A case study of lean digital transformation through robotic process automation in healthcare.

Under Taiwan's National Health Insurance (NHI) system, it's crucial for all healthcare providers to accurately submit medical expense claims to the National Health Insurance Administration (NHIA) to avoid incorrect deductions. With changes in healthcare policies and adjustments in hospital management strategies, the complexity of claiming rules has resulted in hospitals expending significant manpower and time on the medical expense claims process. Therefore, this study utilizes the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) management approach to identify wasteful and non-value-added steps in the process. Simultaneously, it introduces Robotic Process Automation (RPA) tools to replace manual operations. After implementation, the study effectively reduces the process time by 380 min and enhances Process Cycle Efficiency (PCE) from 69.07 to 95.54%. This research validates a real-world case of Lean digital transformation in healthcare institutions. It enables human resources to be allocated to more valuable and creative tasks while assisting hospitals in providing more comprehensive and patient-centric services.

Incidence and Factors Associated with Falls in Older People in a Long-Term Care Facility: A Prospective Study in Taiwan.

BACKGROUND: The effectiveness of applying a fall-risk assessment to prevent falls in residents of long-term care facilities has not been investigated. METHODS: This prospective study enrolled elderly residents in a long-term care facility in Taiwan. Caregivers were provided with a health-status assessment and fall-risk data to enhance their fall-prevention practices. A multivariate analysis was performed to identify the factors associated with falls. RESULTS: A total of 123 subjects, including 68 and 55 for general and nursing-care models, respectively, were assessed. Their health status and risk of falls were provided to the care units to enhance their fall-prevention practices. Subjects in the nursing-care model had more dementia and more prescribed medications, worse physiologic conditions, and higher fall risk. Of them, 28 (23%) had subsequent falls. A univariate analysis showed that those with and without falls were similar in demographic characteristics, prescribed medications, physiologic function, and fall risk. There was a tendency for more falls in the nursing-care model residents (accounting for 61% of those who fell; p = 0.053). A regression analysis showed that gender (beta = 1.359; 95% confidence interval = 0.345-2.374; p = 0.010) and NPI score (beta = 0.101; 95% CI = 0.001-0.200; p = 0.047) were associated with the risk of falls. CONCLUSION: Residents at the long-term care facility had a significant risk of falls despite knowledge of their fall risk and the implementation of preventive measures. In this context of being aware of the risk, gender, and psychiatric symptoms were significantly associated with falls. Caregivers at long-term care facilities should implement further measures to prevent falls based on behavioral and psychological symptoms.

Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review.

Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.

Immunometabolic features of natural killer cells are associated with infection outcomes in critical illness.

Immunosuppression increases the risk of nosocomial infection in patients with chronic critical illness. This exploratory study aimed to determine the immunometabolic signature associated with nosocomial infection during chronic critical illness. We prospectively recruited patients who were admitted to the respiratory care center and who had received mechanical ventilator support for more than 10 days in the intensive care unit. The study subjects were followed for the occurrence of nosocomial infection until 6 weeks after admission, hospital discharge, or death. The cytokine levels in the plasma samples were measured. Single-cell immunometabolic regulome profiling by mass cytometry, which analyzed 16 metabolic regulators in 21 immune subsets, was performed to identify immunometabolic features associated with the risk of nosocomial infection. During the study period, 37 patients were enrolled, and 16 patients (43.2%) developed nosocomial infection. Unsupervised immunologic clustering using multidimensional scaling and logistic regression analyses revealed that expression of nuclear respiratory factor 1 (NRF1) and carnitine palmitoyltransferase 1a (CPT1a), key regulators of mitochondrial biogenesis and fatty acid transport, respectively, in natural killer (NK) cells was significantly associated with nosocomial infection. Downregulated NRF1 and upregulated CPT1a were found in all subsets of NK cells from patients who developed a nosocomial infection. The risk of nosocomial infection is significantly correlated with the predictive score developed by selecting NK cell-specific features using an elastic net algorithm. Findings were further examined in an independent cohort of COVID-19-infected patients, and the results confirm that COVID-19-related mortality is significantly associated with mitochondria biogenesis and fatty acid oxidation pathways in NK cells. In conclusion, this study uncovers that NK cell-specific immunometabolic features are significantly associated with the occurrence and fatal outcomes of infection in critically ill population, and provides mechanistic insights into NK cell-specific immunity against microbial invasion in critical illness.

Aerosol particle dispersion in spontaneous breathing training of oxygen delivery tracheostomized patients on prolonged mechanical ventilation.

BACKGROUND: Tracheostomized patients undergoing liberation from mechanical ventilation (MV) are exposed to the ambient environment through humidified air, potentially heightening aerosol particle dispersion. This study was designed to evaluate the patterns of aerosol dispersion during spontaneous breathing trials in such patients weaning from prolonged MV. METHODS: Particle Number Concentrations (PNC) at varying distances from tracheostomized patients in a specialized weaning unit were quantified using low-cost particle sensors, calibrated against a Condensation Particle Counter. Different oxygen delivery methods, including T-piece and collar mask both with the humidifier or with a small volume nebulizer (SVN), and simple collar mask, were employed. The PNC at various distances and across different oxygen devices were compared using the Kruskal-Wallis test. RESULTS: Of nine patients receiving prolonged MV, five underwent major surgery, and eight were successfully weaned from ventilation. PNCs at distances ranging from 30 cm to 300 cm showed no significant disparity (H(4) = 8.993, p = 0.061). However, significant differences in PNC were noted among oxygen delivery methods, with Bonferroni-adjusted pairwise comparisons highlighting differences between T-piece or collar mask with SVN and other devices. CONCLUSIONS: Aerosol dispersion within 300 cm of the patient was not significantly different, while the nebulization significantly enhances ambient aerosol dispersion in tracheostomized patients on prolonged MV.

Monitoring the performance of a dedicated weaning unit using risk-adjusted control charts for the weaning rate in prolonged mechanical ventilation.

BACKGROUND: Weaning rate is an important quality indicator of care for patients with prolonged mechanical ventilation (PMV). However, diverse clinical characteristics often affect the measured rate. A risk-adjusted control chart may be beneficial for assessing the quality of care. METHODS: We analyzed patients with PMV who were discharged between 2018 and 2020 from a dedicated weaning unit at a medical center. We generated a formula to estimate monthly weaning rates using multivariate logistic regression for the clinical, laboratory, and physiologic characteristics upon weaning unit admission in the first two years (Phase I). We then applied both multiplicative and additive models for adjusted p-charts, displayed in both non-segmented and segmented formats, to assess whether special cause variation existed. RESULTS: A total of 737 patients were analyzed, including 503 in Phase I and 234 in Phase II, with average weaning rates of 59.4% and 60.3%, respectively. The p-chart of crude weaning rates did not show special cause variation. Ten variables from the regression analysis were selected for the formula to predict individual weaning probability and generate estimated weaning rates in Phases I and II. For risk-adjusted p-charts, both multiplicative and additive models showed similar findings and no special cause variation. CONCLUSION: Risk-adjusted control charts generated using a combination of multivariate logistic regression and control chart-adjustment models may provide a feasible method to assess the quality of care in the setting of PMV with standard care protocols.

Automatic tube compensation for liberation from prolonged mechanical ventilation in tracheostomized patients: A retrospective analysis.

BACKGROUND: To analyze the predictability of an automatic tube compensation (ATC) screening test compared with the conventional direct liberation test performed before continuous oxygen support for MV liberation. METHODS: This retrospective study analyzed tracheostomized patients with prolonged MV in a weaning unit of a medical center in Taiwan. In March 2020, a four-day ATC test to screen patient eligibility for ventilator liberation was implemented, intended to replace the direct liberation test. We compared the predictive accuracy of these two screening methods on the relevant outcomes in the two years before and one year after the implementation of this policy. RESULTS: Of the 403 cases, 246 (61%) and 157 (39%) received direct liberation and ATC screening tests, respectively. These two groups had similar outcomes: successful weaning upon leaving the Respiratory Care Center (RCC), success on day 100 of MV, success at hospital discharge, and in-hospital survival. Receiver operating characteristic curve analysis showed that the ATC screening test had better predictive ability than the direct liberation test for RCC weaning, discharge weaning, 100-day weaning, and in-hospital survival. CONCLUSION: This closed-circuit ATC screening test before ventilator liberation is a feasible and valuable method for screening PMV patients undergoing ventilator liberation in the pandemic era. Its predictability for a comparison with the open-circuit oxygen test requires further investigation.

Gender differences in the intention to withhold life-sustaining treatments involving severe dementia for self and on behalf of parent or spouse.

BACKGROUND: Few studies have explored gender differences in the attitudes toward advanced care planning and the intention to withhold life-sustaining treatments (LSTs) involving severe dementia in Asian countries. We examined gender differences in the attitude toward the Patient Autonomy Act (PAA) in Taiwan and how the gender differences in these attitudes affect the intention to withhold LSTs for severe dementia. We also investigated self-other differences in the intention to withhold LSTs between genders. METHODS: Between March and October 2019, a structured questionnaire was distributed to hospitalized patients' family members through face-to-face contact in an academic medical center. Exploratory factor analysis and independent and paired-sample t-tests were used to describe gender differences. Mediation analyses controlled for age, marital status, and education level were conducted to examine whether the attitude toward the PAA mediates the gender effect on the intention to withhold LSTs for severe dementia. RESULTS: Eighty respondents filled out the questionnaire. Exploratory factor analysis of the attitude toward the PAA revealed three key domains: regarding the PAA as (1) promoting a sense of abandonment, (2) supporting patient autonomy, and (3) contributing to the collective good. Relative to the men, the women had lower average scores for promoting a sense of abandonment (7.48 vs. 8.94, p = 0.030), higher scores for supporting patient autonomy (8.74 vs. 7.94, p = 0.006), and higher scores for contributing to the collective good (8.64 vs. 7.47, p = 0.001). Compared with the women, the men were less likely to withhold LSTs for severe dementia (15.84 vs. 18.88, p = 0.01). Mediation analysis revealed that the attitude toward the PAA fully mediated the gender differences in the intention to withhold LSTs for severe dementia. Both men and women were more likely to withhold LSTs for themselves than for their parents. Compared with the women, the men were more likely to withhold resuscitation for themselves than for their parents (p = 0.05). Women were more likely to agree to enteral tube feeding and a tracheotomy for their husbands than for themselves; men made consistent decisions for themselves and their wives in those LST scenarios. CONCLUSION: Gender influences the attitude toward advanced care planning and consequently affects the intention to withhold LSTs, indicating that there may be a difference in how men and women perceive EOL decision-making for severe dementia in Taiwan. Further studies are warranted.

Improving the Process of Shared Decision-Making by Integrating Online Structured Information and Self-Assessment Tools.

The integration of face-to-face communication and online processes to provide access to information and self-assessment tools may improve shared decision-making (SDM) processes. We aimed to assess the effectiveness of implementing an online SDM process with topics and content developed through a participatory design approach. We analyzed the triggered and completed SDM cases with responses from participants at a medical center in Taiwan. Data were retrieved from the Research Electronic Data Capture (REDCap) database of the hospital for analysis. Each team developed web-based patient decision aids (PDA) with empirical evidence in a multi-digitized manner, allowing patients to scan QR codes on a leaflet using their mobile phones and then read the PDA content online. From July 2019 to December 2020, 48 web-based SDM topics were implemented in the 24 clinical departments of this hospital. The results showed that using the REDCap system improved SDM efficiency and quality. Implementing an online SDM process integrated with face-to-face communication enhanced the practice and effectiveness of SDM, possibly through the flexibility of accessing information, self-assessment, and feedback evaluation.

Effect of implementing decision support to activate a rapid response system by automated screening of verified vital sign data: A retrospective database study.

AIM: Activating a rapid response system (RRS) at general wards requires memorizing trigger criteria, identifying deterioration, and timely notification of abnormalities. We aimed to assess the effect of decision support (DS)-linked RRS activation on management and outcomes. METHODS: We retrospectively analyzed general ward RRS activation cases from 2013 to 2017 and the incidence of cardiopulmonary resuscitations (CPR) from 2013 to 2020. A DS-alerting mechanism was added to the conventional RRS activation process in 2017, with an alert window appearing whenever the system automatically detected any verified abnormal vital sign entry, alerting the nurse to take further action. Logistic and linear regression analyses were used to compare outcomes. RESULTS: We analyzed 27,747 activations and 64,592 DS alerts. RRS activations increased from 3.5 to 30.3 per 1,000 patient-days (P < 0.001) after DS implementation. The first DS activations occurred earlier than conventional ones (-2.9 days, 95% confidence interval = -3.6 to -2.1 days). After adjustment with inverse probability of treatment weighting, main (conventional vs DS-linked activations after implementation) and sensitivity analyses showed that DS activation cases had a lower risk of CPR and in-hospital mortality. Cases with more DS alerts before RRS activation had a higher risk of CPR (P trend = 0.017) and in-hospital mortality (P trend < 0.001). The incidence of CPR at the general ward decreased. CONCLUSION: Implementing a DS mechanism with an automated screening of verified abnormal vital signs linked to RRS activations at general wards was associated with improved practice and timeliness of hospital-wide RRS activations and reduced in-hospital resuscitations and mortality.

End-Expiratory Lung Volumes During Spontaneous Breathing Trials in Tracheostomized Subjects on Prolonged Mechanical Ventilation.

BACKGROUND: The role of end-expiratory lung volume (EELV) during a spontaneous breathing trial (SBT) in patients who were tracheostomized and on prolonged mechanical ventilation is unclear. This study aimed to assess EELV during a 60-min SBT and its correlation with weaning success. METHODS: Enrolled subjects admitted to a weaning unit were measured for EELV and relevant parameters before and after the SBT. RESULTS: Of the 44 enrolled subjects, 29 (66%) were successfully liberated, defined as not needing mechanical ventilation for 5 d. The success group had fewer subjects with chronic kidney disease (41% vs 73%, P = .044), stronger mean ± SD maximum inspiratory pressure (41.6 ± 10.4 vs 34.1 ± 7.1 cm H2O; P = .02) and mean ± SD maximum expiratory pressure (46.9 ± 11.7 vs 35.3 ± 16.9 cm H2O; P = .01) versus the failure group. Toward the end of the SBT, the success group had a significant increase in the mean ± SD EELV (before vs after: 1,278 ± 744 vs 1,493 ± 867 mL; P = .040) and a decrease in the mean ± SD rapid shallow breathing index (83.8 ± 39.4 vs 66.3 ± 29.4; P = .02), whereas there were no significant changes in these 2 parameters in the failure group. The Cox regression analysis showed that, at the beginning of SBT, a greater difference between EELV with a PEEP of 0 cm H2O and with a PEEP of 5 cm H2O was significantly correlated to a higher likelihood of weaning success. Toward the end of the SBT, a greater EELV level at a PEEP of 0 cm H2O was also correlated with weaning success. Also, the greater difference of EELV at a PEEP of 0 cm H2O between the beginning and the end of the SBT was also correlated with a shorter duration to weaning success. CONCLUSIONS: The change in EELV during a 60-min SBT may be of prognostic value for liberation from prolonged mechanical ventilation in patients who had a tracheostomy. Our findings suggest a model to understand the underlying mechanism of failure of liberation from mechanical ventilation in these patients.

In-Hospital Patient Safety Events, Healthcare Costs and Utilization: An Analysis from the Incident Reporting System in an Academic Medical Center.

The possible association of patient safety events (PSEs) with the costs and utilization remains a concern. In this retrospective analysis, we investigated adult hospitalizations at a medical center between 2010 and 2015 with or without reported PSEs. Administrative and claims data were analyzed to compare the costs and length of stay (LOS) between cases with and without PSEs of the three most common categories during the first 14 days of hospitalization. Two models, including linear regression and propensity score-matched comparison, were performed for each reference day group of hospitalizations. Of 14,181 PSEs from 424,635 hospitalizations, 69.8% were near miss or no-harm events. Costs and LOS were similar between fall cases and controls in all of the 14 reference days. In contrast, for cases of tube and line events and controls, there were consistent differences in costs and LOS in the majority of the reference days (86% and 57%, respectively). Consistent differences were less frequently seen for medication events and control events (36% and 43%, respectively). Our study approach of comparing cases with PSEs and those without any PSE showed significant differences in costs and LOS for tube and line events, and medication events. No difference in cost or LOS was found regarding fall events. Further studies exploring adjustments for event risks and harm-oriented analysis are warranted.

Kinetics of oxygen uptake during unassisted breathing trials in prolonged mechanical ventilation: a prospective pilot study.

Few studies have investigated the measurement of oxygen uptake ([Formula: see text]O2) in tracheostomized patients undergoing unassisted breathing trials (UBTs) for liberation from mechanical ventilation (MV). Using an open-circuit, breath-to-breath method, we continuously measured [Formula: see text]O2 and relevant parameters during 120-min UBTs via a T-tube in 49 tracheostomized patients with prolonged MV, and calculated mean values in the first and last 5-min periods. Forty-one (84%) patients successfully completed the UBTs. The median [Formula: see text]O2 increased significantly (from 235.8 to 298.2 ml/min; P = 0.025) in the failure group, but there was no significant change in the success group (from 223.1 to 221.6 ml/min; P = 0.505). In multivariate logistic regression analysis, an increase in [Formula: see text]O2 > 17% from the beginning period (odds ratio [OR] 0.084; 95% confidence interval [CI] 0.012-0.600; P = 0.014) and a peak inspiratory pressure greater than - 30 cmH2O (OR 11.083; 95% CI 1.117-109.944; P = 0.04) were significantly associated with the success of 120-min UBT. A refined prediction model combining heart rate, energy expenditure, end-tidal CO2 and oxygen equivalent showed a modest increase in the area under the receiver operating characteristic curve of 0.788 (P = 0.578) and lower Akaike information criterion score of 41.83 compared to the traditional prediction model including heart rate and respiratory rate for achieving 48 h of unassisted breathing. Our findings show the potential of monitoring [Formula: see text]O2 in the final phase of weaning in tracheostomized patients with prolonged MV.

Identification of quality gaps in healthcare services using the SERVQUAL instrument and importance-performance analysis in medical intensive care: a prospective study at a medical center in Taiwan.

BACKGROUND: Assessing patients' expectations and perceptions of health service delivery is challenging. To understand the service quality in intensive care units (ICUs), we investigated the expected and perceived service quality of ICU care. METHODS: We conducted this study at an ICU of a university-affiliated medical center in Taiwan from April to September 2019. Admitted patients or their family members responded to a questionnaire survey adopted from the SERVQUAL instrument consisting of 22 items in five dimensions. The questionnaire was provided on ICU admission for expectation and before ICU discharge for perception. We analyzed the quality gaps between the surveys and applied important-performance analysis (IPA). RESULTS: A total of 117 patients were included (62.4% males, average age: 65.9 years, average length of stay: 10.1 days, and 76.9% survival to ICU discharge). The overall weighted mean scores for the surveys were similar (4.57 ± 0.81 and 4.58 ± 0.52, respectively). The 'tangibles' dimension had a higher perception than expectation (3.99 ± 0.55 and 4.31 ± 0.63 for expectation and perception, respectively, p < 0.001). IPA showed that most of the items in 'reliability,' 'responsiveness' and 'assurance' were located in the quadrant of high expectation and high perception, whereas most of the items in 'tangibles' and 'empathy' were located in the quadrant of low expectation and low perception. One item (item 1 for 'tangibles') was found in the quadrant of high expectation and low perception. CONCLUSIONS: The SERVQUAL approach and IPA might provide useful information regarding the feedback by patients and their families for ICU service quality. In most aspects, the performance of the ICU satisfactorily matched the needs perceived by the patients and their families.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness.

AIM: Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation. DESIGN AND IMPLEMENTATION: We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including 'VITAL' (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, 'STOP' (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and 'STOP' (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme. RESULTS: The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001). CONCLUSION: The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Association of weaning preparedness with extubation outcome of mechanically ventilated patients in medical intensive care units: a retrospective analysis.

BACKGROUND: Assessment of preparedness of weaning has been recommended before extubation for mechanically ventilated patients. We aimed to understand the association of a structured assessment of weaning preparedness with successful liberation. METHODS: We retrospectively investigated patients with acute respiratory failure who experienced an extubation trial at the medical intensive care units of a medical center and compared the demographic and clinical characteristics between those patients with successful and failed extubation. A composite score to assess the preparedness of weaning, the WEANSNOW score, was generated consisting of eight components, including Weaning parameters, Endotracheal tube, Arterial blood gas analysis, Nutrition, Secretions, Neuromuscular-affecting agents, Obstructive airway problems and Wakefulness. The prognostic ability of the WEANSNOW score for extubation was then analyzed. RESULTS: Of the 205 patients included, 138 (67.3%) patients had successful extubation. Compared with the failure group, the success group had a significantly shorter duration of MV before the weaning attempt (11.2 ± 11.6 vs. 31.7 ± 26.2 days, p < 0.001), more with congestive heart failure (42.0% vs. 25.4%, p = 0.020), and had different distribution of the types of acute respiratory failure (p = 0.037). The failure group also had a higher WEANSNOW score (1.22 ± 0.85 vs. 0.51 ± 0.71, p < 0.001) and worse Rapid Shallow Breathing Index (93.9 ± 63.8 vs. 56.3 ± 35.1, p < 0.001). Multivariate logistic regression analysis showed that a WEANSNOW Score = 1 or higher (OR = 2.880 (95% CI [1.291-6.426]), p = 0.010) and intubation duration >21 days (OR = 7.752 (95% CI [3.560-16.879]), p < 0.001) were independently associated with an increased probability of extubation failure. CONCLUSION: Assessing the pre-extubation status of intubated patients in a checklist-based approach using the WEANSNOW score might provide valuable insights into extubation failure in patients in a medical ICU for acute respiratory failure. Further prospective studies are warranted to elucidate the practice of assessing weaning preparedness.

Maximal expiratory pressure is associated with reinstitution of mechanical ventilation after successful unassisted breathing trials in tracheostomized patients with prolonged mechanical ventilation.

OBJECTIVE: Reinstitution of mechanical ventilation (MV) for tracheostomized patients after successful weaning may occur as the care setting changes from critical care to general care. We aimed to investigate the occurrence, consequence and associated factors of MV reinstitution. METHODS: We analyzed the clinical data and physiological measurements of tracheostomized patients with prolonged MV discharged from the weaning unit to general wards after successful weaning to compare between those with and without in-hospital MV reinstitution within 60 days. RESULTS: Of 454 patients successfully weaned, 116 (25.6%) reinstituted MV at general wards within 60 days; at hospital discharge, 42 (36.2%) of them were eventually liberated from MV, 51 (44.0%) remained MV dependent, and 33 (28.4%) died. Of the 338 patients without reinstitution within 60 days, only 3 (0.9%) were later reinstituted with MV before discharge (on day 67, 89 and 136 at general wards, respectively), and 322 (95.2%) were successfully weaned again at discharge, while 13 (3.8%) died. Patients with MV reinstitution had a significantly lower level of maximal expiratory pressure (PEmax) before unassisted breathing trial compared to those without reinstitution. Multivariable Cox regression analysis showed fever at RCC discharge (hazard ratio [HR] 14.00, 95% confidence interval [CI] 3.2-61.9) chronic obstructive pulmonary disease (HR 2.37, 95% CI 1.34-4.18), renal replacement therapy at the ICU (HR 2.29, 95% CI 1.50-3.49) and extubation failure before tracheostomy (HR 1.76, 95% CI 1.18-2.63) were associated with increased risks of reinstitution, while PEmax > 30 cmH2O (HR 0.51, 95% CI 0.35-0.76) was associated with a decreased risk of reinstitution. CONCLUSIONS: The reinstitution of MV at the general ward is significant, with poor outcomes. The PEmax measured before unassisted breathing trial was significantly associated with the risk of reinstituting MV at the general wards.

Changes in albuminuria during the spontaneous breathing trial: A prospective observational study.

BACKGROUND: We hypothesized urine albumin concentration may detect the early increasing cardiac load during the spontaneous breathing trial (SBT). The purpose of our study is to determine whether the changes in urine albumin concentration before and after the SBT correlate with SBT outcome. METHODS: This prospective observational study was conducted from January 2013 to September 2013. Patients receiving endotracheal tube intubation due to acute respiratory failure were included. Urine albumin concentration was measured upon admission to the intensive care unit, before and after the SBT. RESULTS: A total of 211 patients with respiratory failure were screened. Finally, 69 patients were included for analysis. Among the 69 patients received the SBT, 61 patients passed the SBT while 8 patients didn't. Urine albumin concentration upon admission was 251.00 ± 108.21 mg/g in the SBT success group and 260.87 ± 77.95 mg/g in the SBT failure group (p = 0.97). The mean percent change in urine albumin concentration during the SBT was significantly higher in the SBT failure group (+58.44%) than in the SBT success group (+13.11%) (p = 0.02). Univariable and multivariable logistic regression model showed that the difference of urine albumin concentration before and after the SBT correlated significantly with SBT failure (adjusted OR:1.04, p = 0.01). CONCLUSION: This open label pilot study demonstrates the significant association of the changes in urine albumin concentration with SBT outcome. Further study is warranted to investigate the predictive value of urine albumin concentration.

Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments.

BACKGROUND: Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent. METHODS: We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days. RESULTS: Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001). CONCLUSION: Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.

Reinforcement of Tobacco Control and Reduction in Medical Utilization for Asthma in Taiwan: A Population-Based Study.

Environmental air quality can affect asthma control and the development of overt asthmatic manifestations. In this population-based study, we investigated the effect of reinforcing a smoking ban in Taiwan through the enactment of the Tobacco Hazards and Prevention Act (THPA) on healthcare utilization rate by asthmatics. Analysis was performed based on data relevant to non-hospitalized asthmatic patients with insurance claims between 2005 and 2013 from the National Health Insurance Research Database of Taiwan, reported data on Asian dust storms, and penalty rates for violations of the tobacco ban. Poisson regression showed that the risk for outpatient visits for asthma was lower after enactment of the THPA (RR = 0.98, 95% CI = 0.98-0.99), with a yearly trend of a reduced risk (RR = 0.99, 95% CI = 0.99-1.00), also lower in geographic regions with medium (RR = 0.79, 95% CI = 0.79-0.80) and high (RR = 0.91, 95% CI = 0.91-0.92) penalty rates. Subgroup analysis showed that asthma visit rates were reduced in both male and female groups after the enactment of the THPA. The risk of an asthma ER visit was increased after the enactment of the amended THPA (RR = 1.07, 95% CI = 1.05-1.09), although the yearly trend was not significant (RR = 1.00, 95% CI = 1.00-1.00). The risk of emergency room visits for asthma was significantly reduced in regions with medium (RR = 0.68, 95% CI = 0.68-0.69) and high (RR = 0.75, 95% CI = 0.74-0.76) penalty rates. Subgroup analysis showed that the visit rates were similar in both male and female groups. The effectiveness of reinforcing the smoking ban warrants further policies aimed at further reducing passive smoking.