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Background: The demand for urgent psychiatric care is increasing, but in Spain there are no clear recommendations for emergency departments (ED) on how to optimize care for patients with psychiatric emergencies. We aimed to provide expert consensus recommendations on the requirements for general hospitals´ emergency departments to treat patients with urgent psychiatric symptoms., Methods: We used a modified Delphi technique. A scientific committee compiled 36 statements based on literature search and clinical experience. The statements covered the organizational model, facilities, staffing, safety, patient interventions, and staff training. A panel of 38 psychiatry specialists with expertise in psychiatric emergencies evaluated the questionnaire in two rounds., Results: After two rounds of voting, 30 out of 36 proposed items (83%) were agreed upon. The panel agreed that psychiatric emergencies should be managed in a general hospital, with dedicated facilities for patient assessment, direct supervision of patients at risk, and an observation unit run by the psychiatric service. In addition to the psychiatrist, the ED should have specialist nurses and security staff available 24/7. Social workers should also be readily available. ED and consulting rooms should be designed to ensure patient and staff safety. A triage system should be established for patients with psychiatric symptoms, with medical evaluation preceding psychiatric evaluation. Guidance on supplies, equipment, and staff training is also provided., Conclusion: All ED in general hospitals should have adequate resources to handle any psychiatric emergency. This paper provides recommendations on the minimum requirements to achieve this goal., (© 2024. The Author(s).)

Objective: Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments., Data Sources: The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS)., Study Design: Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems., Data Collection: Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms., Principal Findings: Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system., Conclusions: The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted., (© Health Research and Educational Trust.)

Objective: The recent COVID-19 outbreak has forced notable adjustments to surgical procedure preparation, including neurosurgical services. However, due to the uniqueness of the recent situation, neurosurgical centers, especially those located in low-resource settings, are facing several challenges such as a lack of coordination, poor equipment, and shortage of medical personnel. Therefore, several guidelines from local authorities and international neurosurgical bodies have been published to help clinicians manage their patients. In addition, the academic health system (AHS), which is an integrated system containing a medical institution, universities, and a teaching hospital, may play some role in the management of patients during COVID-19. The objective of this study was to describe how each hospital in the authors' network adjusted their neurosurgical practice and how the AHS of the Universitas Gadjah Mada (UGM) played its role in the adaptation process during the pandemic., Methods: The authors gathered both local and national data about the number of COVID-19 infections from the government's database. To assess the contribution of the AHS to the efforts of each hospital to address the pandemic, questionnaires were given to 6 neurosurgeons, 1 resident, and 2 general surgeons about the management of neurosurgical cases during the pandemic in their hospitals., Results: The data illustrate various strategies to manage neurosurgical cases by hospitals within the authors' networks. The hospitals were grouped into three categories based on the transmission risk in each region. Most of these hospitals stated that UGM AHS had a positive impact on the changes in their strategies. In the early phase of the outbreak, some hospitals faced a lack of coordination between hospitals and related stakeholders, inadequate amount of personal protective equipment (PPE), and unclear regulations. As the nation enters a new phase, almost all hospitals had performed routine screening tests, had a sufficient amount of PPE for the medical personnel, and followed both national and international guidelines in caring for their neurosurgical patients., Conclusions: The management of neurosurgical procedures during the outbreak has been a challenging task and a role of the AHS in improving patient care has been experienced by most hospitals in the authors' network. In the future, the authors expect to develop a better collaboration for the next possible pandemic.

Background: A vigilant prescription of drugs during pregnancy can potentially safeguard the growing fetus from the deleterious effect of the drug while attempting to manage the mother's health problems. There is a paucity of information about the drug utilization pattern in the area of investigation. Hence, this study was implemented to investigate the pattern of drug utilization and its associated factors among pregnant women in Adigrat general hospital, Northern Ethiopia., Methods: An institution-based cross-sectional study was conducted among randomly selected 314 pregnant women who attended obstetrics-gynecology and antenatal care units of the hospital. Relevant data were retrieved from the pregnant women's medical records and registration logbook. The drugs prescribed were categorized based on the United States Food and Drug Administration (US-FDA) fetal harm classification system. Data analysis was done using SPSS version 20 statistical software. Multivariate logistic regression was employed to analyze the association of the explanatory variables with the medication use, and p < 0.05 was declared statistically significant., Results: The overall prescribed drug use in this study was found to be 87.7%. A considerable percentage of the study participants (41.4%) were prescribed with supplemental drugs (iron folate being the most prescribed drug) followed by antibiotics (23.4%) and analgesics (9.2%). According to the US-FDA drug's risk classification, 42.5, 37, 13, and 7% of the drugs prescribed were from categories A, B, C, and D or X respectively. Prescribed drug use was more likely among pregnant women who completed primary [AOR = 5.34, 95% CI (1.53-18.6)] and secondary education [AOR = 4.1, 95% CI (1.16-14)], who had a history of chronic illness [AOR = 7.9, 95% CI (3.14-19.94)] and among multigravida women [AOR = 2.9, 95% CI (1.57 5.45)]., Conclusions: The finding of this study revealed that a substantial proportion of pregnant women received drugs with potential harm to the mother and fetus. Reasonably, notifying health practitioners to rely on up-to-date treatment guidelines strictly is highly demanded. Moreover, counseling and educating pregnant women on the safe and appropriate use of medications during pregnancy are crucial to mitigate the burden that the mother and the growing fetus could face.

Introduction: The prevalence of daily smoking in France was 24 % in 2019 and tobacco control remains a major public health issue. A hospital stay provides an opportunity for smoking cessation intervention. Identification and management of smokers during a hospital stay may be variously integrated into electronic health records (EHR)., State of the Art: Smoking status identification, which have included pre-filled forms, check-box, reminders, icons, is heterogeneous. Specific modules in EHR have been implemented for smoking cessation management such as counselling sessions, tobacco cessation prescriptions, smoking cessation guidelines and long-term follow-up. EHR-based intervention to identify and manage smokers with a long-term follow-up for at least one month after hospital discharge has shown an increase in smoking abstinence at 6-12 months., Outlook: Due to the lower quality of free data about smoking status, systematic identification with check-box, reminders or icons in EHR may be more appropriate. Integration of functionalities such as help for prescription, reminders and follow-up of patients would make tobacco cessation management easier for health professionals., Conclusion: EHR interventions to identify smokers and manage smoking cessation during hospital stays are an opportunity to increase smoking cessation., (Copyright © 2020 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

This paper assesses the economic efficiency of Brazilian general hospitals that provide inpatient care for the Unified Health System (SUS). We combined data envelopment analysis (DEA) and spatial analysis to identify predominant clusters, measure hospital inefficiency and analyze the spatial pattern of inefficiency throughout the country. Our findings pointed to a high level of hospital inefficiency, mostly associated with small size and distributed across all Brazilian states. Many of these hospitals could increase production and reduce inputs to achieve higher efficiency standards. These findings suggest room for optimization, but inequalities in access and the matching of demand and supply must be carefully considered in any attempt to reorganize the hospital system in Brazil.

The direct impact of hospital accreditation on patients' clinical outcomes is unclear. The purpose of this study was to evaluate whether mortality within 30 days of hospitalization for acute myocardial infarction (AMI), ischemic stroke (IS), and hemorrhagic stroke (HS) differed before and after hospital accreditation. This study targeted patients who had been hospitalized for the three diseases at the general hospitals newly accredited by the government in 2014. Thirty-day mortality rates of three years before and after accreditation were compared. Mortality within 30 days of hospitalization for the three diseases was lower after accreditation than before (7.34% vs. 6.15% for AMI; 4.64% vs. 3.80% for IS; and 18.52% vs. 15.81% for HS). In addition, hospitals that meet the criteria of the patient care process domain have a statistically lower mortality rate than hospitals that do not. In the newly accredited Korean general hospital, it was confirmed that in-hospital mortality rates of major cardiovascular diseases were lower than before the accreditation.

It is currently a critical period for the prevention and control of the COVID-19 pandemic. Since the medical waste disposal could be an important way to control the source of infection, standardization, and strict implementation of the management of COVID-19 related medical waste should be with careful consideration to reduce the risk of epidemic within hospitals. This study illustrates the practice of medical waste disposal responding to the 2019-2020 novel coronavirus pandemic., (Copyright © 2020 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

WHAT IS KNOWN ON THE SUBJECT?: People with mental health problems have higher rates of physical health concerns and hospital admissions than those without mental health problems. These patients have poorer outcomes from surgery and have worse experiences of care when admitted for medical or surgical procedures. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper looks to understand why care may be poorer for patients with mental health problems by speaking to staff providing care in these settings. We spoke to 30 general hospital staff about mental health on the wards and found that a lack of leadership and ownership for prioritising mental health led to people not seeing it as their job, and that it was somebody else's business to manage that side of care. We also found that the emotional effect of caring for people who had attempted suicide or had self-harm injuries was difficult for staff, impacting on staff well-being and leading them to distance themselves from providing care in those cases. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need for staff to be supported from the top-down, with management providing clear leadership around issues and pathways for mental health needs so they know the best way to provide care and encourage collaborative working. In addition, bottom-up support is needed to help staff personally manage their own well-being and mental health, including supervision and debriefing from mental health specialists to improve understanding from the patient's perspective and to provide emotional support to manage difficulties. RELEVANCE STATEMENT: This paper places focus on the care of patients with mental health problems in medical and surgical care settings highlighting the interplay between mental and physical health from a perspective that is less often explored. This paper provides insights into the multidisciplinary nature of nursing and the need for integrated care. This provides findings that build a picture of how mental health nursing specialism is needed beyond psychiatric wards and within medical and surgical settings. ABSTRACT: Introduction Evidence shows that patients with mental health problems have poorer physical health outcomes, increased mortality and experience poorer care during surgery and medical admissions. Issues related to lack of training, stigmatizing attitudes, fear or hopelessness may help understand these poor outcomes. Aim To explore the experiences of staff in providing care for people with mental health problems. Method A qualitative service evaluation approach was used. Participants working in an acute care hospital in inner-city London were recruited across professions and job levels using a self-selection sampling method. A total of 30 participants took part in semi-structured interviews (n = 17) and two focus groups (n = 13), and data were thematically analysed. Relevant organizational documents and service use data were utilized to inform the evaluation. Results Key themes were organized across the macro, meso and micro levels to understand the levels of disconnection and silence around mental health in acute care. Themes include systemic factors surrounding the institutional culture, ward cultures and collaborative working, and individuals' sense-making of mental health and personal well-being. Implications for practice These findings signpost the growing need for greater mental health nursing input on medical and surgical wards and within these teams to provide informed knowledge, support and supervision., (© 2020 John Wiley & Sons Ltd.)

Introduction: UK and European guidelines recommend consideration of a self-expandable metallic stent (SEMS) as an alternative to emergency surgery in left-sided colonic obstruction. However, there is no clear consensus on stenting owing to concern for complications and long-term outcomes. Our study is the first to explore SEMS provision across England., Methods: All colorectal surgery department leads in England were contacted in 2018 and invited to complete an objective multiple choice questionnaire pertaining to service provision of colorectal stenting (including referrals, time, location and specialty)., Results: Of 182 hospitals contacted, 79 responded (24 teaching hospitals, 55 district general hospitals). All hospitals considered stenting, with 92% performing stenting and the remainder referring. The majority (93%) performed fewer than four stenting procedures per month. Most (96%) stented during normal weekday hours, with only 25% stenting out of hours and 23% at weekends. Compared with district general hospitals, a higher proportion of teaching hospitals stented out of hours and at weekends. Stenting was performed in the radiology department (64%), the endoscopy department (44%) and operating theatres (15%), by surgeons (63%), radiologists (60%) and gastroenterologists (48%). A radiologist was present in 66% of cases. Of 14 hospitals that received referrals, 3 had a protocol, 3 returned patients the same day and 4 returned patients for management in the event of failure., Conclusions: All responding hospitals in England consider the use of SEMS in colonic obstruction. Nevertheless, there is great variation in stenting practices, and challenges in terms of access and expertise. Centralisation and regional referral networks may help maximise availability and expertise but more work is needed to support this.

Objective: This study investigates how patients and medical staff assess the physical environments of two recently built hospitals in Sulaimani City to understand the extent to which indoor environmental factors influence the creation of an optimal healing environment., Background: A contemporary healing environment may be recognized by the quality of an indoor environment in positively influencing patients' psychological comfort and supporting their recovery., Method: Post-occupancy evaluations were conducted in Shar General Hospital and Faruk Medical City wards. A 43-item questionnaire was distributed to 312 patients, doctors, and nurses to gather their perspectives. In total, 175 valid questionnaires were retrieved., Results: The results show that the quality of the indoor environments met patients' psychological needs and expectations, and as a result, they were generally satisfied with the indoor healing environments. The findings from the patient and medical staff surveys suggest three essential factors in creating a healing environment, which are (1) Interior appearance , (2) Privacy , and (3) Comfort and control . Significant negative correlations of some demographic characteristics, such as educational attainment and age, with patient satisfaction were observed., Conclusions: This study shows that exploring patients' and medical staff's experiences can reveal factors that positively influence patients' satisfaction levels, which may vary depending on their sociocultural perspectives and personal characteristics. Additionally, the findings emphasize the role of the tested factors in increasing patients' satisfaction levels, optimizing healing environments, and informing design decisions.

Objective: To measure patient safety climate and the associated factors from the perspective of the multiprofessional team., Method: This was an analytical cross-sectional study, developed in a medium-sized hospital in the Southern region of Brazil. The Safety Attitudes Questionnaire (SAQ) was used as the data collection tool and applied to 199 workers of the multiprofessional and support team between November 2017 and February 2018. Data analysis was descriptive and analytical. A positive score was considered when ≥75., Results: The overall SAQ score was positive (75.1). The domain Satisfaction at Work was the one with the highest score (88.7), while Stress Perception showed the worst score (59.1). It was observed that professionals without a College/University degree better evaluated the domains Satisfaction at Work, Management Perception and Working Conditions, whereas the ones with a College/University degree had better stress perception. Medical doctors showed better Stress Perception when compared to the other health professionals., Conclusion: There is a positive safety climate in health organizations from the perspective of the multiprofessional team. However, the domains Safety Climate, Working Conditions and Stress Perception constitute areas that need improvement in terms of patient safety in the institution.

Background: There is a longstanding interest in the field of management science to study high performance organizations. Applied to medicine, research on hospital performance indicates that some hospitals are high performing, while others are not. The objective of this study was to identify a cluster of high-performing emergency general surgery (EGS) hospitals and assess whether high performance at one EGS operation was associated with high performance on all EGS operations., Methods: Adult patients who underwent one of eight EGS operations were identified in the California State Inpatient Database (2010-2011), which we linked to the American Hospital Association database. Beta regression was used to estimate a hospital's risk-adjusted mortality, accounting for patient- and hospital-level factors. Centroid cluster analysis grouped hospitals by patterns of mortality rates across the eight EGS operations using z scores. Multinomial logistic regression compared hospital characteristics by cluster., Results: A total of 220 acute care hospitals were included. Three distinct clusters of hospitals were defined based on assessment of mortality for each operation type: high-performing hospitals (n = 66), average performing (n = 99), and low performing (n = 55). The mortality by individual operation type at the high-performing cluster was consistently at least 1.5 standard deviations better than the low-performing cluster (p < 0.001). Within-cluster variation was minimal at high-performing hospitals compared with wide variation at low-performing hospitals. A hospital's high performance in one EGS operation type predicted high performance on all EGS operation types., Conclusion: High-performing EGS hospitals attain excellence across all types of EGS operations, with minimal variability in mortality. Poor-performing hospitals are persistently below average, even for low-risk operations. These findings suggest that top-performing EGS hospitals are highly reliable, with systems of care in place to achieve consistently superior results. Further investigation and collaboration are needed to identify the factors associated with high performance., Level of Evidence: Prognostic, level III.

Background: Australia has among the highest prevalence of Crohn disease and ulcerative colitis in the world. Management of the chronic gastrointestinal disorders results in significant societal costs and the standard of care is inconsistent across Australia., Aim: To audit the quality of care received by patients admitted for inflammatory bowel disease (IBD) across Australia against national IBD standards., Methods: A retrospective cross-sectional survey and clinical audit was undertaken assessing organisational resources, clinical processes and outcome measures. This study was conducted in Australian hospitals that care for inpatients with Crohn disease or ulcerative colitis. The main outcome measures were adherence to national IBD standards and comparison of quality of care between hospitals with and without multidisciplinary IBD services., Results: A total of 71 hospitals completed the organisational survey. Only one hospital had a complete multidisciplinary IBD service and 17 had a partial IBD service (IBD nurse, helpline and clinical lead). A total of 1440 inpatient records was reviewed from 52 hospitals (mean age 37 years; 51% female, 53% Crohn disease), approximately 26% of IBD inpatient episodes over a 12-month period in Australia. These patients were chronically unwell with high rates of anaemia (30%) and frequent readmissions (40% within 2 years). In general, care was inconsistent, and documentation was poor. Hospitals with a partial IBD service performed better in many processes and outcome measures: for example, 22% reduction in admissions through emergency departments and greater adherence to standards for safety monitoring of biological (89% vs 59%) and immunosuppressive drugs (79% vs 55%) in those hospitals than those without., Conclusion: Patients admitted to hospital suffering from IBD are young, chronically unwell and are subject to substantial variations in clinical documentation and quality of care. Only one hospital met accepted standards for multidisciplinary care; hospitals with even a minimal IBD service provided improved care., (© 2019 Royal Australasian College of Physicians.)

Sierra Leone has a high tuberculosis (TB) burden with a prevalence of 441 cases per 100 000 population. As a result of the Global Fund, some facilities in the country have access to improved diagnostics, including Xpert MTB/RIF testing, of particular use in diagnosing those at risk of drug resistance, in the form of rifampicin-resistant (RR) TB. This quality improvement project describes how a small, rural district general hospital in Masanga village improved the diagnosis of TB and RR-TB by creating a formal link with the regional hospital in Makeni city. In an effort to improve diagnosis, all patients with a suspicion of TB and one of the following would have a sample sent for Xpert MTB/RIF testing: previous TB treatment (of any course length), HIV positive or known contact of a RR-TB case. The samples were transported by the logistics team, who already drove weekly from Masanga to Makeni for supplies, and the results were texted to the clinician in charge of the medical ward. Over the course of the first 4 months of this intervention, 34 samples had Xpert MTB/RIF testing performed compared with two samples in the previous 12 months since the machine had been installed. This yielded nine additional diagnoses of TB (in patients with negative or unavailable smear results) and five diagnoses of RR-TB with subsequent appropriate isolation and transfer to the central tertiary centre. This study shows that it is feasible to centralise Xpert MTB/RIF testing in low-resource settings using creative methods for sample transfer and results dissemination, leading to both improved diagnostics and infection control., Competing Interests: Competing interests: None declared.

Background: Given the increased attention to sepsis at the population level there is a need to assess hospital performance in the care of sepsis patients using widely-available administrative data. The goal of this study was to develop an administrative risk-adjustment model suitable for profiling hospitals on their 30-day mortality rates for patients with sepsis., Methods: We conducted a retrospective cohort study using hospital discharge data from general acute care hospitals in Pennsylvania in 2012 and 2013. We identified adult patients with sepsis as determined by validated diagnosis and procedure codes. We developed an administrative risk-adjustment model in 2012 data. We then validated this model in two ways: by examining the stability of performance assessments over time between 2012 and 2013, and by examining the stability of performance assessments in 2012 after the addition of laboratory variables measured on day one of hospital admission., Results: In 2012 there were 115,213 sepsis encounters in 152 hospitals. The overall unadjusted mortality rate was 18.5%. The final risk-adjustment model had good discrimination (C-statistic = 0.78) and calibration (slope and intercept of the calibration curve = 0.960 and 0.007, respectively). Based on this model, hospital-specific risk-standardized mortality rates ranged from 12.2 to 24.5%. Comparing performance assessments between years, correlation in risk-adjusted mortality rates was good (Pearson's correlation = 0.53) and only 19.7% of hospitals changed by more than one quintile in performance rankings. Comparing performance assessments after the addition of laboratory variables, correlation in risk-adjusted mortality rates was excellent (Pearson's correlation = 0.93) and only 2.6% of hospitals changed by more than one quintile in performance rankings., Conclusions: A novel claims-based risk-adjustment model demonstrated wide variation in risk-standardized 30-day sepsis mortality rates across hospitals. Individual hospitals' performance rankings were stable across years and after the addition of laboratory data. This model provides a robust way to rank hospitals on sepsis mortality while adjusting for patient risk.

Purpose: The purpose of this paper is to analyze two process standardization theoretical conceptual constructs: process variants unification; and distinction between standard, routine and non-routine processes., Design/methodology/approach: The authors analyze two conceptual constructs based on a single case study representing a general hospital's (GH) process standardization, approach and results. The authors research whether process standardization implemented in a GH conforms to the process variants unification concept approach and its assumed benefits and whether implemented process standardization enables process management improvement based on distinguishing standard, routine and non-routine processes., Findings: In accordance with the process variants unification conceptual construct, the hospital task force determined a uniform basic patient comprehensive treatment process at the hospital level, which allows synergy among departments. Uniform process activities reflect the differences between standard, routine and non-routine processes., Practical Implications: Process standardization through unification improves performance by establishing a common framework enabling shared experience based on improved process understanding. Distinguishing standard, routine and non-routine processes is useful for analyzing process management. This distinction provides guidelines for process implementation and measurement improvement. The paper also shows that increased routinization and standardization represent levers for process improvement., Originality/value: The authors analyze theoretical constructs based on a single case study and confirm that theoretical conceptual construct application can provide better process management, which is important for practitioners.

Aims: Diabetes mellitus is a commonly encountered diagnosis in hospitalised patients that is associated with prolonged admissions and mortality. One in six hospital beds in the UK are occupied by diabetes patients. Therefore, healthcare providers need to have a sound knowledge in managing in-patients with diabetes. Thus the aim of this clinical survey was to assess the diabetes-related knowledge of healthcare professionals in a district general hospital., Methods: A 24-item questionnaire, based on the 'Think Check Act (TCA)' diabetes modules implemented by the Healthcare Improvement Scotland was issued to the medical and nursing staff. Simple statistics were used for data collation and analysis., Results: 30 questionnaires were completed by 10 doctors at varying stages of training, 17 nurses, 1 physician associate and 2 healthcare assistants. The mean percentage score of the participants were 57.4%. 22 (73.3%) correctly defined hypoglycaemia and 27 (90%) knew the location of hypo box and 7 (23.3%) were aware of TCA. Responses to other management related to diabetes emergencies were average. The responses between doctors and nurses were insignificant except for hypo box location (p = 0.0413)., Conclusion: Knowledge about managing inpatient diabetes problems amongst healthcare professional at a district general hospital appears mediocre. Significant gaps have been identified which would be targeted for future educational events., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

Objective: To analyze the active failures and the latent conditions related to errors in intensive nursing care and to discuss the reactive and proactive measures mentioned by the nursing team., Method: Qualitative, descriptive, exploratory study conducted at the Intensive Care Unit of a general hospital. Data were collected through interviews, participant observation and submitted to lexical analysis in the ALCESTE® software and to ethnographic analysis., Results: 36 professionals of the nursing team participated in the study. The analysis originated three lexical classes: Error in intensive care nursing; Active failures and latent conditions related to errors in the intensive care nursing team; Reactive and proactive measures adopted by the nursing team regarding errors in intensive care., Conclusion: Reactive and proactive measures influenced the safety culture, in particular, the recognition of errors by professionals, contributing to their prevention, safety and quality care.

Introduction: China has a very high tuberculosis (TB) burden. The interferon-gamma release assay (IGRA) is more specific for the diagnosis of latent tuberculosis infection (LTBI) than the tuberculin skin test, especially among populations with a high degree of coverage by the BCG vaccine., Objectives: To evaluate the first screening of healthcare workers (HCW) for LTBI using the IGRA at a general hospital in Beijing., Methods: A pilot screening program for LTBI was triggered by accidental contact between HCW and two patients with active TB in the emergency department (ED). Given the necessity of estimating the overall LTBI prevalence in the institution, a sample of 518 HCW was enrolled in our cross-sectional study. The second IGRA was repeated with 43 of the 121 HCW in the ED after exposure to index TB cases. Data on putative risk factors were collected with a self-administered questionnaire., Results: The prevalence of LTBI in the targeted population was 21.8%. Differences in the prevalence of LTBI were significantly related to age, employment duration, and history of occupational exposure. A lack of childhood BCG vaccination was independently associated with the prevalence of LTBI (adjusted OR: 1.686, 95% CI: 1.045-2.723, P = .0325). No new LTBI was diagnosed 12 weeks postexposure. No HCW adopted the preventive treatment for LTBI., Conclusions: Considering the high morbidity of LTBI among HCW even in general hospitals, it is essential to formulate government policies and institutional operation protocols for the systematic screening, registration, and administration of prophylaxes for the control of LTBI., (© 2018 John Wiley & Sons Ltd.)

Objective: To define generic quality indicators for general hospital psychiatry from the perspectives of patients, professionals (physicians, nurses, and managers), and payers (health insurance companies)., Methods: Quality variables were identified by reviewing the relevant literature. A working. group consisting of patients', professionals' and payers' representatives was mandated by their respective umbrella organizations. The working group prioritized the quality variables that were identified. Core values were defined and subsequently linked to preliminary quality indicators. These were tested for feasibility in ten hospitals in a four-week period. Stakeholder consultation took place by means of two invitational conferences and two written commentary rounds., Results: Forty-one quality variables were identified from the literature. After prioritization, seven core values were defined and translated to 22 preliminary indicators. Overall, the feasibility study showed high relevance scores and good implementability of the preliminary quality indicators. A final set of twenty-two quality indicators (17 structure, 3 process and 2 outcome indicators) was then established using a consensus-based approach., Conclusion: Consensus on a quality framework for general hospital psychiatry was built by incorporating the perspectives of relevant stakeholders. Results of the feasibility study suggest broad support and good implementability of the final quality indicators. Structural indicators were broadly defined, and process and outcome indicators are generic to facilitate quality measurement across settings. The quality indicator set can now be used to facilitate quality and outcome assessment, stimulate standardization of services, and help demonstrate (cost-) effectiveness., (Copyright © 2018 Elsevier Inc. All rights reserved.)

This study applied the non-parametric four-stage data envelopment analysis method (Four-Stage DEA) to measure the relative efficiencies of Chinese public hospitals from 2010 to 2016, and to determine how efficiencies were affected by eight factors. A sample of public hospitals (n = 84) was selected from Chongqing, China, including general hospitals and traditional Chinese medicine hospitals graded level 2 or above. The Four-Stage-DEA method was chosen since it enables the control of the impact of environment factors on efficiency evaluation results. Data on the number of staff, government financial subsidies, the number of beds and fixed assets were used as input whereas the number of out-patients and emergency department patients and visits, the number of discharged patients, medical and health service income and hospital bed utilization rate were chosen as study outputs. As relevant environmental variables, we selected GDP per capita, permanent population, population density, number of hospitals and number of available sickbeds in local medical institutions. The relative efficiencies (i.e. technical, pure technical, scale) of sample hospitals were also calculated to analyze the change between the first stage and fourth stage every year. The study found that Four-Stage-DEA can effectively filter the impact of environmental factors on evaluation results, which sets it apart from other models commonly used in existing studies., Competing Interests: This study was partly supported by the World Bank Project. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

Rationale, Aims, and Objectives: A reduction in the provision of hospital services on the weekend probably explains higher mortality for patients who are either admitted to hospital or undergo procedures on the weekend. The aim was to examine the effect of the day of the week of admission (DOWOA) upon the efficiency and quality of care for a cohort of General Medical inpatients., Methods: Electronic records were selected for unplanned adult admissions to 2 large public hospitals in Adelaide, South Australia, July 2012 to June 2017., Results: The cohort consisted of 50 323 records. The number of admissions on each day of the week differed significantly from 6389 on Sundays to 7548 on Thursdays (P < 0.001). Discharges were most frequent on Fridays, and fewest occurred on weekends (P < 0.001) especially if aged over 80 years, if they had significant comorbidity or if they were discharged to a residential aged care facility. The DOWOA did not significantly influence the proportion of cases who died in hospital (5.6% to 6.4%; P = 0.47). The DOWOA significantly affected median inpatient length of stay (IPLOS; 3.1 to 3.9 days; P < 0.001). The median inpatient length of stay (IPLOS) matched the number of days from the ensuing weekend to the DOWOA with the longest median IPLOS., Conclusions: General Medicine has an inpatient mortality unaffected by the DOWOA. Care efficiency, however, follows a weekly cycle. The "weekend effect" for General Medical inpatients is a prolongation in their IPLOS as a result of fewer weekend discharges., (© 2018 John Wiley & Sons, Ltd.)

Background: About three - quarters of all neonatal deaths occur during the first week of life, with over half of these occurring within the first 24 h after birth. The first minutes after birth are critical to reducing neonatal mortality. Successful neonatal resuscitation (NR) has the potential to prevent these perinatal mortalities related to birth asphyxia. This study described the practice of NR and outcomes of newborns with birth asphyxia in a busy referral hospital., Methods: Direct observations of 138 NRs by 28 healthcare providers (HCPs) were conducted using a predetermined checklist adapted from the national pediatric resuscitation protocol. Descriptive statistics were computed and chi - square tests were used to test associations between the newborn outcome at 1 h and the NR processes for the observed newborns. Logistic regression models assessed the relationship between the survival status at 1 h versus the NR processes and newborn characteristics., Results: Nurses performed 72.5% of the NRs. A warm environment was maintained in 71% of the resuscitations. Airway was checked for almost all newborns (98%) who did not initiate spontaneous breathing after stimulation. However, only 40% of newborns were correctly cared for in case of meconium presence in airway. Bag and mask ventilation (BMV) was initiated in 100% of newborns who did not respond to stimulation and airway maintenance. About 86.2% of resuscitated newborns survived after 1 h. Removing wet cloth (P = 0.035, OR = 2.90, CI = 1.08-7.76), keeping baby warm (P = 0.018, OR = 3.30, CI = 1.22-8.88), meconium in airway (P = 0.042, OR = 0.34, CI = 0.12-0.96) and gestation age (P = 0.007, OR = 1.38, CI = 1.10-1.75) were associated with newborn outcome at 1 h., Conclusions: Mentorship and regular cost - effective NR trainings with focus on maintaining the warm chain during NR, airway maintenance in meconium presence, BMV and care for premature babies are needed for HCPs providing NR.

Background: Paediatric Early Warning Scores (PEWS) are increasingly being used for early identification and management of clinical deterioration in paediatric patients. A PEWS system includes scores, cut-off points and appropriate early intervention. In 2011, The Dutch Ministry of Health advised hospitals to implement a PEWS system in order to improve patient safety in paediatric wards. The objective of this study was to examine the results of implementation of PEWS systems and to gain insight into the attitudes of professionals towards using a PEWS system in Dutch non-university hospitals., Methods: Quantitative data were gathered at start, midway and at the end of the implementation period through retrospective patient record review (n = 554). Semi-structured interviews with professionals (n = 8) were used to gain insight in the implementation process and experiences. The interviews were transcribed and analysed using an inductive approach., Results: Looking at PEWS systems of the five participating hospitals, different parameters and policies were found. While all hospitals included heart rate and respiratory rate, other variables differed among hospitals. At baseline, none of the hospitals used a PEWS system. After 1 year, PEWS were recorded in 69.2% of the patient records and elevated PEWS resulted in appropriate action in 49.1%. Three themes emerged from the interviews: 1) while the importance of using a PEWS system was acknowledged, professionals voiced some doubts about the effectiveness and validity of their PEWS system 2) registering PEWS required little extra effort and was facilitated by PEWS being integrated into the electronic patient record 3) Without a national PEWS system or guidelines, hospitals found it difficult to identify a suitable PEWS system for their setting. Existing systems were not always considered applicable in a non-university setting., Conclusions: After 1 year, hospitals showed improvements in the use of their PEWS system, although some were decidedly more successful than others. Doubts among staff about validity, effectiveness and communication with other hospitals during transfer to higher level care hospital might hinder sustainable implementation. For these purposes the development of a national PEWS system is recommended, consisting of a "core set" of PEWS, cut-off points and associated early intervention.

In hospitals, use of constant observation (CO) causes significant economic burden without demonstrated reduction in adverse events. A novel quality improvement (QI) project was developed to reduce use of CO by integrating proactive behavioral health management of all patients requiring CO in a general hospital. Specific nonpharmacologic and pharmacologic interventions used in this project, which included 491 patients, are discussed. Data collected were compared with data from a baseline period before project implementation. The average monthly cost of observers was reduced by 33%, and length of stay was reduced 15% without increased complications. Using QI to develop proactive and consistent involvement of a designated behavioral health team and potentially reproducible care protocols for patients requiring CO resulted in improvement in quality, reduction in cost, and enhanced behavioral health integration in the general hospital.

This paper develops and tests a dynamic model of hospital focus. It does so by tracing the performance trajectories of specialist and general hospitals to identify whether a performance gap exists and whether it widens or shrinks over time. Our longitudinal analyses of all hospital organizations within the English National Health Service (NHS) reveal not only a notable performance gap between specialist and general hospitals in particular with regards to patient satisfaction that widens over time, but also the emergence of a gap especially with regards to hospital staff job satisfaction. These findings reflect the considerable potential of specialization as a means to enhance hospital effectiveness. However, they also alert health policy makers to the threat of a widening performance gap between specialist and general hospitals with potential negative repercussions at the patient and health system level.

Objective: In order to apply the index system for clinical evaluation of implementation effect in hospitals.
 Methods: A total of 862 patients with vaginal delivery from 9 hospitals were randomly divided into an clinical pathway group (n=496) and a control group (n=366). The patients in the control group received traditional treatment procedure while the patients in the clinical pathway group experienced procedure of the clinical treatment. The index system was used for clinical evaluation of implementation effect.
 Results: There were obvious advantages in 15 indicators in the clinical pathway group than those in the control group (P<0.05). The comprehensive score of the clinical pathway group was higher than the control group of the corresponding grade and nature of the hospital. The comprehensive score for secondary hospitals (Ci=0.7967) were higher than that for the tertiary hospitals (Ci=0.2033). The comprehensive score for the general hospitals (Ci=0.8948) were higher than that for the specialized hospitals (Ci=0.1052). As for clinical implementation effect, the secondary hospitals were better than the tertiary hospital, and the general hospitals were better than the specialized hospitals.
 Conclusion: The index system for clinical evaluation could quantify the implementation effect, and compare the implementation effect in different hospitals, which provides reference for the management of clinical pathway.

This study aims at assessing the gap in secondary fracture prevention at a regional general hospital setting in Singapore. Male patients have significantly lower rate of being investigated and treated for osteoporosis than their female counterparts. Vitamin D deficiency is prevalent in our population., Purpose: Secondary fracture prevention services are not routine in Singapore; we seek to assess the treatment gap that exists in the lack of diagnosis and treatment of osteoporosis in fragility fracture patients., Methods: We performed a retrospective analysis of all admissions for fragility fractures between December 2013 and December 2014. Demographic data, rates of BMD performance, serum vitamin D investigation and calcium and vitamin D supplementation as well as antiresorptive initiation 1 year post admission were analysed., Results: There were 125 fragility fractures in patients below 65 and 615 fractures in older patients. There was a slightly higher proportion of males in the younger population, whereas females predominated in the older population. Median vitamin D levels were low in both younger (19.1 μg/L) and older (22.0 μg/L) groups, but supplementation was lower in younger patients (4.8 versus 16.6%, p = 0.003). Rate of BMD performance was lower in younger patients (34.4 versus 64.6%, p < 0.01); there was a significant difference of BMD performance between male and female patients in the younger population (19.1 versus 52.8%, p < 0.01) which was not present in the older age group. Antiresportive initiation was significantly lower in the younger age group versus older (10.4 versus 31.5%, p < 0.01); male patients in the younger and older age groups had significantly lower antiresorptive initiation rate compared to the females., Conclusion: There is a significant treatment gap in diagnosis and treatment of osteoporosis in fragility fracture patients in a regional hospital setting in Singapore. Male osteoporosis remains inadequately investigated and treated in both age groups.

Background: The present study investigates changes in spontaneous reporting (SR) compliance and ADR patterns following adoption of a new hospital SR system, and multiple interventions designed for its improvement use under modified drug administration guidelines., Methods: In total, 1389 ADR cases were reviewed. Cases were divided into two groups, cases from period 1 (n = 557, from January 2006 to June 2011) under the old SR system and cases in period 2 (n = 832, from July 2011 to December 2016) under the new SR system with multiple interventions to improve physician SR compliance. General information, drug information, and clinical manifestations were investigated and compared between periods., Results: Interventions for improved clinician training, education on knowledge, attitudes, and practices (KAP), and economic incentives substantially improved SR adherence. We also found that changing drug usage patterns (based on the new drug administration guidelines) greatly influenced ADR occurrence and type., Conclusions: We found the SR compliance can be improved by multifaceted interventions. Drug usage patterns also influence ADR occurrence, so programs tailored for rational use are essential. These results could lead to further improvements in the SR system for ADRs in China, and provide guidance for establishing better methods of pharmacovigilance.

Background: The European Society of Breast Cancer Specialists (EUSOMA) has defined quality indicators for breast cancer (BC). The aim of this study was to describe the preoperative clinical pathway of breast cancer patients and evaluate the determinants of compliance with EUSOMA quality indicators in the Optisoins01 cohort., Methods: Optisoins01 is a prospective, multicentric study. Data from operable BC patients were collected, including results from before surgery to 1 year follow-up. Seven preoperative EUSOMA quality indicators were compared with the clinical pathways Optisoins01., Results: Six hundred and four patients were included. European Society of Breast Cancer Specialists targets were reached for indicator 1 (completeness of clinical and imaging diagnostic work-up), 3 (preoperative definitive diagnosis) and 5 (waiting time). For indicator 8 (multidisciplinary discussion), the minimum standard of 90% of the patients was reached only in general hospitals and comprehensive cancer centres. Having more than 1 medical examination within the centre was associated with an increased waiting time for surgery, whereas it was reduced by having an outpatient breast biopsy. The comprehensive cancer centre type was the only parameter associated with the other quality indicators., Conclusions: European Society of Breast Cancer Specialists quality indicators are a useful tool to evaluate care organisations. This study highlights the need for a standardised and coordinated preoperative clinical pathway.

Objective: Explore the experiences of liaison psychiatry professionals, to gain a greater understanding of the quality of care patients with mental illness receive in the general hospital setting; the factors that affect the quality of care; and their insights on interventions that could improve care., Methods: A survey questionnaire and qualitative in depth interviews were used to collect data. Data collection took place at the Royal College of Psychiatrists Faculty of Liaison Psychiatry Annual conference. Qualitative analysis was done using thematic analysis., Results: Areas of concern in the quality of care of patients with co-morbid mental illness included 'diagnostic overshadowing', 'poor communication with patient', 'patient dignity not respected' and 'delay in investigation or treatment'. Eleven contributing factors were identified, the two most frequently mentioned were 'stigmatising attitudes of staff towards patients with co-morbid mental illness' and 'complex diagnosis'. The general overview of care was positive with areas for improvement highlighted. Interventions suggested included 'formal education' and 'changing the liaison psychiatry team'., Conclusion: The cases discussed highlighted several areas where the quality of care received by patients with co-morbid mental illness is lacking, the consequences of which could be contributing to physical health disparities. It was acknowledged that it is the dual responsibility of both the general hospital staff and liaison staff in improving care., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Patients admitted to a psychiatric hospital commonly suffer from comorbid medical problems which sometimes require urgent medical attention. Twenty-two percent of emergency medical transfers from the Institute of Mental Health (IMH) to the emergency rooms of general hospitals were preventable and could be managed at IMH itself. We undertook a quality improvement project to understand the reasons behind such preventable referrals and implemented changes to address this., Methods: Using the model for improvement, we deconstructed our processes and analysed root causes for such preventable referrals. Thereafter changes were implemented with Plan-Do-Study-Act (PDSA) cycles to analyse their outcomes., Results: During the 6-month study period, we achieved a 100% reduction in preventable referrals through strategies aimed at reducing pressure on our on-call physicians in the making of medical decisions, maximising usage of our medical resources, constant education and raising awareness of this issue., Conclusions: Reducing preventable transfer of inpatients from a psychiatric hospital to the emergency departments of general hospitals is a worthwhile endeavour. Such initiatives optimise use of healthcare resources, improve patient care and increase satisfaction.

Objectives: The optimal care of people with dementia in general hospitals has become a policy and practice imperative over recent years. However, despite this emphasis, the everyday experience of staff caring for this patient group is poorly understood. This review aimed to synthesise the findings from recent qualitative studies in this topic published prior to January 2014 to develop knowledge and provide a framework to help inform future training needs., Method: A systematic search of the literature was conducted across five academic databases and inclusion/exclusion criteria applied to the retrieved papers. A meta-ethnographic approach was utilised to synthesise the resulting 14 qualitative papers., Results: Five key themes were constructed from the findings: overcoming uncertainty in care; constraints of the environmental and wider organisational context; inequality of care; recognising the benefits of person-centred care; and identifying the need for training. These themes explore the opportunities and challenges associated with caring for this group of patients, as well as suggestions to improve staff experiences and patient care., Conclusion: The synthesis highlighted a lack of knowledge and understanding of dementia within general hospital staff, particularly with regard to communication with patients and managing behaviours that are considered challenging. This limited understanding, coupled with organisational constraints on a busy hospital ward, contributed to low staff confidence, negative attitudes towards patients with dementia and an inability to provide person-centred care. The benefits of dementia training for both ward staff and hospital management and peer discussion/support for ward staff are discussed.

Background: Irrational medicine use including excessive use and abuse of antibiotics remains a crucial problem for the healthcare systems. In this regard, studies examining approaches to improving the clinical use of medicines are highly important., Aim: to assess the efficacy rate of management for the rational use of antibiotics in surgical departments of a multi-disciplinary hospital., Material and Methods: The intervention complex combined the research, educational, and methodological activities: local protocols for perioperative antibiotic prophylaxis (PABP) for various surgical departments were developed; local PABP protocols were discussed with the physicians of specialized surgical departments; official order on implementation of PABP was issued; the list of drug prescriptions for registration of the first pre-operative antibiotic dose was changed; audit and feedback processes were introduced as well as consultations of a clinical pharmacologist were implemented. We assessed the efficacy rate of the interventions basing on the changes in consumption of antibiotics (both quantitatively and qualitatively) at surgical departments of a hospital using ATC/DDD methodology. Comparison of the studied outcomes was performed before and after the intervention implementation and between the departments (vascular and abdominal surgery). The consumption of antibacterial agents (ATCJ01) was measured as a number of defined daily doses (DDD) per 100 bed-days (DDD/100 bed-days, indicator recommended by the World Health Organization, WHO) and DDD per 100 treated patients (DDD/100 treated patients)., Results: From 2006 to 2012, a decrease in antibacterial consumption in surgical departments by 188 DDD/100 treated patients was observed. We obtained the opposite results when using an indicator of DDD/100 bed-days (increase by 2.5 DDD/100 bed-days) which could be explained by the dependence on indices of overall hospital work and its changes during the examined period. Observed changes in antibacterial consumption varied in different surgical departments. The most pronounced positive changes were noted in the department of vascular surgery: decrease in total antibacterial consumption by 298 DDD/100 treated patients, decrease in the use of cephalosporins of the III generation from 141 to 38 DDD/100 treated patients. These positive changes were accompanied by the same (low) level of consumption/use of reserve antibiotics. In the department of abdominal surgery, there was no decrease in total antibiotic consumption, as well as in consumption of broad-spectrum cephalosporins of the III generation and fluoroquinolones, and we observed an increase in the use of reserve antibiotics (carbapenems) during the study period. Positive changes in antibiotic consumption were associated with the positive attitude of the manager/head of the department towards interventions: we observed the most pronounced decrease in antibiotic consumption straight after the publication of the administrative order on perioperative antibacterial prophylaxis., Conclusion: The combination of scientific, educational, and methodological interventions is effective for improving antibiotic application. The study results provide the rationale for analyzing the drug consumption using the DDD/100 treated patients measure in addition to the WHO-recommended indicator of DDD/100 bed-days which depends on overall hospital performance.

The cause-of-death-statistics and the release of the body for burial depend primarily on the information contained in the death certificate. How to handle the death certificate has been critically discussed in professional circles again and again. A retrospective review of 1,315 deaths from six acute care hospitals in Germany was carried out with regard to the quality of the death certificates, taking into account information contained in the medical records. The review covered the readability of the death certificate, the quality of the epicrisis, misclassifications relating to the manner of death and the degree of certainty regarding the cause of death. In 93 % of cases (n= 1,221), death certificates were clearly legible. In about half the cases (43.3 %, n=569), the quality of the entries in the "epicrisis" section was good. In 45 % of cases (n= 592), no details were provided in the "epicrisis " section. In 3.9 % (n = 42) of deaths classified as natural, information was given indicating a non-natural death. Most of these deaths occurred in connection with a fall or an injury (n = 27) or possible errors relating to treatment or care (n = 7). Overall, the review showed that clinicians handled the medical death certificate in a competent and careful manner. However, based on the content of the files, the review identified individual and avoidable misclassifications as to the manner of death and improbable causes of death; it also demonstrated that information on the epicrisis is often missing and needs significant improvement.

Background In the Japanese healthcare system, board certification not only maintains the quality of daily practice but is also required for hospitals to receive healthcare reimbursement. To date, no data on the effects of the board certification system in Japanese hospitals have been reported. Objective We performed a survey to clarify the impact of pharmacist certification on the quality of chemotherapy. Setting A nationwide mailing survey was conducted in Japan. Method We surveyed oncology pharmacists from 388 cancer designated hospitals (DHs) and 984 randomly selected general hospitals (GHs). Main outcome measure Multivariate analysis of factors for compliance with standard cancer chemotherapy to clarify the impact of pharmacist certification on the quality of chemotherapy. Results The response rate was 70.6 % (274/388) at the DHs and 43.4 % (428/984) at the GHs. Of the 13 different regimens, 66.1 % (181/274) of DHs and 64.7 % (277/428) of GHs reported having experienced either improper doses or intervals of drug administration. The median number of improper regimens was 1 at both the DHs (range 0-15) and GHs (range 0-22). We identified two groups of hospitals, those with two or more improper regimens and those with one improper regimen or less. Univariate analysis showed significant differences in the number of DHs (p < 0.01), performance of more than 10 chemotherapies per day (p < 0.05), presence of more than 400 beds (p < 0.01) and the professional qualifications of oncology pharmacists or medical oncologists. From multivariate analysis, significant differences were observed in certifications from the Japanese Society of Pharmacy Healthcare and Sciences certified Senior Oncology Pharmacist (odds ratio 0.29, p < 0.01) and the Japanese Society of Medical Oncology certified oncologist (odds ratio 0.48, p < 0.01). Conclusion Board certification was more prevalent in the designated (cancer specialist) hospitals than general hospitals and adherence to appropriate therapy was better when the DH was involved. Board certification was shown to be beneficial in terms of adherence to adequate chemotherapy.

Unlabelled: We sought to describe the practice of pediatric nuclear medicine at general hospitals in the United States and to assess the impact of dose awareness campaigns such as Image Gently., Methods: A web-based survey was developed that requested information regarding hospital type, whether the hospital practices pediatric nuclear medicine, and the hospital's method for determining the administered activity for children. The survey invitation was emailed to a sample of general hospitals with more than 300 beds, excluding dedicated pediatric, veterans, psychiatric, and rehabilitation hospitals. Data were collected for 5 procedures performed on children: (99m)Tc-methylene diphosphate (MDP) bone scans, (99m)Tc-mercaptoacetyltriglycine (MAG3) renograms, (99m)Tc-dimercaptosuccinic acid (DMSA) renal cortical scans, (99m)Tc-based hepatobiliary scans, and (18)F-FDG PET scans. The sites reported dosage by weight (MBq/kg), minimum and maximum dosages, and the activities that they would administer to 2 hypothetical patients: a 5-y-old boy (20 kg, 110 cm tall) and a 10-y-old girl (30 kg, 140 cm tall)., Results: The invitation was delivered to 196 sites, with 121 (61.7%) responding. Eighty-two hospitals (67.8%) performed nuclear medicine on children. All sites scaled administered activity for children, mostly by body weight. Also, 82.4% of sites indicated they were familiar with Image Gently, 57.1% were familiar with the 2010 North American consensus guidelines for children, and 54.9% altered their protocols because of the guidelines. The median value for parameters defined by the guidelines was equal to the guideline-recommended value for all procedures. More than 50% of the sites-particularly those familiar with the guidelines-were compliant with the guidelines regarding both the acquisition parameters and the administered activities for the 2 hypothetical patients. However, there remained a wide variation in practice, sometimes by more than a factor of 10, for sites not familiar with the guidelines., Conclusion: Image Gently and the North American guidelines have had a substantial impact on pediatric nuclear medicine practice in the United States. However, a wide variation in practice still exists, particularly for sites not familiar with the guidelines. Further promotion and dissemination of the guidelines and best practice are still necessary., (© 2016 by the Society of Nuclear Medicine and Molecular Imaging, Inc.)

Aim: Italian national guidelines on pain management were published in 2010, but there is little information on how effective pain management is in paediatric emergency care, with other countries reporting poor levels. Using headache as an indicator, we described pain assessment in Italian emergency departments and identified predictors of algometric scale use., Methods: All Italian paediatric and maternal and child hospitals participated, plus four general hospitals. Data on all children aged 4-14 years admitted during a one-month period with headache as their chief complaint were abstracted from clinical records. Multivariable analyses identified predictors of algometric assessment, taking into account the cluster study design., Results: We studied 470 admissions. During triage, pain was assessed using a standardised scale (41.5%), informally (15.5%) or was not recorded (42.9%). Only 32.1% of the children received analgesia in the emergency department. The odds ratios for predictors of algometric assessment were non-Italian nationality (3.6), prehospital medication (1.8), admission to a research hospital (7.3) and a more favourable nurses-to-admissions ratio of 10.8 for the highest versus lowest tertile., Conclusion: Despite national guidelines, paediatric pain assessment in Italian emergency care was suboptimal. Hospital variables appeared to be stronger predictors of adequate assessment than patient characteristics., (©2016 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Neutropenic sepsis is a life-threatening condition with mortality rates reported to range between 2 and 21% in adults. It can occur following chemotherapy treatment, due to disease (such as haematological conditions affecting the bone marrow) and in patients on disease-modifying agents (such as patients receiving methotrexate for rheumatoid arthritis). Appropriate emergency treatment is essential and achieving intravenous antibiotic door-to-needle time of less than 1 hour is a key target. Shortfalls in the management of patients presenting to teams with limited expertise in this area were identified in the National Confidential Enquiry into Patient Outcome and Death report in 2008, leading to recommendations including the need for an acute oncology service (AOS) at all hospitals with either an emergency department or medical admissions unit. Practice at Weston General Hospital has been audited at three time points since 2008 (in 2008, 2011 and 2013-14) during which there have been several service developments relevant to the management of neutropenic sepsis, including the introduction of an AOS in June 2013. The percentage of patients in which intravenous antibiotic 1-hour door-to-needle time was achieved has improved from 14% (2008) to 31% (2011) to 79% (2013-14) and neutropenic sepsis mortality has decreased from 39% (2008) to 14% (2011) to 0% (2013-14)., (© Royal College of Physicians 2015. All rights reserved.)

Background: The 2011 Appropriate Use Criteria (AUC) were developed by the American Society of Echocardiography (ASE) to provide guidance for referring physicians in response to growing concerns about unnecessary transthoracic echocardiogram (TTE) requests. When applied in multiple centres overseas, the rate of inappropriate referrals was as high as 22%., Aim: To assess the applicability of, and the level of adherence to the 2011 AUC in an Australian regional hospital where the AUC have not been tested systematically., Methods: A retrospective analysis of 1000 inpatient and outpatient TTE referrals was conducted between January 2014 and June 2014 at Bendigo Hospital, a major regional referral hospital., Results: Ninety-eight percent of the TTE referrals were classifiable. The most common indication for ordering TTE was to evaluate symptoms potentially related to a cardiac aetiology. Of the classifiable referrals, 77% were appropriate, 20.3% were inappropriate and 2.7% were uncertain. The most common inappropriate indications were routine surveillance of the left ventricular (LV) function in stable chronic cardiac conditions and routine perioperative evaluation of the LV function with no symptoms or signs of cardiovascular disease. Inappropriate referrals were significantly more frequent in outpatients compared with inpatients (24.4% vs 9.6%, P < 0.001)., Conclusion: This study provides a novel insight into the ordering of TTEs in regional Australia. In this study, one in five referrals had an inappropriate indication and could be avoided. This may have significant implications for healthcare resources in regional centres, and strategies to reduce inappropriate echocardiography ordering need to be implemented., (© 2015 Royal Australasian College of Physicians.)

Introduction: Service quality assessments have assumed increasing importance in the last two decades. They are useful in identifying gaps in services been provided with the ultimate aim of guaranteeing quality assurance. The objective of this study was to assess the client perception of service quality at the outpatient clinics of Randle General hospital, Lagos., Methods: A descriptive cross sectional study was conducted from March to May 2013. A multistage sampling technique was used to select respondents and data was collected with the aid of modified SERVQUAL questionnaires. The data was analysed with aid of EPI-INFO 2002 and statistical significance was set at a P value 0.05 for statistical significance., Results: Total of 400 respondents were interviewed. The mean age was 40 years with a standard deviation of 15.2 yrs. The highest mean score of 4.35 out of a possible maximum of 5 was recorded in assurance domain while the lowest mean score of 4.00 was recorded in the responsiveness domain. The overall mean score of all the domains was 4.20 with standard deviation of 0.51. Overall majority (80.8%) of respondents rated the overall service quality as good/ very good. After linear regression, the assurance domain was the most important predictor of the overall perceived service quality (p< 0.001)., Conclusion: The overall perceived service quality was good. The major deficiencies were in the responsiveness domain and especially the waiting time. The hospital management should implement measures to improve the responsiveness of services by ensuring prompt delivery of services.

Introduction: Improvement of the work environment and staff training are health promotion strategies that can contribute to improving the supply of health care. This study evaluated the effects of reorganization of health services on antenatal care (ANC) activities., Materials and Methods: A cross-sectional study was conducted over a period of 4 months in the ANC unit of Marcory General Hospital in Abidjan. The study population was health workers in charge of ANC and pregnant women attending the health facility. Self-administered questionnaires and observation sheets were used to collect data that were analysed with Epi Info 3.5.1 software. results: After reorganization, health workers said they were satisfied with the work environment and the care provided in 91% and 96.9% of cases, respectively. These results were confirmed by all pregnant respondents (100%) attending the centre, who said they were satisfied with the quality of care received. This could explain the ANC 4 coverage rate, which increased from 39.4% in 2010 to 56.7% in 2012 and tetanus vaccination coverage which increased from 59.4% to 87.5%, although the waiting time was still too long., Conclusion: This study showed an increase of ANC activity indicators, such as ANC 4 and tetanus vaccination coverage rate, after reorganization of health care services. This strategy could be an opportunity to strengthen ANC services.

Introduction: The aim of this study was to evaluate the reduction in costs and the increase in time devoted to the patient, by applying Lean Healthcare methodology., Material and Methods: A multidisciplinary team was formed, setting up three potential areas for improvement by performing a diagnostic process, including the storage and standardization of materials, and professional tasks in the therapeutic areas, by implementing three Lean tools: kanban, 5S and 2P., Results: Stored material costs decreased by 43%, the cost of consumables per patient treated by 19%, and time dedicated to patient treatment increased by 7%., Conclusions: The processes were standardized and "muda" (wastefulness) was eliminated, thus reducing costs and increasing the value to the patient. All this demonstrates that it is possible to apply tools of industrial origin to the health sector, with the aim of improving the quality of care and achieve maximum efficiency., (Copyright © 2014 SECA. Published by Elsevier Espana. All rights reserved.)

Background and Purpose: The number of certified primary stroke centers (PSCs) have increased dramatically during the past decade in the United States We aimed to understand the factors affecting PSC distribution in the United States, including the impact of state stroke legislation., Methods: PSCs certified by national organization or state until December 2013 were searched from available databases. The proportion of PSC among short-term general hospitals in each state was calculated and factors affecting its distribution were analyzed., Results: By the end of 2013, the proportion of PSC varied from 4% to 100% among the 50 states and District of Columbia. The 18 states that had legislation in designating stroke centers and regulating stroke triage had higher PSC percentages (median, 43%; range, 13%-100%) than the remaining states (median, 13%; range, 4%-75%; P<0.001). State stroke legislation, urbanization, state economic output, and larger hospital size independently increased the likelihood of a hospital to be stroke certified. From 2009 to 2013, states with stroke legislation had greater increase of PSC percentages when compared with the states without legislation (median increase, 16% versus 6%; P=0.0067). Among the 1505 stroke centers, 74% were certified by the Joint Commission, 20% by state, and 6% by other organizations. Stroke centers certified only by state were smaller in size by hospital bed count compared with those certified by the Joint Commission (P<0.001)., Conclusions: State stroke legislation, a generalizable intervention, increased the number of certified stroke centers in the United States, potentially improving accessibility of standardized care for patients with acute ischemic stroke., (© 2015 American Heart Association, Inc.)