Networks as a way to hospital and primary/community care integration: findings from a narrative review of the main international models.

Background Healthcare systems are complex systems. Achieving financial, social, and environmental sustainability of these systems requires a high degree of integration and coordination at all levels, especially between acute-care settings and primary/community care services. Some authors have, therefore, suggest redirecting integrated healthcare research towards the network theory and network concepts as a useful lens. Objective The current paper proposes to investigate the existence, the institutional level of formalization and the degree of development of hospital/primary-community care Networks currently present in the main types of healthcare systems worldwide by studying an appropriate selection of representative countries for each system typology. Materials and Methods A narrative review of the scientific and gray literature following the methodology by Green et al. was, therefore, conducted to describe hospital and primary/community care networks and their integration/coordination in the main international models. To select these models, one country with the current highest life expectancy at birth for each of the B öhm's five healthcare system categories was chosen. The grade of integration of the Networks retrieved for each State was therefore qualitatively appraised (high, medium or low degree), following Valentijn's framework. Results The networks retrieved show: in Norway, Australia and Japan both at the government/ national and at the regional/lower level/other a high degree of systemic, organizational, normative and functional integration; in Switzerland both at the government/national and at the regional/lower level/other a medium degree of systemic, organizational, normative and functional integration; in the USA at the governmental/institution level a low degree of systemic, organizational and normative integration, with a medium degree of functional integration and at the regional/lower level/other integration a low degree of systemic and normative integration with medium degree of organization integration and high degree of functional integration. Discussion The high levels and degree of hospital/primary - community care integration of Norway, Australia and Japan are in line with what could be expected from the universalistic healthcare system in place. The medium levels of integration of Switzerland are also in line with what the Social health insurance system and, especially, the cantonal system. The low levels of integration of the USA are in line with the privatistic healthcare systems. However, a medium degree was found for functional integration probably due to its unparalleled technological advancement. Conclusions The study shows how the levels of hospital/primary-community care integration are connected to the specific healthcare system in place in each country. COVID-19 showed how complex systems like healthcare systems had to reconfigure themselves to reach high levels of integration in small time to be able to save lives and contain the spread of the virus. These results will prove useful for policymakers, healthcare and public health professionals in the task of establishing effective Networks to achieve high levels of integration in their institutions.

Multiple-access versus telemedicine home-based sleep apnea testing for obstructive sleep apnea (OSA) diagnosis: a cost-minimization study.

PURPOSE: The aim of the present study was to compare two clinical pathways: the multiple-access outpatient pathway versus the telemedicine pathway. METHODS: The multiple-access outpatient pathway and the telemedicine pathway were both performed with WatchPAT and implemented in a real-life healthcare scenario, adopting a cost-minimization approach. A cost-minimization analysis was undertaken to assess the economic impact of the two alternatives. The cost analyses were performed in euros for the year 2021 adopting the patient, the hospital, and the societal perspectives. Given the chosen perspectives, direct medical costs, direct nonmedical costs, and indirect costs were considered. In addition, a univariate sensitivity analysis was conducted. RESULTS: From a hospital perspective, the telemedicine approach was estimated to cost €49 more than the multiple-access alternative. Considering the patient perspective, the telemedicine approach was estimated to cost €167 less than the multiple-access pathway. Considering the societal perspective, the telemedicine approach is estimated to cost €119 less than the multiple-access pathway. CONCLUSION: The adoption of telemedicine home sleep apnea testing could improve the efficiency of the healthcare processes if considering the direct and indirect costs incurred by patients and not only by healthcare providers.

[The progressive patient care program as a model of field training of public health practitioners: the experience of the Roman Public Health Academy]. / L'ospedale ad Intensità di cura come modello di formazione condivisa sul campo: l'esperienza dell'Accademia Romana di Sanità Pubblica.

The management of healthcare facilities has become increasingly complex in recent years, leading to a greater demand for public health physicians in Italy. Public Health physicians are responsible for evaluating community needs, with particular attention to health determinants and, at the same time, to final user feedback. During their training, they must acquire the competencies to manage a wide range of problems. The Roman Public Health Academy (ARSP) was developed to motivate young residents in Public Health to acquire the knowhow, skills and abilities required of a public health practitioner. It therefore implemented a special training program offering different educational opportunities for residents. In particular, the program offers a team of three young residents field training opportunities, allowing them to become engaged in solving complex technical and management problems. In this paper we describe the methods through which, following a specific request by the director of a hospital in Rome, the team supported a project involving the reorganization of several hospital wards. The aim of the reorganization was to enhance the performance and efficiency of the wards, according to the Progressive Patients Care program.

Transsternal thymectomy.

Thymectomy is a well-established indication for management of myasthenia gravis and it represents the most effective treatment for thymic tumors. The traditional surgical approach is median sternotomy. More recently, different less-invasive surgical approaches for thymectomy have been proposed as an alternative to open surgery. This article discusses the main technical aspects and results of literature.

[Correction: Adverse events and preventable consequences: retrospective study in five large Italian hospitals]. / Correzione: Eventi avversi e conseguenze prevenibili: studio retrospettivo in cinque grandi ospedali italiani.

[This corrects the Table 4 of the article: pmid: 22828228].

The incidence of adverse events in an Italian acute care hospital: findings of a two-stage method in a retrospective cohort study.

BACKGROUND: The promotion of safer healthcare interventions in hospitals is a relevant public health topic. This study is aimed to investigate predictors of Adverse Events (AEs) taking into consideration the Charlson Index in order to control for confounding biases related to comorbidity. METHODS: The study was a retrospective cohort study based on a two-stage assessment tool which was used to identify AEs. In stage 1, two physicians reviewed a random sample of patient records from 2008 discharges. In stage 2, reviewers independently assessed each screened record to confirm the presence of AEs. A univariable and multivariable analysis was conducted to identify prognostic factors of AEs; socio-demographic and some main organizational variables were taken into consideration. Charlson comorbidity Index was calculated using the algorithm developed by Quan et al. RESULTS: A total of 1501 records were reviewed; mean patients age was 60 (SD: 19) and 1415 (94.3%) patients were Italian. Forty-six (3.3%) AEs were registered; they most took place in medical wards (33, 71.7%), followed by surgical ones (9, 19.6%) and intensive care unit (ICU) (4, 8.7%). According to the logistic regression model and controlling for Charlson Index, the following variables were associated to AEs: type of admission (emergency vs elective: OR 3.47, 95% CI: 1.60-7.53), discharge ward (surgical and ICU vs medical wards: OR 2.29, 95% CI: 1.00-5.21 and OR 4.80, 95% CI: 1.47-15.66 respectively) and length of stay (OR 1.03, 95% CI 1.01-1.04). Among patients experiencing AEs a higher frequency of elderly (≥65 years) was shown (58.7% vs 49.3% among patients without AEs) but this difference was not statistically significant. Interestingly, a higher percentage of patients admitted through emergency department was found among patients experiencing AEs (69.7% vs 55.1% among patients without AEs). CONCLUSIONS: The incidence of AEs was associated with length of stay, type of admission and unit of discharge, independently by comorbidity. On the basis of our results, it appears that organizational characteristics, taking into account the adjustment for comorbidity, are the main factors responsible for AEs while patient vulnerability played a minor role.

Neutralizing Antibodies against SARS-CoV-2 Beta and Omicron Variants Inhibition Comparison after BNT162b2 mRNA Booster Doses with a New PETIA sVNT Assay.

BACKGROUND: Monitoring antibody response following SARS-CoV-2 vaccination is strategic, and neutralizing antibodies represent the gold standard. The neutralizing response to Beta and Omicron VOCs was evaluated versus the gold standard by a new commercial automated assay. METHODS: Serum samples from 100 healthcare workers from the Fondazione Policlinico Universitario Campus Biomedico and the Pescara Hospital were collected. IgG levels were determined by chemiluminescent immunoassay (Abbott Laboratories, Wiesbaden, Germany) and serum neutralization assay as the gold standard. Moreover, a new commercial immunoassay, the PETIA test Nab (SGM, Rome, Italy), was used for neutralization evaluation. Statistical analysis was performed with R software, version 3.6.0. RESULTS: Anti-SARS-CoV-2 IgG titers decayed during the first ninety days after the vaccine second dose. The following booster dose significantly (p < 0.001) increased IgG levels. A correlation between IgG expression and neutralizing activity modulation was found with a significant increase after the second and the third booster dose (p < 0.05. Compared to the Beta variant of the virus, the Omicron VOC was associated with a significantly larger quantity of IgG antibodies needed to achieve the same degree of neutralization. The best Nab test cutoff for high neutralization titer (≥1:80) was set for both Beta and Omicron variants. CONCLUSION: This study correlates vaccine-induced IgG expression and neutralizing activity using a new PETIA assay, suggesting its usefulness for SARS-CoV2 infection management.

[Adverse events and preventable consequences: retrospective study in five large Italian hospitals]. / Eventi avversi e conseguenze prevenibili: studio retrospettivo in cinque grandi ospedali italiani.

OBJECTIVE: To define the incidence of adverse events and their preventability in a representative sample of patients in five acute hospitals located in the North, the Centre and the South of Italy. Other objectives include the evaluation of the consequences of adverse events and their distribution according to specialties. DESIGN: Retrospective and multicentre study. The methodology is focused on the review of clinical records related to hospital admissions in the year 2008 with a sample of 5 hospitals belonging to the national healthcare system selected according to criteria of location (North, Centre and South of Italy) and complexity (regional reference hospitals). The clinical records included in the study were selected in a random way starting from the electronic archives of the hospital discharges of each participating centre. SETTING AND PARTICIPANTS: 7,573 clinical records were reviewed with a process of two stages managed by two reviewers each. The first stage of the review process involved 7 physicians, 1 nurse, 1 pharmacist and 1 biologist with skills and experiences in clinical risk management and in analysis of clinical documentation. The second stage was realized by 10 physicians (5 specialists, 3 experts in public health and 2 forensic physicians), also for the second stage every person involved had specific training in clinical risk management. The reviewers attended a 20-hour training course. MAIN OUTCOME MEASURES: Study of the incidence of adverse events identified during the admissions included. In the case of more than one adverse event for each admission, it is calculated the cumulative incidence of adverse events for each patient. We also considered the percentage of re-admitted patients for each adverse event, the percentage of adverse events which occurred in the phase of pre hospitalization and the degree of preventability of adverse events. A description of the identified adverse events was realized. The sample of the data included in the study was described in terms of included and excluded subjects with respect to the planned research design. Different products and results were tested and validated in the study and could be reused in the future research products. RESULTS: The overall average of the incidences of adverse events was 5.2%, the median was 5.5% and it is consistent with the expected results mentioned in the protocol of the study. The identified incidence of adverse events is lower than the median rate of international studies (9.2%). The distribution of adverse events for specialties underlines the majority of adverse events in the medical area (37.5%), in opposition to the results of other studies; the surgery is the second specialty for number of adverse events (30.1%), followed by the emergency room (6.2%) and obstetrics (4.4%). The study identified 56.7% of adverse events as preventable. The consequences of adverse events were classified in different typologies: the prolonged stay was the most frequent consequence, followed by the disability at discharge. The death of the patient had a median occurrence of 9.45%. The concordance between the two reviewers in the evaluation of the clinical records was very high (higher than 95%) except for two centres. CONCLUSIONS: The results were consistent with the results of other international studies similar in scope in terms of type of study (definition of the rate of adverse events) and epidemiological study design (retrospective study). The incidence rate, previously mentioned as 5.2%, coincides with the unfavorable rates of events determined in varied countries. The preventability resulted in an average of 56.7%. The variability of the results obtained in our inquiry are likely attributable to varied factors occurred during the study.

Vaccines Administration in the Perspective of Patient Safety and Quality of Healthcare: Lesson from the Experience of an Italian Teaching Hospital for Pandemic Preparedness.

The development and administration of vaccines against COVID-19 was a key element in the fight against the pandemic, as it protected health systems and helped restore global economies. National implementation plans and vaccination strategies for COVID-19 vaccines ensured the immunization of large segments of the population in the shortest time. However, even before the start of the vaccination campaign, it was clear to decision-makers that the usual methods of vaccination were not suitable. The aim of this report is to share the experience of an Italian teaching hospital in the organisation of spaces and activities of healthcare workers to realise a safe vaccination campaign. An in-depth analysis of how the vaccination campaign was organised could be useful to understand strengths and weaknesses learnt from this experience and plan an effective, efficient, and resilient response to future pandemics right away. The adoption of a systemic clinical risk management (SCRM) could guarantee healthcare organizations a more adequate and resilient response in an ethics of a job well done perspective, allowing them to maintain high patient safety standards regardless of the contingent situation for which safety first should be the motto of a disaster response plan.

Queueing Theory and COVID-19 Prevention: Model Proposal to Maximize Safety and Performance of Vaccination Sites.

Introduction: COVID-19 (Coronavirus Disease 19) has rapidly spread all around the world. Vaccination represents one of the most promising counter-pandemic measures. There is still little specific evidence in literature on how to safely and effectively program access and flow through specific healthcare settings to avoid overcrowding in order to prevent SARS-CoV-2 transmission. Literature regarding appointment scheduling in healthcare is vast. Unpunctuality however, especially when targeting healthcare workers during working hours, is always possible. Therefore, when determining how many subjects to book, using a linear method assuming perfect adhesion to scheduled time could lead to organizational problems. Methods: This study proposes a "Queuing theory" based approach. A COVID-19 vaccination site targeting healthcare workers based in a teaching hospital in Rome was studied to determine real-life arrival rate variability. Three simulations using Queueing theory were performed. Results: Queueing theory application reduced subjects queueing over maximum safety requirements by 112 in a real-life based vaccination setting, by 483 in a double-sized setting and by 750 in a mass vaccination model compared with a linear approach. In the 3 settings, respectively, the percentage of station's time utilization was 98.6, 99.4 and 99.8%, while the average waiting time was 27.2, 33.84, and 33.84 min. Conclusions: Queueing theory has already been applied in healthcare. This study, in line with recent literature developments, proposes the adoption of a Queueing theory base approach to vaccination sites modeling, during the COVID-19 pandemic, as this tool enables to quantify ahead of time the outcome of organizational choices on both safety and performance of vaccination sites.

The Short Stay Unit as a new option for hospitals: a review of the scientific literature.

BACKGROUND: The short stay unit (SSU) is a ward providing targeted care for patients requiring brief hospitalization and dischargeable as soon as clinical conditions are resolved. Therefore, SSU is an alternative to the ordinary ward (OW) for the treatment of selected patients. The SSU model has been tested in only a few hospitals, and the literature lacks systematic evaluation of the impact of SSU use. The aim of our study was to evaluate the use of SSUs in terms of length of hospital stay, mortality and readmission rate. MATERIAL/METHODS: A random effect meta-analysis was carried out by consulting electronic databases. Studies were selected that focused on comparison between use of SSUs and OWs. Mean difference of length of stay was calculated within 95% confidence intervals. RESULTS: Six articles were selected, for a total of 21 264 patients. The estimated mean difference was -3.06 days (95% CI -4.71, -1.40) in favor of the SSU. The selected articles did not show any differences in terms of mortality and readmission rate. CONCLUSIONS: Use of SSUs could reduce patient length of stay in hospital, representing an alternative to the ordinary ward for selected patients. A shorter period of hospitalization could reduce the risk of hospital-acquired infections, increase patient satisfaction and yield more efficient use of hospital beds. Findings of this study are useful for institutional, managerial and clinical decision-makers regarding the implementation of the SSU in a hospital setting, and for better management of continuity of care.

UltraViolet SANitizing System for Sterilization of Ambulances Fleets and for Real-Time Monitoring of Their Sterilization Level.

BACKGROUND: The contamination of ambulances with pathogenic agents represents a potential threat for the public health, not only for common pathogens but also for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The aim of this project was to exploits the germicidal effect of the UVC radiation at 254 nm to sanitize the patient's compartment of ambulances with an advanced UltraViolet SANitizing System (UV-SAN) and assess its relevance for avoiding the spread of COVID-19 and other drug resistant pathogens. METHODS: The system is equipped with UVC lamps that are activated when the ambulance compartment is empty and sanitize the environment in less than 15 min. An Ozone sensor continuously monitors the gas concentration, ensuring it does not exceed threshold value harmful for patients and operators' health. The system is relying on GNSS data and a satellite communication link, which allow to monitor and record traceability (when, where and what) of all the sanitation operations performed. This information is real-time monitored from a dedicated web-application. RESULTS: UVC irradiation efficiently reduced SARS-CoV-2 virus titer (>99.99%), on inanimate surfaces such as plastic, stainless steel or rubber, with doses ranging from 5.5 to 24.8 mJ/cm2 and the UV-SAN system is effective against multi drug resistant (MDR) bacteria up to >99.99%, after 10 to 30 min of irradiation. CONCLUSIONS: UV-SAN can provide rapid, efficient and sustainable sanitization procedures of ambulances.

Urologic surgery in a safe hospital during the COVID-19 pandemic scenario.

BACKGROUND: The COVID-19 pandemic induced a global emergency that overwhelmed most hospitals around the world. Access to hospitals has been restricted to selective oncological and urgent patients to minimize surgeries requiring Intensive Care Unit care. All other kind of non-urgent and benign surgeries have been rescheduled. The burden of oncological and urgent cases on the healthcare system has increased. METHODS: We have been asked to become the referral center for major oncological and urgent urological surgeries, increasing our surgical volume. Through meticulous hospital protocols on PPE, use of nasopharyngeal swabs, controlled hospital access and the prompt management of suspected/positive cases, we were able to perform 31% more urological surgical procedures during the COVID-19 pandemic compared to the same period in 2019. RESULTS: We observed a 72% increase in oncological surgical procedures and 150% in urgent procedures. CONCLUSIONS: Our experience shows how the management of oncological and urgent cases can be maintained during unexpected, global emergencies, such as COVID-19.

Appropriateness of fresh-frozen plasma usage in hospital settings: a meta-analysis of the impact of organizational interventions.

BACKGROUND: Transfusions of fresh-frozen plasma (FFP) are a worldwide ever-growing practice. The most advanced health care organizations, to guarantee high-quality standards of interventions and safe procedures, should disseminate scientific evidence for promoting the appropriateness of transfusions and reducing avoidable risks. STUDY DESIGN AND METHODS: We carried out a systematic review of scientific literature searching for studies focused on the implementation of different strategy of organizational interventions aimed at improving clinicians' practice. RESULTS: Of 915 studies, 10 articles were included in our meta-analysis of risk of inappropriate transfusion after the implementation of an organizational intervention. The risk ratio of inappropriate transfusions before organizational interventions was 2.02 (95% confidence interval, 1.44-2.84) compared with after interventions. CONCLUSION: The organizational interventions showed a positive impact on the reduction of rates of inappropriate FFP transfusion episodes.

The effectiveness of computerized clinical guidelines in the process of care: a systematic review.

BACKGROUND: Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines. METHODS: Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG's features with positive effect on the process of care. RESULTS: Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7; 95%CI: 1.3-34.3) were statistically significant predictors. CONCLUSIONS: From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.

A review on the impact of systematic safety processes for the control of error in medicine.

Among risk management initiatives, systematic safety processes (SSPs), implemented within health care organizations, could be useful in managing patient safety. The purpose of this article is to conduct a systematic literature review assessing the impact of SSPs on different error categories. Articles that investigated the relation between SSPs, clinical and organizational outcomes were selected from scientific literature. The proportion and impact of proactive and reactive SSPs were calculated among five error categories. Proactive interventions impacted more positively than reactive ones in reducing medication errors, technical errors and errors due to personnel. PSSPs and RSSPs had similar effects in reducing errors related to a wrong procedure. A single reactive study influenced non-positively communication errors. A relevant prevalence of the impact of proactive processes on reactive ones is reported. This article can help decision makers in identifying which SSP can be the most appropriate against specific error categories.

Postoperative pulmonary function in open versus laparoscopic cholecystectomy: a meta-analysis of the Tiffenau index.

BACKGROUND: Available scientific literature about open cholecystectomy (OC) and laparoscopic cholecystectomy (LC) does not show univocal results in terms of postoperative pulmonary function. A meta-analysis was carried out to evaluate the postoperative pulmonary function after OC and LC focusing on the Tiffenau index. METHODS: Electronic databases were consulted (Cochrane Library, Embase and Pubmed). Standardized mean difference (SMD) with 95% CI was calculated for the Tiffenau Index. The kappa test was performed to evaluate agreement between the reviewers regarding the quality of the selected studies. A sensitivity analysis was carried out to assess the robustness of our study. Heterogeneity among studies was tested by using a chi(2) test at 0.05 significance level. A random effects model meta-analysis was performed. RESULTS: Meta-analysis of the 13 articles included, resulted in a SMD of 53% (95% CI 0.04, 1.02) for the Tiffenau Index in favor of laparoscopic cholecystectomy. The chi(2) test analysis showed the presence of heterogeneity among studies (Tiffenau index chi(2) = 99.97, p = 0.03). The sensitivity analysis confirms the validity of our results. CONCLUSIONS: Postoperative pulmonary function is better preserved after laparoscopic cholecystectomy than open cholecystectomy.