Estratégias de liderança dos enfermeiros em hospitais universitários frente às mudanças no cuidado na COVID-19: sob a perspectiva do modelo de Kotter / Leadership strategies of nurses in university hospitals in the face of changes in care during COVID-19: from the perspective of Kotter's model

Este estudo objetivou analisar as estratégias de liderança dos enfermeiros frente às mudanças na gestão do cuidado durante o enfrentamento da COVID-19 em hospitais universitários federais no Brasil, sob a perspectiva do modelo de John Kotter. Trata-se de uma pesquisa multicêntrica, de natureza qualitativa, do tipo analítico, subsidiada pela abordagem dos conceitos do modelo de mudanças de John Kotter. E está integrada ao projeto matriz, multicêntrico nacional, cuja denominação é "Avaliação do Cuidado de Enfermagem a Pacientes com COVID-19 em Hospitais Universitários Brasileiros". Para tanto, o cenário foi composto por 10 hospitais universitários, no Brasil, que representaram as cinco regiões brasileiras: Norte, Nordeste, Sul, Sudeste e Centro-Oeste. Após o parecer favorável pelo Comitê de Ética em Pesquisa, aconteceu a coleta de dados, no período de março de 2021 a abril de 2022, mediante a técnica de entrevista semiestruturada. E constituiram-se como participantes da pesquisa 139 enfermeiros atuantes no atendimento ao paciente com COVID-19 desses 10 hospitais universitários. As entrevistas foram realizadas em formato virtual pelo Google Meet, e de forma presencial, devido à situação da COVID-19 ainda delicada no momento das entrevistas, e essas foram agendadas em contato prévio com os participantes. Após, realizou-se a análise dos dados, com o apoio do Sofware webQDA, pela análise de conteúdo de Bardin e conduzida pelo referencial teórico metodológico adotado neste estudo, que foi o modelo de mudanças de oito etapas de John Kotter. Os resultados, portanto, foram oportunos de serem relacionados pela perspectiva do modelo de Kotter, revelando que os enfermeiros-líderes demonstraram determinação para mitigar o Senso de Urgência oriundo da COVID-19, em questões como: frente à provisão de recursos materiais, por exemplo, dos EPIs; processos seletivos para a contratação de profissionais de saúde; novos protocolos ou mudanças nos já existentes, entre outros. Diante de uma Coalização Administrativa, destacaram-se os elementos de confiança e respeito do enfermeiro e sua equipe de enfermagem. Os enfermeiros-líderes demonstraram criarem uma Visão e Estratégias inspiradoras de forma ágil, para contribuírem com a qualidade na assistência. A Comunicação foi um elemento que emergiu como fortalecedor para proporcionar confiança e um bom trabalho em equipe, de maneira clara e segura. O Empowerment também surgiu frente às capacitações que os enfermeiros-líderes realizaram, na busca por novos aprendizados acerca da COVID-19 e treinamento de sua equipe de enfermagem. As Conquistas a curto prazo se destacaram pela implementação das videochamadas, podendo aproximar o paciente de seus familiares. A Consolidação dos Ganhos e os Novos Métodos de Cultura foram evidenciados pelos aprendizados de novos conhecimentos diante do enfrentamento de uma pandemia. Conclui-se que pesquisas que abordem a liderança na enfermagem são essenciais para o desenvolvimento do enfermeiro-líder e, se essas abarcarem instrumentos que auxiliem este profissional no papel de liderança, serão valiosas para contribuírem com as melhorias na qualidade da assistência. Sugere-se a realização de novas pesquisas acerca da abordagem da liderança de enfermeiros, que possam sinalizar novas ferramentas para facilitar a sua prática como líderes e no processo de tomada de decisões, e, assim, sugere-se a aplicação do modelo de mudanças de oito etapas em organizações de saúde.(AU)

This study aimed to analyze nurses' leadership strategies in the face of changes in care management during the COVID-19 pandemic in federal university hospitals in Brazil from the perspective of John Kotter's model. This is a multi-center, qualitative, analytical study based on the concepts of John Kotter's model of change. It is part of a national multicenter matrix project called "Evaluation of Nursing Care for Patients with Covid-19 in Brazilian University Hospitals". To this end, the scenario consisted of 10 University Hospitals in Brazil, representing the five Brazilian regions of North, Northeast, South, Southeast and Center-West. After being approved by the research ethics committee, data was collected from March 2021 to April 2022 using a semi-structured interview technique. The research participants were 139 nurses working with COVID-19 patients at these 10 university hospitals. The interviews were conducted virtually via Google Meet, and in person, due to the still delicate COVID-19 situation at the time of the interviews, these were scheduled in advance contact with the participants. The data was then analyzed using webQDA software, Bardin's content analysis and the methodological theoretical framework adopted in this study, which was John Kotter's eight-stage model of change. The results, therefore, were timely to be related from the perspective of Kotter's model, revealing that nurse leaders showed determination to mitigate the Sense of Urgency arising from COVID-19, such as issues regarding the provision of material resources, for example, EPI´s; selection processes for hiring health professionals; new protocols or changes to existing ones, among others. In the face of an Administrative Coalition, the elements of trust and respect for the nurse and his or her nursing team stood out. The nurse leaders demonstrated that they created an inspiring Vision and Strategies in an agile way to contribute to quality care. Communication was an element that emerged as an enabler of trust and good teamwork, in a clear and safe manner. Empowerment also emerged in the face of the training that the nurse leaders undertook in the search for new learning about COVID-19 and training for their nursing team. Short-term Achievements were the implementation of video calls, which brought patients closer to their families. The Consolidation of gains and New methods of culture were evidenced by the learning of new knowledge in the face of a pandemic. It can be concluded that research into leadership in nursing is essential for the development of nurse leaders, and if it includes tools that help these professionals in their leadership role, it will be valuable in contributing to improvements in the quality of care. It is suggested that further research be carried out into the approach to nurse leadership, which could point to new tools to facilitate their practice as leaders and in the decision-making process, as well as suggesting the application of the eight-stage change model in healthcare organizations.(AU)

Impact of the COVID-19 pandemic on clinical research in hospitals: observational study in the first epicenter of the epidemic during the general lockdown in France.

OBJECTIVE: The COVID-19 epidemic has had a strong impact on the entire healthcare sector in France with priority being given to research for new therapeutic options for COVID-19. Nevertheless, continuity of care for patients suffering from other diseases represents a crucial challenge, and clinical research is no exception in this respect. This study aims to assess the impact of the strict Covid-19 lockdown on non-Covid-19 clinical research in the French University Hospital of Strasbourg. MATERIALS AND METHODS: Clinical research activity (non-Covid-19) from the point of view of pharmacy department was estimated and compared to the pre-lockdown period. The impact of lockdown was assessed through five indicators: site initiation visits, the initiation of experimental therapies in non-Covid-19 patients, the delivery of non-Covid-19 investigational medical products, the number of drug shipments to patients' homes, and the number of monitoring or closure visits. RESULTS: During the study period, the number of site initiation visits decreased by 90%, total inclusions by 72%, and delivery of investigational medical products by 30%. During the lockdown period, 15 treatments were sent to patients' homes. Monitoring activity decreased by 98%. CONCLUSIONS: Although the COVID-19 outbreak has created an incredible momentum in the field of clinical research, research not focused on SaRS-CoV-2 has suffered greatly from this situation. The impact on patients is difficult to estimate but should be further investigated.

The challenge of maintaining necessary vascular and endovascular services at a referral center in Northern Italy during the COVID-19 outbreak.

OBJECTIVES: The Padova Hospital Vascular Surgery Division is located in Veneto, one of the area of the Northern Italy most hit by the Coronavirus disease 2019 outbreak. The aim of this paper is to describe the protocols adopted and to evaluate their impact during the acute phase of Coronavirus spread, focusing on the management of elective and urgent/emergent surgery, outpatients activity, and also health staff preservation from intra-hospital Coronavirus disease 2019 infection. METHODS: Several measures were progressively adopted in the Padova University Hospital to front the Coronavirus disease 2019 outbreak, with a clear strong asset established by 9 March 2020, after the Northern Italy lockdown. Since this date, the Vascular Surgery Unit started a "scaled-down" activity, both for elective surgical procedures and for the outpatient Clinical activities; different protocols were developed for health preservation of staff and patients. We compared a two months period, 30 days before and 30 days after this time point. In particular, emergent vascular surgery was regularly guaranteed as well as urgent surgery (to be performed within 24 h). Elective cases were scheduled for "non-deferrable" pathology. A swab test protocol for COVID-19 was applied to health-care professionals and hospitalized patients. RESULTS: The number of urgent or emergent aortic cases remained stable during the two months period, while the number of Hospital admissions via Emergency Room related to critical limb ischemia decreased after national lockdown by about 20%. Elective vascular surgery was scaled down by 50% starting from 9 March; 35% of scheduled elective cases refused hospitalization during the lockdown period and 20% of those contacted for hospitalization where postponed due to fever, respiratory symptoms, or close contacts with Coronavirus disease 2019 suspected cases. Elective surgery reduction did not negatively influence overall carotid or aortic outcomes, while we reported a higher major limb amputation rate for critical limb ischemia (about 10%, compared to 4% for the standard practice period). We found that 4 out of 98 (4%) health-care providers on the floor had an asymptomatic positive swab test. Among 22 vascular doctors, 3 had a confirmed Coronavirus disease 2019 infection (asymptomatic); a total of 72 swab were performed (mean = 3.4 swab/person/month) during this period; no cases of severe Coronavirus disease 2019 (deaths or requiring intensive care treatment) infection were reported within this period for the staff or hospitalized patients. CONCLUSIONS: Elective vascular surgery needs to be guaranteed as possible during Coronavirus disease 2019 outbreak. The number of truly emergent cases did not reduce, on the other side, Emergency Room accesses for non-emergent cases decreased. Our preliminary results seem to describe a scenario where, if the curve of the outbreak in the regional population is flattened, in association with appropriate hospitals containment rules, it may be possible to continue the activity of the Vascular Surgery Units and guarantee the minimal standard of care.

Analgesic consumption evolution at the emergency department of a university hospital (2006-2017): a defined daily doses based analysis.

OBJECTIVE: Pain management in the emergency department (ED) is a key issue that must be regularly evaluated. Practice evaluation gold standard remains patient file analysis, but is highly time consuming. The aim of this study is to evaluate the interest of a defined daily dose (DDD) based analysis in the evaluation of pain management in the ED. METHODS: A local indicator was elaborated based on the DDD concept: the defined dose per admission (DDA). Unlike the DDD that corresponds to a standardised total dose administered over a day, the DDA represents the average total dose administrated to a patient throughout the stay in the ED. A DDA was assigned to every analgesic, from step 1 to step 3. Oral and injectable forms were studied, but transdermal forms were not considered. DDA values were assimilated to the existing DDDs when these were officially established by the WHO. When values were not defined by the WHO, mean values observed in local practice were selected. Annual numbers of patients admitted to the ED and quantities of each analgesic supplied by the pharmacy ward were annually extracted from respective data files. Paediatric patients being treated at a specific separate ED, only adults were considered throughout the study. Raw quantities of analgesics used each year were converted to their equivalent amounts in DDA, and then expressed in numbers of DDA per 100 admissions (DDA/100A). This indicator allowed us to describe relative evolutions of analgesics prescriptions from 2006 to 2017. RESULTS: Analgesic overall use rose from 18.4 to 30.2 DDA/100A between 2006 and 2017, representing a prescription increase of 64%. Throughout the study, step 1 analgesics rose from 10.8 to 19.3 DDA/100A (+79%), step 3 from 1.8 to 5.4 (+200%) and step 2 remained stable around 5.6 DDA/100A. The integration of orodispersible paracetamol tablets in 2013 allowed us to halve the consumption of injectable paracetamol in the long term and had no effect on classic paracetamol oral forms such as tablets or capsules. Tramadol increased from 41% to 78% among step 2 analgesics after the withdrawal of dextropropoxyphene in 2011. Codeine use shows a steady decline from 1.9 DDA/100A in 2011 to 0.72 in 2017. DISCUSSION/CONCLUSION: The DDA concept appears to be an effective tool for assessing long-term analgesic-use trends at hospital EDs. This tool can also mitigate one major bias at EDs, that is the lack of traceability of analgesic administration in emergency contexts. This tool could be adjusted by integrating the average length of stay in the ED.

Rapid Adaptation of a Surgical Research Unit to Conduct Clinical Trials During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has brought most ongoing clinical trials to a standstill, while at the same time emphasizing the need for new therapeutic treatments and strategies to mitigate the morbidity and mortality related to COVID-19. Recent publication of several observational studies has generated much discussion surrounding efficacy of drugs including hydroxychloroquine, azithromycin, and remdesivir, stressing the need for high-quality prospective, randomized control trials in patients with COVID-19. Ongoing "stay at home" orders and institutional policies mandating "work from home" for nonessential employees, which includes most research personnel, have impacted the ability to implement and conduct clinical studies. This article discusses the approach of an experienced clinical trials unit to make adjustments for ongoing studies and ensure the safety of study participants. At the same time, plans were implemented to continue collection of data to achieve endpoints, safely enroll and follow participants in studies offering potential benefit, and quickly implement new COVID-19 clinical trials. The existence of a Division of Clinical Research with regulatory, budgeting, contracting, and coordinating expertise within a department of surgery can successfully accommodate a crisis situation and rapidly adapt to new requirements for the safe, efficient, and effective conversion to a remote work force without compromising the research process.

The most common pediatric and adult dermatology patient complaints in a month of the COVID-19 pandemic in Turkey.

Severe acute respiratory syndrome coronavirus 2 is the coronavirus strain that causes coronavirus disease 2019 (COVID-19). The World Health Organization (WHO) has designated the ongoing COVID-19 outbreak a Public Health Emergency of International Concern. WHO declared COVID-19 as a pandemic on 11 March 2020. During the pandemic and lockdown period, many dermatologic clinics were temporarily closed in Turkey as well as all over the world. Taking the necessary precautions, the hospital continued to examine all emergent and elective patients who applied to our dermatology clinic. We investigated the most common reasons for admission of pediatric and adult patients who were admitted to our outpatient clinic between 30 March and 30 April 2020, the period with the highest number of COVID-19 patients in Turkey. In children and adult age groups, the most common reason for admission was acne (N: 10 [16.4%] and N: 89 [20.9%], respectively). Of the 99 acne patients, 70 (70.7%) were using systemic isotretinoin and applied to our clinic to repeat the prescription or continue the agent. The number of pediatric patients admitted to the dermatology department drastically reduced during the lockdown period, which was attributed to the curfew for children in the country.

The Number of Patients Diagnosed with Brain Death and Organ Donation Rates at the Baskent University Konya Hospital: 6-Year Experience.

OBJECTIVES: Kidney transplant started at Baskent University Konya Hospital in July 2016. In this study, we compared the causes of brain death and the organ donation rates in our center between 2013 and 2016 versus between 2016 and 2019. MATERIALS AND METHODS: Patient files and records were analyzed retrospectively. Age, biologic sex, cause of brain death, and organ donation rates of patients diagnosed with brain death were examined and compared. RESULTS: The number of patients who were diagnosed with brain death and became deceased donors at our center increased 4-fold during the period from 2016 to 2019 compared with that shown from 2013 to 2016. In addition, organ donation rates increased to 71.4%, which is much higher than the average in Turkey (24%-28%). Between 2013 and 2016, trauma was the leading cause of brain death (42.8%), whereas between 2016 and 2019 cerebral hemorrhages rose to first place with a rate of 89.3%. In 2018 and 2019, there were 199 and 62 brain deaths, respectively, reported in our organ donation coordination region with an approximate organ donation rate of 25%. In our center, 12 patients were diagnosed with brain death in 2018 and 8 of these patients (66.7%) became donors; 6 brain deaths were diagnosed in 2019, and 4 patients (66.7%) became donors. Since we started kidney transplant at our center in 2016, the number of patients diagnosed with brain death has increased significantly. CONCLUSIONS: Establishing a healthy communication with relatives of patients and having a dedicated organ transplant center are important reasons for our much higher organ donation rates compared with the general rate in Turkey. A healthy communication is the most effective way to establish trust with next-of-kin and the general public.

Cardiac implantable electrical devices in patients with hypertrophic cardiomyopathy: single center implant data extracted from the Swedish pacemaker and ICD registry.

Objectives: To investigate cardiac implantable electrical device (CIED) first implants in patients with hypertrophic cardiomyopathy (HCM) in a Swedish tertiary university hospital. Design: Clinical and technical data on pacemaker, implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) first implants performed in HCM patients at the Karolinska University Hospital from 2005 to 2016 were extracted from the Swedish Pacemaker and ICD Registry. Echocardiographic data were obtained by review of hospital recordings. Results: The number of first pacemaker implants in HCM patients was 70 (1.5% of total pacemaker implants). The mean age of HCM pacemaker patients was 71 ± 10 years. Pacemaker implants were almost uniformly distributed between genders. Dual-chamber pacemakers with or without CRT properties were prevalent (6 and 93%, respectively). The number of first ICD implants in HCM patients was 99 (5.1% of total ICD implants). HCM patients receiving an ICD were 53 ± 15 years and prevalently men (70%). Sixty-five (66%) patients were implanted for primary prevention. Dual-chamber ICDs with or without CRT were 21 and 65%, respectively. Obstructive HCM was present in 47% pacemaker patients and 25% ICD patients with available pre-implant echo. Conclusions: This retrospective registry-based study provides a picture of CIED first implants in HCM patients in a Swedish tertiary university hospital. ICDs were the most commonly implanted devices, covering 59% of CIED implants. HCM patients receiving a pacemaker or an ICD had different epidemiological and clinical profiles.

Trends in the Incidence, Etiology, Treatment, and Outcomes of Pleural Infections in Adults Over a Decade in a Finnish University Hospital.

BACKGROUND AND AIMS: The aim of the study was to ascertain changes in the incidence, etiology, treatment, and outcomes of pleural infections over a decade in a Finnish University Hospital. MATERIALS AND METHODS: All patients treated for pleural infections in Tampere University Hospital during 2000-2008 and 2012-2016 were included. The incidence rates and the epidemiologic data and medical history of patients, etiology of infection, and treatment trends and outcomes were compared between the cohorts. RESULTS: The incidence of pleural infections increased from 4.4 during 2000-2008 to 9.9 during 2012-2016 per 100.000 patient-years, p < 0.001. The patients in the latter group were older, 63 versus 57 years, p = 0.001, and the prevalence of chronic lung disease, hypertension, heart failure, dyslipidemia, and immunosuppressive medication were higher. The causes of infection remained similar and pneumonia accounted for 70% of all cases. The identification rate of the microbe pathogens increased from 49% to 64%, p = 0.002, while the distribution of identified pathogens was unchanged. More patients in the latter cohort were treated operatively, 88.3% versus 80.9%, p = 0.005, and, in these, the proportion of thoracoscopic surgery was higher, 57.4% versus 8.0%, p < 0.001, and the delay to surgery shorter, 5 versus 7 days, p < 0.001. Radiologic outcomes were similar. The 30-day mortality rate was 3.1% during 2000-2008 and 5.1% during 2012-2016, p = 0.293. CONCLUSION: The overall incidence of pleural infections has increased significantly while the causes of pleural infections and the distribution of pathogens remain unchanged. Contemporary patients are older with higher prevalence of comorbidities and more frequently undergo thoracoscopic surgery.

Past, present and future of university hospitals.

Objectives: Health care systems worldwide are changing and taking new forms. The old, more hierarchically oriented, model with individual institutional and bilateral interactions between primary, secondary, tertiary and quaternary care is being replaced by an integrated and dynamic network model. We aim to look at what role university hospitals will play in this future organization of health care.Method: In this paper, we look at the relevant literature on the history of academic medicine and university hospitals. Subsequently, we look at the challenges university hospitals are facing according to contemporary literature on the topic.Results: Our current model of academic medicine with its university hospitals finds its origin in the institutionalization of the academic mission in the late 18th century. Currently, the sustainability of the model is under immense pressure. University hospitals are facing economic challenges, teaching challenges and research challenges. However, there is reason to believe that they can continue to play a role of importance in tomorrow's medicine. The organization of health care is undergoing two important changes. The first is the evolution towards a more dynamic and integrated network model. University hospitals can become an important hub within this network. The second change is an evolution towards evidence based medicine and translational research.Conclusion: Due to their unique tripartite mission, we argue that university hospitals can continue to play an important and critical role in promoting evidence-based medicine and speedy translation of new evidence.

Implementation of clinical pharmacist recommendations and services at a University Hospital in Yemen.

Background Studies have revealed that the inclusion of a clinical pharmacist as a member in multidisciplinary medical team has been associated with improved medication use, reduced adverse drug reaction, reduced cost of treatment, and improved health outcomes. Objective The objectives of this study were to evaluate the implementation of clinical pharmacy recommendations and services, the acceptance rate by the physicians, and the anticipated outcomes of the recommendations at a hospital in Yemen. Methods Different units of the University of Science and Technology Hospital, Sana'a were included in this study. All the recommendations and services provided by the clinical pharmacist during daily activities were documented between June 2013 and November 2015. The provided recommendations were classified based on the type, acceptance rate, and the anticipated outcomes. Main outcome measure Type and quality of clinical pharmacists' recommendations, anticipated impact of the recommendations on health outcomes, and their acceptance rate. Results Throughout the study period, a total of 957 patients in different hospital units were visited and provided with a total of 3307 interventions and services. The most frequent types of clinical pharmacist's interventions were drug discontinuation (23.6%, n = 782), inappropriate dose interval or time (n = 735, 22.2%), and add medication (18.9%, n = 626). Overall, 61.8% (n = 2044) of the provided recommendations were accepted by the physicians. The most anticipated outcomes were improved the effectiveness of therapy (45.1%, n = 1909), avoid adverse drug reactions (29%, n = 1228), and decrease the cost of medications (18.8%, n = 797). Conclusion Clinical pharmacist's recommendations resulted in improving drug therapy and decreasing adverse effects for inpatients at the University of Science and Technology Hospital. This suggests that the implementation of clinical pharmacy services is essential and has a positive outcome on patient care.

Knowledge and awareness among patients with epilepsy observed at Jordan University Hospital.

The objective of this study was to assess the level of knowledge and awareness about epilepsy among patients with epilepsy (PWE) and to determine the correlation with sociodemographic and disease-related factors. A prospective cross-sectional study was set, and it included PWE attending the adult neurology clinic at Jordan University Hospital (JUH), Amman, Jordan. A structured questionnaire was utilized, which consisted of 3 parts: sociodemographic factors, disease characteristics, and an epilepsy knowledge scale - the Epilepsy Knowledge Profile-General (E.K.P-G) scale. There was a total of 108 patients, 43 males and 65 females with an age range from 16 to 63 years. The average score of the subjects in the E.K.P-G scale was 16.4/34 (48%). Twenty out of the 34 questions were answered correctly by less than 50% of the respondents. There was an overall poor understanding of the etiology of epilepsy. A higher E.K.P-G score was significantly correlated with higher levels of education, higher household income, controlled seizures for more than 2 years, and living in urban areas. On the other hand, there was no significant correlation between the level of knowledge and age, gender, marital status, occupational status, type of seizure, duration of epilepsy, source of information, number of antiepileptic drugs (AEDs), and family history of epilepsy. In conclusion, the study showed a significant lack of knowledge about epilepsy among PWE at JUH. A public educational program is necessary in Jordan to educate PWE about their disorder.

The protective role of pre-morbid type 2 diabetes in patients with amyotrophic lateral sclerosis: a center-based survey in China.

Objective: To assess the role of premorbid type 2 diabetes in patients with amyotrophic lateral sclerosis (ALS) in China.Methods: We compared data from ALS patients with premorbid type 2 diabetes (T2D) and ALS patients without T2D with regard to the age of onset of ALS. In addition, survival was compared between these two groups of patients using propensity score matching (PSM). Results: Among 1331 consecutive sporadic ALS patients, 100 (7.5%) were labeled as ALS-T2D and 1231 were labeled as ALS-control according to the presence or absence of premorbid T2D. The mean age of onset in patients in the ALS-T2D group was 57.0 years, with a 4.4-year delay compared to that in the ALS-control group [57.0 (SD, 9.6) years vs 52.6 (SD, 10.3) years, respectively; p = 0.000]. This 4.4-year delay was significant after adjusting for sex and the site of onset in a multiple linear regression model. Additionally, after comparison with matched pairs, a nonsignificant increase in survival was observed among the ALS patients with premorbid T2D. Conclusions: The results support the protective role of diabetes in ALS. It is possible to infer that these beneficial effects occur mainly in the preclinical and early stages of the disease course.

Reduced Rate of Inpatient Hospital Admissions in 18 German University Hospitals During the COVID-19 Lockdown.

The COVID-19 pandemic has caused strains on health systems worldwide disrupting routine hospital services for all non-COVID patients. Within this retrospective study, we analyzed inpatient hospital admissions across 18 German university hospitals during the 2020 lockdown period compared to 2018. Patients admitted to hospital between January 1 and May 31, 2020 and the corresponding periods in 2018 and 2019 were included in this study. Data derived from electronic health records were collected and analyzed using the data integration center infrastructure implemented in the university hospitals that are part of the four consortia funded by the German Medical Informatics Initiative. Admissions were grouped and counted by ICD 10 chapters and specific reasons for treatment at each site. Pooled aggregated data were centrally analyzed with descriptive statistics to compare absolute and relative differences between time periods of different years. The results illustrate how care process adoptions depended on the COVID-19 epidemiological situation and the criticality of the disease. Overall inpatient hospital admissions decreased by 35% in weeks 1 to 4 and by 30.3% in weeks 5 to 8 after the lockdown announcement compared to 2018. Even hospital admissions for critical care conditions such as malignant cancer treatments were reduced. We also noted a high reduction of emergency admissions such as myocardial infarction (38.7%), whereas the reduction in stroke admissions was smaller (19.6%). In contrast, we observed a considerable reduction in admissions for non-critical clinical situations, such as hysterectomies for benign tumors (78.8%) and hip replacements due to arthrosis (82.4%). In summary, our study shows that the university hospital admission rates in Germany were substantially reduced following the national COVID-19 lockdown. These included critical care or emergency conditions in which deferral is expected to impair clinical outcomes. Future studies are needed to delineate how appropriate medical care of critically ill patients can be maintained during a pandemic.

Unplanned readmission prevention by a geriatric emergency network for transitional care (URGENT): a prospective before-after study.

BACKGROUND: URGENT is a comprehensive geriatric assessment (CGA) based nurse-led care model in the emergency department (ED) with geriatric follow-up after ED discharge aiming to prevent unplanned ED readmissions. METHODS: A quasi-experimental study (sequential design with two cohorts) was conducted in the ED of University Hospitals Leuven (Belgium). Dutch-speaking, community-dwelling ED patients aged 70 years or older were eligible for enrolment. Patients in the control cohort received usual care. Patient in the intervention cohort received the URGENT care model. A geriatric emergency nurse conducted CGA and interdisciplinary care planning among older patients identified as at risk for adverse events (e.g. unplanned ED readmission, functional decline) with the interRAI ED Screener© and clinical judgement of ED staff. Case manager follow-up was offered to at risk patients without hospitalization after index ED visit. For inpatients, geriatric follow-up was guaranteed on an acute geriatric ward or by the inpatient geriatric consultation team on a non-geriatric ward if considered necessary. Primary outcome was unplanned 90-day ED readmission. Secondary outcomes were ED length of stay (LOS), hospitalization rate, in-hospital LOS, 90-day higher level of care, 90-day functional decline and 90-day post-hospitalization mortality. RESULTS: Almost half of intervention patients (404/886 = 45.6%) were categorized at risk. These received on average seven advices. Adherence rate to advices on the ED, during hospitalization and in community care was 86.1, 74.6 and 34.1%, respectively. One out of four at risk patients without hospitalization after index ED visit accepted case manager follow-up. Unplanned ED readmission occurred in 170 of 768 (22.1%) control patients and in 205 of 857 (23.9%) intervention patients (p = .11). The intervention group had shorter ED LOS (12.7 h versus 19.1 h in the control group; p < .001), but higher rate of hospitalization (70.0% versus 67.0% in the control group; p = .003). CONCLUSIONS: The URGENT care model shortened ED LOS and increased the hospitalization rate, but did not prevent unplanned ED readmissions. A geriatric emergency nurse could improve in-hospital patient management, but failed to introduce substantial out-hospital case-management. TRIAL REGISTRATION: The protocol of this study was registered retrospectively with ISRCTN ( ISRCTN91449949 ; registered 20 June 2017).

Management of febrile infants aged 1 month and less than 3 months in a French university hospital: Clinical practice evaluation.

BACKGROUND: Management of febrile infants is challenging due to the increased risk of serious bacterial infections and it varies among physicians and hospitals. The goals of this study were to describe and compare the management of febrile infants aged 1-2 months in a hospital in 2011 and 2016. METHODS: We conducted a retrospective study in the Bordeaux Pellegrin University Hospital, France, in 2011 and 2016. All infants aged 1-2 months with diagnosis codes referring to fever were included. Data on infant characteristics, fever episodes, clinical symptoms, and management were collected from medical charts. Univariate analyses and multivariate logistic models were used. RESULTS: A total of 530 infants were included; 89.2% had blood testing and 81.1% urine testing; 79.6% of the infants were hospitalized, three of them in the pediatric intensive care unit. The median hospitalization duration was 3 days. In the sample investigated, 59.8% of the infants received antibiotic therapy and 128 (24.1%) had bacterial infections with no difference between 2011 and 2016. The main bacterial infection was pyelonephritis (86.7%). Urethral catheterization was implemented in 2016, whereas a urine bag was utilized for 174 out of 177 infants in 2011. The percentage of contaminated urine cultures was higher in 2011 (35.9%) than in 2016 (19.6%, P<0.001). The hospitalization rate was higher in 2016. CONCLUSIONS: Management of febrile infants changed between 2011 and 2016. The hospitalization rate and antibiotic therapy use remained high regarding the rate of bacterial infection. Use of urethral catheterization decreased the level of contamination.

El laboratorio de práctica profesional, como estrategia educativa, en el marco del cambio curricular / The professional practice laboratory, as a strategy educational, within the framework of curricular change

En vista de la transformación que se está produciendo en la educación universitaria en general y en la educación para profesionales de la salud en particular, el Instituto Universitario del Hospital Italiano plantea un cambio curricular para la carrera de Medicina. Esto implica, una forma de cambio sociocultural profunda, que afecta los distintos aspectos de la vida institucional. Se propone dejar atrás, el "sistema flexneriano" de enseñanza, proponiendo el sistema Aprendizaje Basado en Problemas (ABP), sumado a talleres y laboratorios donde el conocimiento y las habilidades se irán adquiriendo con diferente grado de complejidad en forma espiralada. El Laboratorio de Práctica Profesional (LPP) es el espacio y el ambiente educacional donde ocurre la máxima integración, trabajando sobre todos los conocimientos necesarios para llevar adelante la actividad profesional correspondiente. En el primer módulo, el enfoque fue guiado, fundamentalmente, hacia lo comunicacional persiguiendo como objetivo que el alumno desarrolle habilidades que le permitan establecer una adecuada relación médico-paciente-familia, así como vínculos adecuados con el equipo de trabajo y la comunidad . Se evaluó el taller en sí mismo y a los tutores mediante encuestas a los estudiantes, y estos últimos a su vez fueron evaluados periódicamente por los tutores y al final del módulo con un examen escrito y un examen tipo evaluación clínica objetiva estructurada. Por lo trabajado creemos que el LPP, como estrategia de enseñanza, contribuye a la formación de habilidades complejas; el resultado de las evaluaciones y el feedback rsultan indispensables para establecer un plan de mejoras. (AU)

In view of the transformation that is taking place in university education in general and in education for health professionals in particular, it is that the University Institute of the Italian Hospital proposes a curricular change for the Medicine career. This implies a socio-cultural change that affects the different aspects of institutional life. It is proposed to leave behind the "Flexnerian system", proposing a system based on: Problem Based Learning, in addition to workshops and laboratories where knowledge and skills will be acquired with a different degree of complexity in spiral form. The Professional Practice Laboratory is the space and educational environment where maximum integration occurs, working on all the necessary knowledge to carry out the corresponding professional activity. In the first module the focus was guided, fundamentally, to the communicational pursuing as objective: that the student develops skills that allow him to establish an adequate doctor-patient-family relationship, as well as adequate links, with the work team and the community. The evaluation was carried out to workshop itself and to the tutors through students' quiz. The students were periodically evaluated by the tutors and at the end of the module with a written exam and a structured Objective Clinical Evaluation type test. For what we have worked to this moment, we believe that: The laboratory of professional practice, as a teaching strategy, contributes to the formation of complex skills; being the result of the evaluations and the feedback, fundamental to establish an improvement plan. (AU)

Maternal obesity trends in a large Irish university hospital.

OBJECTIVE(S): This study aimed to examine recent trends in maternal obesity. STUDY DESIGN: This retrospective observational study used routinely computerised clinical and sociodemographic data of women who presented for antenatal care in a large maternity hospital in Ireland during the eight years 2010-17. Women with complete body mass index (BMI) data who delivered a baby weighing ≥500 g were included in the study. BMI was based on the measurement of weight and height and was categorised into the World Health Organizations (WHO) classifications. RESULTS: The number of women delivered was 67,949 and 99.1% had complete data. The overall obesity rate increased from 16.0% (95% CI 15.3-16.8%) in 2010 to 18.9% (95% CI 18.0-19.7%) in 2017 (+18.1%, p < 0.001). This increase occurred in the mild, moderate and severe obesity subcategories (all p < 0.01). Overall, obesity was associated with multiparity, maternal age, maternal birth in Ireland or the United Kingdom (UK), depression, unemployment and unplanned pregnancy. The increase in obesity was more pronounced in nulliparas than in multiparas, particularly nulliparas <30 years. The increased obesity levels were accompanied by major sociodemographic changes in the hospital population from 2010 to 2017 with an increase in the average maternal age from 30.5 years to 32.2 years (p < 0.001) and a decrease in the proportion of nulliparas aged <30 years (from 40.6% to 28.8%, p < 0.001). CONCLUSION(S): It is likely that the escalating maternal obesity levels will lead to further increases in obstetric complications and interventions. The escalation was accompanied by major sociodemographic changes which have implications for healthcare planning and public health interventions.

Age is associated with increased mortality in the RETTS-A triage scale.

BACKGROUND: Triage is widely used in the emergency department (ED) in order to identify the patient's level of urgency and often based on the patient's chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System - Adult (RETTS-A), the most widely used triage tool in Sweden. METHODS: In this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18-59, 60-79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality. RESULTS: We observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18-59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively. CONCLUSION: Compared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.