recognition and management of toxicities. Methods: A retrospective observational cohort study was conducted for patients who had undergone CAR T therapy in the past 6 months and visited the ED of The University of Texas MD Anderson Cancer Center between 04/01/2018 and 08/ 01/2022. The timing of presentation after CAR T product infusion, patient characteristics, and outcomes of the ED visit were examined. Survival analyses were conducted using Cox proportional hazards regression and Kaplan-Meier estimates. Results: During the period studied, there were 276 ED visits by 168 unique patients. Most patients had diffuse large B-cell lymphoma (103/168; 61.3%), multiple myeloma (21/168; 12.5%), or mantle cell lymphoma (16/168; 9.5%). Almost all 276 visits required urgent (60.5%) or emergent (37.7%) care, and 73.5% of visits led to admission to the hospital or observation unit. Fever was the most frequent presenting complaint, reported in 19.6% of the visits. The 30- day and 90-day mortality rates after the index ED visits were 17.0% and 32.2%, respectively. Patients who had their first ED visit >14 days after CAR T product infusion had significantly worse overall survival (multivariable hazard ratio 3.27; 95% confidence interval 1.29–8.27; P=0.012) than patients who first visited the ED within 14 days of CAR T product infusion. Conclusion: Cancer patients who receive CAR T therapy commonly visit the ED, and most are admitted and/or require urgent or emergent care. During early ED visits patients mainly present with constitutional symptoms such as fever and fatigue, and these early visits are associated with better overall survival. [ABSTRACT FROM AUTHOR]

The understanding of what ethnography looks like, and its purpose, is continuously evolving. COVID-19 posed a significant challenge to ethnographers, particularly those working in health-related research. Researchers have developed alternative forms of ethnography to overcome some of these challenges; we developed the Mobile Instant Messaging Ethnography (MIME) adaptation to ethnography in 2021 to overcome restrictions to our own research with hospital doctors. However, for ethnographic innovations to make a substantial contribution to methodology, they should not simply be borne of necessity, but of a dedicated drive to expand paradigms of research, to empower participant groups and to produce change – in local systems, in participant-collaborators and in researchers and the research process itself. In this paper, we reflect on our experiences using MIME, involving collaborative remote observation and reflection with 28 hospital doctors in Ireland from June to December 2021. After reviewing literature on ethnography in COVID-19 and general epistemological developments in ethnography, we detail the MIME approach and illustrate how MIME presents an evolution of the ethnographic approach, not only practically but in terms of its reflexive shift, its connected and co-creative foundations, and its ability to drive change in research approaches, participant life-worlds and real-world improvement. [ABSTRACT FROM AUTHOR]

Background: Adverse drug reactions (ADRs) have continued to be a public health challenge with significant clinical and healthcare costs. However, little is known regarding the incidence of ADR in Ethiopia, particularly in the study setting. Thus, this study aimed to assess the incidence and patterns of ADRs in patients admitted to the University of Gondar comprehensive specialized hospital (UoGCSH). Methods: A prospective observational follow-up study was conducted on admitted patients at the medical ward in the UoGCSH from May to August 2022. A multifaceted approach involving daily chart review and patient interviews was employed to collect the data. A standard Naranjo ADR Probability Scale measuring tool was used to characterize the probability of existing ADR. The data was analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Logistic regression analysis was employed to determine the association between the occurrence of ADRs and other variables. A p-value at the 95% confidence interval was considered statistically significant. Results: This study included 237 participants in total. The average length of follow-up was 16.4 (±5.2) days. Overall, 65 ADRs were identified, resulting an incidence rate of 27.4 (95% CI: 19.8–30.4) per 100 admissions. The most common ADRs were hypokalemia (10.7%), followed by constipation, diarrhea, hypotension, and rash (9.2% each). The majority of these ADRs (73.8%) were classified as "definite" by the Naranjo ADR probability scale. Gastrointestinal tract (GIT) (41.5%) and metabolic (18.6%) were the most frequently exposed systems for ADR. Antibiotics (26.2%) and cardiovascular medications (24.7%) were the most frequently implicated medications in existing ADRs. ADRs were significantly associated with age (p = 0.035), the presence of comorbidities (p = 0.021) and complications (p = 0.008), and receiving a higher number of medications (p = 0.04). Conclusion: In this study, ADR was identified in about one-fourth of the participants. Older patients, patients with comorbidities and complications, and patients who received a higher number of medications were more likely exposed for ADRs. Healthcare providers should strictly follow the admitted patients to minimize ADRs. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Driven by innovations in healthcare, observation medicine (OM) is expanding as a medical specialty. Despite exponential growth, education on OM remains underemphasized in the internal medicine (IM) residency programs. We assessed the impact of an educational intervention pairing didactic and experiential learning with an interdepartmental approach on IM residents' confidence, knowledge, and attitudes when providing observation care to patients with neuro-cardiovascular diseases in the hospital setting. METHODS: Our multifaceted intervention incorporated OM's principles and practice in a flipped classroom with the team-, case-, lecture- and evidence-based learning model. Kirkpatrick's evaluation model was used to assess the educational intervention's effectiveness according to the first three levels, ie, reaction, learning, and behavior, using quantitative surveys. The surveys were completed pre-intervention, and immediately upon completion of the educational intervention. RESULTS: Of 55 eligible residents, 55 (100%) participated in this intervention. Fifty (90%) completed the pre-intervention survey, and 21 (38%) completed the immediate post-intervention survey. Kirkpatrick's evaluation framework showed that the intervention had a positive impact on residents' motivational reaction (attention, relevance, confidence, and satisfaction [ARCS], M=3.8, SD=0.87), their knowledge of common observation diagnoses (pre=49%, post=63%), particularly on cardiac diagnostic workup and approach to patients with transient neurological symptoms (P < .05), and their behavior and self-assessment of core competency domains (pre-mean=2.69, post-mean=3.18, P < .001). CONCLUSIONS: Our multimodal intervention provides a framework for a structured OM educational experience that can be incorporated into residency training, even without a formal observation unit rotation. The analysis also offers literary data on the current state of OM education in an IM residency program and supports the need to expand OM's educational resources to counteract the growth in hospital observation services. Future research should include an analysis of residents' knowledge and skills from a longitudinal OM experience and advancing the results to residency programs where observation care is as applicable as ours. [ABSTRACT FROM AUTHOR]

Simple Summary: Pain is an important yet undertreated complication of cancer that has been shown to affect patients' quality of life. For patients presenting in an acute care setting with cancer-related pain, there have traditionally been two routes to management: inpatient or outpatient. However, with the advent of observation units, there is now an opportunity for these patients to utilize hospital resources without an inpatient stay. To better understand the role of an observation unit in pain management, this study analyzed charts for patients who had their pain managed in an observation unit. Patient characteristics and outcomes were statistically analyzed and summarized. Predictors of admission or discharge from the observation unit were also derived from the analysis. Factors that predicted an inpatient hospitalization from the observation unit included patients' pain scores and the need for consult service recommendations while in the observation unit. Indeed, this research showed that patients in an observation unit for pain management received appropriate consultations and admissions when necessary. However, most were discharged home safely and without a quick return to the acute care setting. Pain remains an undertreated complication of cancer, with poor pain control decreasing patients' quality of life. Traditionally, patients presenting to an emergency department with pain have only had two dispositions available to them: hospitalization or discharge. A third emerging healthcare environment, the emergency department observation unit (EDOU), affords patients access to a hospital's resources without hospitalization. To define the role of an EDOU in the management of cancer pain, we conducted a retrospective study analyzing patients placed in an EDOU with uncontrolled cancer pain for one year. Patient characteristics were summarized using descriptive statistics and predictors of disposition from the EDOU and were identified with univariate and multivariate analyses. Most patients were discharged home, and discharged patients had low 72-hour revisit and 30-day mortality rates. Significant predictors of hospitalization were initial EDOU pain score (odds ratio (OR) = 1.12; 95% CI 1.06–1.19; p < 0.001) and supportive care (OR = 2.04; 95% CI 1.37–3.04; p < 0.001) or pain service (OR = 2.67; 95% CI 1.63–4.40; p < 0.001) consultations. We concluded that an EDOU appears to be the appropriate venue to care for a subsegment of patients presenting to an emergency department with cancer pain, with patients receiving safe care as well as appropriate consultation and admission when indicated. [ABSTRACT FROM AUTHOR]

BACKGROUND: Standardized acute asthma management with score-based, respiratory therapist (RT)--driven pathways and protocols improves outcomes including decreased length of stay (LOS) and time on continuous albuterol therapy. Limited data are available for the safety of continuous albuterol used outside of pediatric ICU (PICU). We use a modified pediatric asthma score (PAS) for the asthma pathway at our institution. The safety and effectiveness of using PAS to initiate/stop continuous albuterol as part of a score-based, RT-driven asthma pathway were evaluated. METHODS: A retrospective review of children ≥ 2 y admitted for asthma exacerbation to the PICU and step-down unit who received continuous albuterol as part of the asthma pathway during 2017-2019 was completed. Demographic and clinical data were extracted including PAS, dose and duration of continuous albuterol, LOS, and complications. Outcomes of subjects admitted to the PICU and step-down unit were compared. RESULTS: Results are expressed as median (interquartile range). The study included 412 children (61% male, 59.9% Black, 92.7% non-Hispanic, 44.9% moderate persistent asthma) with age and weight of 6.4 (4.0-10.0) y and 24.8 (17.3-39.5) kg, respectively. Most children were admitted to step-down unit (71.1%). Initial albuterol dose, duration, and LOS were 15 (10-20) mg/h, 9.1 (5.7-16.0) h, and 1.4 (0.9-2.3) d, respectively. Respiratory support was required by 29% of subjects. Need to restart therapy (2.9%), transfer to PICU (1.7%), and intubation (0.5%) were infrequent. No pneumothoraces or deaths were reported. Emergency department visits (3.9%) or readmissions (0.7%) within 30 d of discharge were low. Subjects admitted to the PICU were sicker and required more therapies and respiratory support than those admitted to the step-down unit. CONCLUSIONS: Use of an RT-driven, score-based pathway for initiation and discontinuation of continuous albuterol for treatment of pediatric asthma exacerbation was safe and effective in the PICU and step-down unit. [ABSTRACT FROM AUTHOR]

Owing to concerns about delayed gastric emptying or hyperglycemia, evidence is lacking regarding whether pre-operative carbohydrate loading can be routinely administered to patients with type 2 diabetes. The objective of this study was to determine the aspiration risk and gastric volume after pre-operative carbohydrate loading in patients with type 2 diabetes. A prospective, single-center, observational cohort study. The study was conducted at a tertiary teaching hospital in Seoul, Korea, from May 2020 to May 2021. Patients (n = 49) with type 2 diabetes underwent elective noncardiac surgery. All patients were administered carbohydrate loading two hours before surgery. Once in the operating room, they underwent gastric ultrasonography to determine gastric volume. The anesthesiologists monitored the patients' glucose concentrations during and after surgery. The primary outcome was the predicted risk of aspiration. The secondary outcomes were gastric volume, antral grade, satisfaction score, and perioperative glucose profile. Forty-nine patients were analyzed. All patients had a low risk of aspiration after carbohydrate loading, as follows: 33 (67.3%) patients classified as antral grade 0 and 16 (32.7%) patients classified as antral grade 1. The median time from carbohydrate drink ingestion to ultrasound examination was 120 min (IQR 115–139). After carbohydrate loading, the median gastric volume in the right-lateral position after carbohydrate loading was 2.64 ml (IQR 0.00–32.05). The mean glucose concentrations (SD) were 134 (24) mg/dl, 159 (37) mg/dl, 150 (32) mg/dl, and 165 (36) mg/dl at baseline, after induction, 30 min after surgery, and in the post anesthesia care unit, respectively. The median satisfaction score of the patients was 5 (IQR 4–5). Pre-operative carbohydrate loading may be feasible for patients with type 2 diabetes and without complications. Trial registration: ClinicalTrials.gov (NCT04456166). Registered on 2 July 2020. [ABSTRACT FROM AUTHOR]

Introduction: The resource burden of healthcare disputes and medico-legal claims has been rising. A dispute resolution system operating at the hospital level could ameliorate this disturbing trend. Methods: This is a retrospective observational study on patient complaints and medico-legal cases received by the dispute resolution unit of an acute tertiary hospital from 2011 to 2015. We described the characteristics and analysed the resolution methodology and outcomes of all closed medico-legal cases. Results: Patient complaints significantly increased at a compound annual growth rate (CAGR) of 4.2% (p<0.01), while medico-legal cases and ex-gratia payments for case settlements decreased at CAGRs of 4.8% (p<0.05) and 15.9% (p = 0.19), respectively. Out of 237 closed medico-legal cases, 88.6% were resolved without legal action, of which 78.1% were closed without any ex-gratia payments or waivers. Of the 11.4% of medico-legal cases that involved legal action, 66.7% were settled without ex-gratia payments or waivers. The primary resolution modes were the Patient Relations Service (PRS)'s engagement of the complainants and facilitation of written replies. No cases were brought to court. Cases were more likely resolved without legal action when there was engagement by the PRS (p = 0.009). These cases incurred a lower median settlement value than those with legal action. Conclusion: Our hospital-based dispute resolution system which addressed patients' core dissatisfactions and providers' perspectives, through a process of early engagement, open disclosure, and fair negotiations, was able to promote claims resolution before legal action was taken. This early dispute resolution strategy contained costs and maintained provider-patient relationships and complements system-level mediation and arbitration to reduce medico-legal litigation. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To evaluate the effectiveness of a pilot smoking cessation service in an emergency department (ED) clinical observation unit. STUDY DESIGN: A descriptive case series review was undertaken of smoking cessation service patients in the short-stay unit of an acute hospital in Singapore from July 1, 2018, to December 31, 2019. METHODS: Upon admission, ED nurses screen all patients regarding their current smoking status and implement the 5 A's framework, which involves the steps of Ask-Advise-Assess-Assist-Arrange. Patients in the "contemplation" and "preparation" stages were offered the following components: (1) a bedside counseling session by a pharmacist and (2) a follow-up appointment at an outpatient smoking cessation clinic. Postdischarge follow-up telephone calls at 1, 6, and 12 months were carried out as part of the study data collection to obtain abstinence information. RESULTS: Forty-seven patients were included in the study; the majority were male (n = 41; 87.2%). The median numbers of cigarettes smoked per day at baseline, 1 month, 6 months, and 12 months were 14, 5, 3, and 5, respectively. The overall point-prevalence abstinence rates over the same follow-up time points were 26.5%, 38.7%, and 31.3%, respectively. The proportions of patients lost to follow-up at 1 month, 6 months, and 12 months were 27.7%, 34.0%, and 31.9%, respectively. CONCLUSIONS: Given the small sample and high number of uncontactable patients, more research is needed to assess whether the trend toward increasing point-prevalence abstinence rate over time and the trend toward decreasing median number of cigarettes smoked are observed in a larger sample. [ABSTRACT FROM AUTHOR]

Objective: Stepped care as a model of provision of mental health services has been frequently described from clinical or health administration perspectives, but less is known about the consumer perspective of stepped models of care. Method: Qualitative interviews were undertaken with 18 consumers across a range of residential mental health services in Melbourne, Australia. Interviews were designed to help understand consumers' needs and experiences in navigating different services to meet their needs at different times in their mental health journey. Results: Consumers experience fluctuations in their mental state that are best responded to by having access to a range of services, as well as to services that can respond flexibly to changing needs. Consumers do not necessarily progress through stepped care in a linear or step-up, step-down fashion. Conclusion: Stepped care services need to be flexible in accommodating people along a continuum of care and responsive to where the consumer is at on their journey, rather than predetermining the trajectory of care. What is known about the topic?: Stepped care has been identified as a critical component of comprehensive mental health care, bridging the gap between primary care and acute mental health services. The components of effective stepped care models have been broadly articulated, but the experience of moving through different components of care in response to changing needs has not previously been well described. What does the paper add?: This paper presents consumer perspectives on a model of stepped care that is designed to respond flexibly to the changing needs of consumers, rather than representing a linear model of progress through the system. What are the implications for practitioners?: Mental health services are increasingly grappling with provision of care to the 'missing middle': people with chronic mental illness yet not in an acute phase requiring in-patient hospital care. This paper presents a model of stepped care that responds to the fluctuating needs of consumers [ABSTRACT FROM AUTHOR]

Aims: To evaluate, in UK acute hospitals, the early implementation of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT), which embeds cardiopulmonary resuscitation (CPR) recommendations within wider emergency treatment plans. To understand for whom and how the process was being used and the quality of form completion.Methods: A retrospective observational study evaluating emergency care and treatment planning approaches used in acute UK hospitals (2015-2019), and in six English hospital trusts the extent of ReSPECT use, patient characteristics and completion quality in a sample 3000 patient case notes.Results: The use of stand-alone Do Not Attempt Cardiopulmonary Resuscitation forms fell from 133/186 hospitals in 2015 to 64/186 in 2019 (a 38% absolute reduction). ReSPECT accounted for 52% (36/69) of changes. In the six sites, ReSPECT was used for approximately 20% of patients (range 6%-41%). They tended to be older, to have had an emergency medical admission, to have cognitive impairment and a lower predicted 10 year survival. Most (653/706 (92%)) included a 'not for attempted resuscitation' recommendation 551/706 (78%) had at least one other treatment recommendation. Capacity was not recorded on 13% (95/706) of forms; 11% (79/706) did not record patient/family involvement.Conclusions: ReSPECT use accounts for 52% of the change, observed between 2015 and 2019, from using standalone DNACPR forms to approaches embedding DNACPR decisions within in wider emergency care plans in NHS hospitals in the UK. Whilst recommendations include other emergencies most still tend to focus on recommendations relating to CPR. Completion of ReSPECT forms requires improvement.Study Registration: https://www.isrctn.com/ISRCTN11112933. [ABSTRACT FROM AUTHOR]

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Posterior urethral valve (PUV) is a common cause of obstructive uropathy in children, leading to renal failure and frequently associated with vesicoureteral reflux (VUR), which can rapidly progress to end-stage renal disease (ESRD). We describe a rare presentation of high-grade VUR opacifying the renal pyramids in a 5-month-old child with sepsis and renal failure. [ABSTRACT FROM AUTHOR]

Background: Urgent care centers (UCCs) provide an alternative to emergency departments (EDs) for low-acuity acute care, as they are convenient with shorter wait time, but little is known about the quality of care at UCCs.Objective: We described and determined the differences in characteristics of patients who were sent to the ED by UCC physicians (provider-referred) with those of patients who went to the ED on their own (self-referred) within 72 h of discharge after a UCC visit. Our primary objective was to investigate whether observation unit use or hospital admission rates were different between the two groups. Our secondary objective was to identify whether their follow-up ED visits were avoidable.Methods: We conducted this prospective cohort study between March 22, 2017 and September 30, 2018 in a closed health system. A total of 53,178 UCC visits resulted in 582 provider-referred and 263 self-referred ED visits. We compared the characteristics of the two groups and measured the outcomes of observation unit or hospital admissions.Results: Patients with self-referred ED visits were younger; mean (standard deviation) age was 47.9 (24.5) years. Provider-referred patients appeared to be significantly associated with observation unit or hospital admission (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.24-2.46). Among the predictors for observation unit or hospital admission, consultation with a specialist in the ED was the strongest (adjusted OR 9.09; 95% CI 6.24-13.24); other significant predictors were Medicaid or no insurance.Conclusions: We found that after an urgent care visit, patients who were sent to the ED by a UCC provider were not more likely than self-referred patients to be admitted to an observation unit or hospital from the ED. Significant predictors for observation unit or hospital admission after UCC discharge were specialist consultation and type of insurance. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. We sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and postdischarge automated text message--based monitoring. STUDY DESIGN: Retrospective matched cohort study of patients hospitalized from December 14, 2020, to January 31, 2021. METHODS: Participants were patients who presented to the emergency department with acute infection due to COVID-19, required hospitalization, and met pathway inclusion criteria. Participants were compared with a propensity score--matched cohort of patients with COVID-19 admitted to the same hospital during the 7 weeks preceding and following pathway implementation. RESULTS: There were 44 patients in the intervention group and 83 patients in the propensity score--matched cohort. The mean (SD) hospital LOS for patients in the intervention group was 1.7 (2.6) days compared with 3.9 (2.3) days for patients in the matched cohort (difference, -2.2 days; 95% CI, -3.3 to -1.1). In the intervention group, 2 patients (5%; 95% CI, 0%-15%) were rehospitalized within 14 days compared with 8 (10%; 95% CI, 4%-17%) in the matched cohort. CONCLUSIONS: Patients with COVID-19 who were managed through an accelerated hospital observation protocol and postdischarge monitoring service had reduced hospital LOS compared with patients receiving standard care. Hospital preparedness for future public health emergencies may involve the design of pathways that reduce the time that patients spend in the hospital, lower cost, and ensure continued recovery upon discharge. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the safety and effectiveness of the careful hand feeding (CHF) programme in a geriatric step-down hospital. Methods. Medical records of patients aged =65 years who received CHF in Fung Yiu King Hospital between February 2017 and November 2021 were retrospectively reviewed. Results. 446 patients (178 men and 268 women) aged 66 to 109 (mean, 91) years were included for analysis. 88% of patients were severely frail or very severely frail. 70% of patients had advanced dementia. 81.3% of patients had dysphagia. 44% of patients were in imminent death status (who were highly likely to die within a week) before starting CHF. Food intake during CHF was poor or very poor in 51% of patients and satisfactory or good in 49% of patients. 90% of patients required clinically assisted hydration. The mean length of hospital stay was 19.3±16 days, and the mean duration of CHF was 14±13.5 days. 39% of patients died during the index admission; most of the remaining 61% of patients were discharged to their original placement. 27 (6%) patients had pneumonia. Independent predictors for pneumonia were the length of hospital stay (odds ratio=1.024, p=0.014) and poor/very poor intake (odds ratio=1.82, p=0.017). Conclusion. CHF is safe in a geriatric step-down hospital and avoids use of a nasogastric feeding tube in patients in their last phase of life. It fosters comfort and dignity for dying patients. Most patients can return to their original placement for CHF after discharge. [ABSTRACT FROM AUTHOR]

Background. Donning personal protective equipment (PPE) and performing cardiopulmonary resuscitation (CPR) are stressful tasks for healthcare professionals, particularly during the COVID-19 pandemic. This study aimed to assess the effectiveness of simulation training on donning PPE and performing CPR with PPE put on for nurses at a geriatric step-down hospital. Methods. A lecture and simulation training on donning PPE and performing CPR were provided for nurses. Confidence in donning PPE and performing CPR, knowledge of CPR, and satisfaction of participants were assessed before training (baseline), after the lecture, and after the simulation training. Results. 50 nurses (33 women and 17 men) attended both the lecture and simulation training, accounting for 90% of nurses in the department. Self-rated confidence in donning PPE and performing CPR improved significantly after the lecture (both p<0.001) and again after the simulation training (both p<0.001). Knowledge of CPR improved significantly after the lecture (p<0.001). Self-rated satisfaction of participants was high (9.3±0.3). Conclusion. Simulation training on donning PPE and performing CPR with PPE put on significantly improves the knowledge and confidence of nurses in a geriatric step-down hospital. This may contribute to improved patient outcomes, particularly during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Adverse drug events (ADEs) are an important public health problem with considerable clinical and economic costs. However there are limited studies of ADE incidence in adult inpatients in low-income countries, particularly in Ethiopia. Hence, this study aimed to assess the incidence of adverse drug events and associated factors in patients hospitalized in the medical wards of Wolaita Sodo University teaching referral hospital (WSUTRH). Methods: A prospective observational study was conducted involving 240 patients admitted to the medical wards of WSUTRH. A checklist was used for data collection, while standard tools were employed for assessing the probability and characterization of ADEs. A multifaceted approach involving daily chart review, patient interview, attendance at ward rounds and/or meetings, and staff reports were employed to collect the data. To identify factors independently associated with ADEs, logistic regression analysis was conducted using Stata version 15. Results: Patients were followed from ward admission to discharge, accounting for 2200 patient-days of hospital stay. Overall, 976 medications were ordered during the hospital stay. Sixty-four ADEs were identified with an incidence of approximately 27 per 100 admissions and 29 per 1000 patient days. Of the total ADEs, 59% were preventable. Regarding the severity, 2% of the ADEs were severe, while 54% were moderate. The risk of ADEs increased with longer hospital stay (LOHS) (p = 0.021), in patients with blood and immune disease diagnosis (p = 0.001), use of cardiovascular medicines (p = 0.028), and an increase in the number of medications prescribed (p = 0.021). Conclusions: In this study, ADEs were identified in about one-quarter of the participants. Longer hospital stays, blood and immune diseases, cardiovascular medicines use, and multiple medication use had increased the likelihood of ADE occurrences. The majority of the ADEs were preventable, indicating the existence of a window of opportunity to ensure patient safety. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Multiple states have passed legislation permitting marijuana use. The impact of legalization on trends in hospital encounters for marijuana exposures in young children across states remains unknown. We aimed to describe trends in marijuana-related hospital encounters over time in children <6 years and assess the association of state-level marijuana legislation with the rate of marijuana-related hospitalizations. METHODS: We identified inpatient, emergency department and observation encounters for children <6 years with marijuana exposures (defined by International Classification of Diseases diagnosis codes) unique on the patient-year level at 52 children's hospitals in the Pediatric Health Information System database from 01/01/2004 to 12/31/2018. Trends in encounters across the study period were evaluated using negative binomial regression with outcome of marijuana-related hospital encounters and year as the predictor variable accounting for clustering by hospital. We then estimated a negative binomial regression difference-in-difference model to examine the association between the main outcome and state recreational and medical marijuana legalization. RESULTS: Of the 1296 included unique patient-year encounters, 50% were female with mean age 2.1 years (standard deviation = 1.4). Fifty percent were inpatient (n = 645) and 15% required intensive care with 4% requiring mechanical ventilation. There was a 13.3-fold increase in exposures in 2018 compared to 2004 (P< .001). We did not find an effect of state legalization status for recreational (P = .24) or medical (P = .30) marijuana. CONCLUSIONS: The observed dramatic increase in marijuana-related hospital encounters highlights the need for prevention strategies aimed at reducing unintentional marijuana exposures in young children, even in states without legislation permitting marijuana use. [ABSTRACT FROM AUTHOR]

Professional ethics and a legal fiduciary duty require that physicians put the interests of their patients ahead of their own, even if that may put them at odds with their employers. When physicians abdicate or somehow lose their ability to decide what care is in the best interests of their patients, patients lose their most valuable and powerful advocate in the health care setting. This potentially impacts not only the quality of patient care, but the cost of that care. Medical debt impacting seniors is a growing crisis in the United States, leaving many Americans with no other option but to file bankruptcy. Indeed, the rate of citizens over the age of 65 who filed for bankruptcy has increased approximately 204% from 1991 to 2016. Social scientists tie this increased trend of bankrupt seniors to the extremely high cost of health care. But health care in the United States has always been expensive relative to other First World countries, so why are so many seniors finding it harder to cover their health care costs now more than ever? This Article postulates that one driving force behind the unaffordable health care costs for the Medicare population is the pressure Medicare places on hospitals to provide more care in an outpatient setting and the deleterious effect that pressure has on physicians' autonomy to choose the best plan of care for their patients. By classifying a patient's care as outpatient, Medicare shifts some of the financial burden of the hospital medical bills onto the patient, and in the case of skilled nursing care needed after outpatient hospital care, Medicare shifts the entire financial burden onto the patient. Medicare created this shift by enacting three waves of statutory reform, each designed to decrease the use of hospital inpatient services and increase the use of outpatient services. The result of these statutory changes is a healthcare system in which hospital administrator feel pressured by Medicare to utilize outpatient observation services for the medical management of patients aged 65 and older, and physicians who feel as though they no longer have a say in whether a patient is admitted as an inpatient or placed in an observation unit. In order to address this loss in physician autonomy and realign medical decision-making to prioritize the best interests of the patient, this Article aims to: (1) educate providers regarding the ethical considerations that should be utilized when determining patient placement; and (2) arm providers with the power to disrupt the detrimental conflicts of interests inherent in the healthcare system so they feel confident advocating for the best interests of their patients. By understanding how the Beauchamp and Childress principles of bioethics apply to patient placement decisions and utilizing the Jonson, Siegler, and Winslade four-box approach to clinical decision-making, this Article lays out a systematic approach to the ethical use of outpatient services for patients in the US healthcare system. [ABSTRACT FROM AUTHOR]

Background: Community-based harm reduction programs reduce morbidity and mortality associated with drug use. While hospital-based inpatient addiction consult services can also improve outcomes for patients using drugs, inpatient clinical care is often focused on acute withdrawal and the medical management of substance use disorders. There has been limited exploration of the integration of community-based harm reduction programs into the hospital setting. We conducted a qualitative study to describe provider perspectives on the implementation of a harm reduction in-reach program. Methods: We conducted 24 semi-structured interviews with providers from three different primary work sites within a safety net hospital in Boston, MA, in 2021. Interviews explored perceived facilitators and barriers to the implementation of the harm reduction in-reach program in the hospital setting and solicited recommendations for potential improvements to the harm reduction in-reach program. Interviews were analyzed using an inductive approach that incorporated principles of grounded theory methodology to identify prevailing themes. Results: Twenty-four participants were interviewed from the harm reduction in-reach program, inpatient addiction consult service, and the hospital observation unit. Thematic analysis revealed seven major themes and multiple facilitators and barriers to the implementation of the harm reduction in-reach program. Participants highlighted the impact of power differences within the medical hierarchy on inter-team communication and clinical care, the persistence of addiction-related stigma, the importance of coordination and role delineation between care team members, and the benefits of a streamlined referral process. Conclusions: Harm reduction programs offer accessible, patient-centered, low-barrier care to patients using drugs. The integration of community-based harm reduction programs into the inpatient setting is a unique opportunity to bridge inpatient and outpatient care and expand the provision of harm reduction services. Trial registration: Not applicable. [ABSTRACT FROM AUTHOR]

PURPOSE Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes. METHODS We performed a retrospective observational study that included all patients age 18 years and older who presented to our emergency department (ED) and were placed in the EDOU between March 1, 2019, and February 29, 2020. The patients' electronic medical records were queried for demographics, comorbidities, diagnosis at the time of placement in the EDOU, length of stay, disposition from the EDOU, ED return within 72 hours after discharge from the EDOU, and mortality outcomes at 14 and 30 days. RESULTS A total of 2,461 visits were eligible for analysis. Cancer-related pain was the main reason for observation in more than one quarter of the visits. The median length of stay in the EDOU was approximately 23 hours, and 69.6% of the patients were discharged. The ED return rate for unscheduled visits at 72 hours was 1.9%. The 14- and 30-day mortality rates were significantly higher for patients who were admitted than for those who were discharged (14 days: 1.7% v 0.3%, P, .001; 30 days: 5.9% v 1.8%, P, .001). CONCLUSION Our data suggest that placing patients with cancer in EDOUs is safe, reduces admissions, and reserves hospital resources for patients who can receive the most benefit without compromising care. [ABSTRACT FROM AUTHOR]