Effects of rural hospital closures on nurse staffing levels and health care utilization at nearby hospitals.

Our study examines the causal effect of rural hospital closures on nearby hospitals' nurse staffing levels and health care utilization. We use data from the 2014-2019 American Hospital Association Survey on nurse staffing level outcomes including licensed practical or vocational nurses (LPNs), registered nurses (RNs), and advanced practice nurses (APNs); and health care utilization outcomes, including inpatient and outpatient surgical operations and emergency department (ED) visits. Using propensity score matching and difference-in-differences (DID) methods, we find that rural hospital closures lead to an average increase of 37.3% in the number of nurses in nearby rural hospitals during the 4 years following the closure. This increase is found across all categories of nurses, including LPNs, RNs, and APNs. We also find a substantial increase in the provision of inpatient and outpatient surgical operations but there is no change in ED visits. We do not find any effects for nearby urban hospitals. Our study suggests that a large proportion of the nursing workforce relocates to nearby hospitals after a rural hospital closure, which mitigates the negative consequences of such closures and allows these nearby hospitals to provide a larger volume of highly profitable services.

A surgical training system designed to help trainees acquire laparoscopic surgical skills at a rural Japanese institute.

PURPOSE: The Endoscopic Surgical Skill Qualification System was established in Japan to evaluate safe endoscopic surgical techniques and teaching skills. Trainee surgeons obtaining this certification in rural hospitals are disadvantaged by the limited number of surgical opportunities. To address this problem, we established a surgical training system to educate trainee surgeons. METHODS: Eighteen certified expert surgeons affiliated with our department were classified into an experienced training system group (E group, n = 9) and a non-experienced group (NE group, n = 9). Results of the training system were then compared between the groups. RESULTS: The number of years required to become board certified was shorter in the E group (14 years) than that in the NE group (18 years). Likewise, the number of surgical procedures performed before certification was lower in the E group (n = 30) than that in the NE group (n = 50). An expert surgeon was involved in the creation of the certification video of all the E group participants. A questionnaire to board-certified surgeons revealed that guidance by a board-certified surgeon and trainee education (surgical training system) was useful for obtaining certification. CONCLUSIONS: Continuous surgical training, starting with trainee surgeons, appears useful for expediting their acquisition of technical certification in rural areas.

A review towards developing a hierarchical model for sustainable hospital solid waste management in rural areas of Zimbabwe.

Management of solid waste from rural hospitals is amongst problems affecting Zimbabwe due to diseases, population, and hospital increase. Solid waste from rural hospitals is receiving little attention translating to environmental health problems. Therefore, 101 secondary sources were used to write a paper aiming to proffer a hierarchical model to achieve sustainable solid waste management at rural hospitals. Rural hospitals' solid waste encompasses electronic waste, sharps, pharmaceutical, pathological, radioactive, chemical, infectious, and general waste. General solid waste from rural hospitals is between 77.35 and 79% whilst hazardous waste is between 21 and 22.65%. Solid waste increase add burden to nearly incapacitated rural hospitals. Rural hospital solid waste management processes include storage, transportation, treatment methods like autoclaving and chlorination, waste reduction alternatives, and disposal. Disposal strategies involve open pits, open burning, dumping, and incineration. Rural hospital solid waste management is guided by legislation, policies, guidelines, and conventions. Effectiveness of legal framework is limited by economic and socio-political problems. Rural hospital solid waste management remain inappropriate causing environmental health risks. Developed hierarchical model can narrow the route to attain sustainable management of rural hospitals' solid waste. Proposed hierarchical model consists of five-layered strategies and acted as a guide for identifying and ranking approaches to manage rural hospitals' solid waste. Additionally, Zimbabwean government, Environmental Management Agency and Ministry of Health is recommended to collaborate to provide sufficient resources to rural hospitals whilst enforcing legal framework. Integration of all hierarchical model's elements is essential whereas all-stakeholder involvement and solid waste minimisation approaches are significant at rural hospitals.

Rural hospital and obstetric unit closures as social determinants of racial and ethnic maternal health disparities: A scoping review.

AIMS: To synthesize literature examining (1) rural hospital or obstetric unit closures as a social determinant of maternal/infant health outcomes and (2) closures as a social determinant of racial/ethnic disparities in maternal/infant health outcomes. DESIGN: Scoping review. DATA SOURCES: MEDLINE, OVID/Embase and CINAHL were searched systematically to identify sources from 31 July 2003 to 31 July 2023. The Arksey and O'Malley methodology for scoping reviews was used. RESULTS: Four studies from the United States and Australia documented the impact of rural hospital or obstetric unit closures on maternal/infant health outcomes, such as increased births in hospitals without obstetric units, out-of-hospital births or babies born before arrival, preterm birth, infant mortality and sociocultural risks that contribute to clinical risk. No eligible studies investigated hospital or obstetric unit closure as a social determinant of racial disparities in rural maternal/infant health outcomes. CONCLUSION: Despite significant racial and ethnic rural maternal health disparities, associations between rural closures and maternal health outcomes for racial and ethnic minorities are understudied. More research is needed to understand the extent to which rural closures, a social determinant of health, could disproportionately, negatively affect the health of racially and ethnically minoritized women. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Rural women have a greater risk of maternal and infant mortality and morbidity compared with urban women, and the impact of rural closures on racial and ethnic maternal health disparities is not well documented. Research about the impact of rural closures on maternal health disparities could inform policy to assure essential obstetric care is available for rural populations globally. IMPACT: Findings provide a call to action for research to understand relationships between rural closures and racial and ethnic maternal health disparities, which is especially important for serving rural Non-Hispanic Black and American Indian/Alaska Native women. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

A retrospective observational study examining interhospital transfers from six New Zealand rural hospitals in 2019.

OBJECTIVE: The aim of this study was to identify the percentage of patients that were transferred from rural hospitals and who received an investigation or intervention at an urban hospital that was not readily available at the rural hospital. METHODS: A retrospective observational study. DESIGN: Patients were randomly selected and clinical records were reviewed. Patient demographic and clinical information was collected, including any interventions or investigations occurring at the urban referral hospital. These were compared against the resources available at the rural hospitals. SETTING: Six New Zealand (NZ) rural hospitals were included. PARTICIPANTS: Patients that were transferred from a rural hospital to an urban hospital between 1 Jan 2019 and 31 December 2019 were included. MAIN OUTCOME MEASURES: The primary outcome measure was the percentage of patients who received an investigation or intervention that was not available at the rural hospital. RESULTS: There were 584 patients included. Overall 73% of patients received an intervention or investigation that was not available at the rural hospital. Of the six rural hospitals, there was one outlier, where only 37% of patients transferred from that hospital received an investigation or intervention that was not available rurally. Patients were most commonly referred to general medicine (23%) and general surgery (18%). Of the investigations or interventions performed, 43% received a CT scan and 25% underwent surgery. CONCLUSIONS: Most patients that are transferred to urban hospitals receive an intervention or investigation that was not available at the rural hospital.

Lean six sigma and stroke in rural hospital - The case of Baruch Padeh Medical Center.

PURPOSE: This case study aims to demonstrate the strengths of the Lean Six Sigma (LSS) methodology to improve the acute ischemic stroke (AIS) treatment rates and reduce process lead time at Baruch Padeh Medical Center (BPMC), a rural hospital in the Galilee region of Northern Israel. The LSS project redefined the BPMC stroke care pathway and increased its efficacy. DESIGN/METHODOLOGY/APPROACH: The LSS methodology was implemented in September 2017 by integrating lean principles and the Six Sigma DMAIC (Define-Measure-Analyze-Improve-Control). Existing procedures, field observation, ad hoc measurement and in-depth interviews were utilized, and the GEMBA method was implemented to identify root cause and improve actions optimizing the stroke pathway. FINDINGS: The presented case shows the usefulness of the LSS methodology in improving quality performance in a rural hospital. The intervention allowed the BPMC to improve the intravenous tissue plasminogen activator (IV-tPA) administration rate (+15.2%), reducing the process lead time. The lead time of door-to-computer tomography decreased from 52 to 26 min, and the door-to-needle time decreased from 94 to 75 min. ORIGINALITY/VALUE: The present case study shows the implementation of the LSS methodology aimed to improve the IV-tPA administration rate and reduce the stroke pathway lead time in a rural hospital. The case demonstrates the potential for the LSS methodology to support the AIS pathway optimization and represents a guide for healthcare organizations located in rural areas.

Filling the Gap between Metropoles and Peripheries: Insights about Hospital Standardization from the British Columbia Hospital Association Conferences, 1918-30.

In this study, we examine British Columbia's Hospital Association conference records (1918-31) to understand how place, gender, and profession shaped debates about hospital standardization during the interwar period. The conference records reveal that hospital standardization was conceptualized as the conformity of smaller, peripheral hospitals to larger metropolitan ones. Arguments about how to best address the gaps in small hospitals were often directed to elite nursing leaders, who suggested improved nursing education as a solution. Hospital affiliation was recommended to ensure adequate training for rural nurses by moving trainee nurses from rural to urban hospitals during the last year of their education. Yet the way that affiliation was conceived was more aligned with the professional goals of the nursing elite, rather than the needs of rank-and-file nurses in small hospitals. These ideas ultimately worked to support the goals of standardization, but obscured the divergent needs of small community hospitals.

Do Hospitals Providing Telehealth in Emergency Departments Have Lower Emergency Department Costs?

Background: Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Introduction: Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. Materials and Methods: A panel of data for 2010-2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. Results: After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. Conclusions: TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory.

INTRODUCTION: Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital. METHODS: This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost-benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted. RESULTS: Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to 'make it work'. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost-benefit analysis showed a clear cost saving to the health system as a whole. CONCLUSIONS: This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

A scope of practice that works 'out here': exploring the effects of a changing medical regulatory environment on a rural New Zealand health service.

INTRODUCTION: In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand's rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand's far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health. METHODS: A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants' views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately. RESULTS: Four themes capturing the main issues were identified: (1) 'What I do': articulating the scope of medical practice at Hokianga, (2) 'What we do': the role of the hospital at Hokianga, (3) 'On the fringes', and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-for-purpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care. CONCLUSION: In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs.

The Challenges of Providing Interventional Radiology Services to Rural and Smaller Community Hospitals.

OBJECTIVE: Recruitment and retention of interventional radiologists for rural and smaller community hospital practices is a serious physician staffing issue. This article explores rural interventional radiology and perspectives of various stakeholders, such as rural radiology group practices, rural hospitals, interventional radiologists, public and private academic institutions, and urban health care providers, and considers the unique health care needs of rural patients. CONCLUSION: Some early solutions are evident. Collaboration among all stakeholders will be necessary to properly address the challenges.

Point-of-care ultrasound in rural New Zealand: Safety, quality and impact on patient management.

OBJECTIVE: To evaluate the safety, quality and impact of point-of-care ultrasound on patient management when performed by rural generalist doctors. DESIGN: Cross-sectional descriptive study. SETTING: Six rural small hospitals serving a range of communities in rural New Zealand. PARTICIPANTS: All generalist doctors practising ultrasound in the study hospitals. MAIN OUTCOME MEASURES: Technical quality, accuracy, impact on diagnostic certainty, patient disposition and overall patient care. RESULT: Participants correctly interpreted 90% of images and a similar percentage of point-of-care ultrasound findings when compared with the results of formal imaging or the final diagnosis. In total, 87% of scans contributed to the diagnostic process, changing the diagnostic probability. There was a 4% overall reduction in the number of patients needing hospital admission or transfer to an urban base hospital. The overall impact on patient care was positive for 71% of point-of-care ultrasound scans. Three percent of scans had the potential for patient harm. CONCLUSION: Rural generalists' practise a broad scope of point-of-care ultrasound that, when used as a part of the full clinical assessment, has a positive impact on patient care, improving diagnostic certainty and reducing the need for hospital admission and inter-hospital transfer. There are challenges in learning and maintaining the skills needed to practise a high standard of point-of-care ultrasound in this context. Further consideration needs to be given to the development safe scopes of practice, training, credentialing and quality assurance.

A model for internal medicine physicians in a small rural hospital.

CONTEXT: Finding providers to work in the hospitals and clinics in the small towns of the USA is a significant struggle. In the traditional model, the primary care doctor sees patients in the inpatient setting in addition to a clinic practice. In the usual hospitalist model, providers specialize to work only in the inpatient setting. ISSUES: Rural communities often lack the resources, facilities, and volume to safely adopt the usual hospitalist model, which has its own disadvantages. Small town hospitals have found several ways to find a middle ground between the two models. A provider staffing model is described that utilizes internal medicine physicians to provide inpatient and consultative outpatient care in a rural 10-bed hospital in Washington State. The hospital is located in a town with a population of about 3100, in a county with an approximate population of 70 000 people. It has a 24-hour emergency room, three primary care clinics, urgent care, X-ray, pharmacy, and laboratory capabilities. In this model, the internist on duty provides care in the inpatient unit and in the afternoon sees patients consulted from primary care providers, as well as follow-up patients from the emergency room and the inpatient setting. LESSONS LEARNED: The model potentially increases access to a higher level of care in the rural setting. It potentially provides work that for the provider is interesting, satisfying, balanced, purposeful, and appropriate to their training level. Specific norms, standards, and leadership are key to functionality, including some continued experience in a larger hospital. The model has been functioning successfully for more than 3 years. The potential cost savings over the usual hospitalist model are substantial. The model could be used in other locations and in training internal medicine physicians in the rural setting. Research in this area could include randomizing communities to this and other staffing models and following the care given and the health of the community members over time.

Barriers and facilitators to effective tuberculosis infection control practices in Madang Province, PNG - a qualitative study.

INTRODUCTION: Tuberculosis (TB) remains a major public health problem in many countries. There is a greater threat of exposure to TB in congregate settings including healthcare facilities, prisons and households where health workers treat patients with TB. In healthcare facilities, the key areas of risk of infection include settings where people with undiagnosed TB, including multidrug-resistant TB, congregate, such as outpatient waiting areas, pathology waiting areas, radiology departments and pharmacies, and wards where untreated patients await investigation results. With high levels of TB in the community, and symptoms leading people to seek treatment, health services can be TB 'hot spots', and in the absence of good TB infection control (TBIC) a clinical service may actually promote the spread of TB, rather than contain it. Practical and relevant control measures are, therefore, necessary to monitor the spread of TB. METHODS: The purpose of this hermeneutic phenomenological research was to explore rural health workers' perspectives of barriers and facilitators to effective TBIC practices in rural health facilities in Madang Province, Papua New Guinea (PNG). The conceptual framework was adopted from WHO policy on TBIC in healthcare facilities, congregate settings and households as a benchmark to guide the study. Qualitative individual and group interviews (with an average time of 30 minutes) and field notes were conducted with 12 key informants comprising clinicians (n=9) and support staff (n=3) from the health facilities. Trustworthy steps were taken during the semi-structured interview to ensure data validity through member check and repeating participants' narratives to ensure accurate representation of participants' experiences. All interviews and field notes were analysed using standard phenomenological methods. RESULTS: The findings showed that numerous interconnected factors have influenced the implementation of TBIC measures in the rural health facilities in Madang Province. They include issues related to inadequacies in the healthcare systems, access to personal protective equipment, separation procedures, sputum status, monitoring and control, training, and health services as TB 'hot spots'. CONCLUSIONS: The study found evidence that health system factors do impact on the capacity to implement TBIC. Further, factors beyond TBIC such as sociocultural factors have an important influence on the way TBIC is implemented. The results of this study are useful for clinicians, health administrators and policymakers to improve the interventions and application of TBIC procedures at the rural health facilities in PNG. The study is limited to health services in Madang Province, and therefore the findings cannot automatically be generalised to other district hospitals and health centres in other parts of PNG. However, the WHO TBIC is a standardised policy and the results of the findings may be useful for other health facilities that manage TB patients in PNG and for future health systems researchers to help improve the generalisability of the findings. Further research is needed to explore health workers' experiences of conditions, actions and everyday practical issues affecting the application of TBIC measures in the rural health facilities of PNG.

Implementation of the Procalcitonin Assay in a Rural Hospital.

Objective: Most positive studies in procalcitonin (PCT) utilization were done in large, tertiary medical centers. Furthermore, there is a paucity of data describing the implementation process. This article is the first to describe in detail the implementation process and initial outcomes after 6 months of PCT testing in a rural, 65-bed, primary hospital. Methods: Education before and during PCT implementation as well as facility rollout are described. Initial outcomes were assessed using a before and after quasi-experimental study design comparing 2 identical 6-month time periods: May to October 2016 and May to October 2017. Antibiotic consumption is described with days of therapy (DOT) per 1000 patient days (PD). Antimicrobial purchasing costs, admission rates, and length of stay (LOS) are also compared. Results: Antimicrobial consumption was variable with the greatest reduction at 6 months: 856 DOT/1000 PD before versus 576 DOT/1000 PD after (P < .0001). Admission rates and LOS were unaffected. There was no associated savings in antibiotic purchasing costs: $114 189.79 before and $139 829.26 after (difference +$25 639.47). Conclusion: Although implementation of PCT testing is feasible in a rural health care facility, after 6 months, it was associated with a marginal decrease in antibiotic consumption with no decrease in admission rates, LOS, or antibiotic cost savings.

Engaging patients with heart failure into the design of health system interventions: Impact on research methods.

The purpose of this study was to engage patients with heart failure (HF) to assess if changes are needed in a research study design, methods and outcomes when transferring interventions used in urban/community hospitals to rural hospital settings. A qualitative structured interview was conducted with eight patients with a diagnosis of HF admitted to two rural hospitals. Patients validated the study design, measures and outcomes, but identified one area that should be added to the study protocol, symptom experience. Results validated that the intervention, methods and outcomes for the planned study were important, but modifications to the study protocol resulted. Patient engagement in the conceptualization of research is essential to guide patient-centered studies.

Cross-sectional study of emergency department presentation triage categories at Goondiwindi Hospital and their effect on the treatment of acute emergencies.

OBJECTIVE: The objective of this study was to investigate the number and proportion of non-acute presentations to a district hospital emergency department in Goondiwindi, a rural Queensland town, both in the treatment of emergency cases and potential barriers patients have in seeing a medical practitioner in the general practice setting. DESIGN: Occasions of service to Goondiwindi Hospital were collated from administrative records according to Australasian Triage Scale categories and analysed by Student's t-test for monthly variations in triage category presentations. SETTING: Outpatient clinic (emergency department of a public district hospital). PARTICIPANTS: All patients presenting to Goondiwindi Hospital Emergency Department from 1 January 2013 to 30 June 2013. MAIN OUTCOME MEASURE: Proportion of high and low triage category presentations in Goondiwindi Hospital during the study period. RESULTS: Triage category 4 and 5 presentations comprised 35.9% (mean = 225 per month) and 44.4% (mean = 278 per month), respectively, of all occasions of service at the Goondiwindi Hospital Emergency Department during this 6 month period. Life-threatening presentations (Triage Category 1 and 2) comprised <5% of all occasions of service at Goondiwindi Hospital. There were statistically insignificant differences between total occasions of service by month of presentation. CONCLUSIONS: Although patients of all acuities presented to Goondiwindi Hospital, low-acuity presentations were more common than reported at larger hospitals. Frequent interruptions impairing attention to more urgent tasks were noted at Goondiwindi Hospital, causing delayed treatment of sick patients. Educating the local community in the appropriate use of public health services would help direct more attention to the most ill seeking medical care at rural emergency departments such as Goondiwindi Hospital.

[The Organization of Rural Physician Unit in the Stavropolskaia Gubernia, the Kubanskaia and Terskaia Oblast Before 1917].

The article considers becoming of rural health care in the Stavropolskaia gubernia, the Kubanskaia and Terskaia oblast prior to 1917. The statistic is presented concerning institutions of people's health.

Antimicrobial stewardship program in a Malaysian district hospital: First year experience.

BACKGROUNDS & OBJECTIVE: Antimicrobial resistance is an alarming public health threat that requires urgent global solution. Implementation of antimicrobial stewardship program (ASP) is an essential practice element for healthcare institutions in gate-keeping judicious antimicrobial use. This study highlighted the development, first year experience, and result of the implementation of ASP utilizing persuasive and restrictive approaches in a Malaysian district hospital. METHODS: An observational study was conducted between January 2015 to December 2015 on implementation of ASP among hospitalized inpatients age 12 years old and above. RESULTS: Recommendations were provided for 60% of cases (110 patients) with the average acceptance rate of 83.33%. Majority of the interventions were to stop the antimicrobial therapy (30.3%), and the most common audited antimicrobials was Piperacillin/Tazobactam (25.5%), followed by Meropenem (11.82%), Amoxicillin/Clavulanate and Vancomycin (8.18%) respectively. The concordance rate towards authorization policy was increased in 2015 (71.59% of cases) as compared before the implementation of ASP in 2014 (60.6% of cases). Restrictive enforcement under ASP had been shown to improve significantly adherence rate towards antimicrobials authorization policy (p-value: 0.004). CONCLUSION: ASP was successfully implemented in a district hospital. Future studies on its clinical outcomes are important to evaluate its effectiveness as well as focus on the improvement to the pre-existing strategies and measures.

Understanding the impacts of rural hospital closures: A scoping review.

PURPOSE: Rural hospitals are closing at unprecedented rates, with hundreds more at risk of closure in the coming 2 years. Multiple federal policies are being developed and implemented without a salient understanding of the emerging literature evaluating rural hospital closures and its impacts. We conducted a scoping review to understand the impacts of rural hospital closure to inform ongoing policy debates and research. METHODS: A comprehensive search strategy was devised by library faculty to collate publications using the PRISMA extension for scoping reviews. Two coauthors then independently performed title and abstract screening, full text review, and study extraction. FINDINGS: We identified 5054 unique citations and assessed 236 full texts for possible inclusion in our narrative synthesis of the literature on the impacts of rural hospital closure. Twenty total original studies were included in our narrative synthesis. Key domains of adverse impacts related to rural hospital closure included emergency medical service transport, local economies, availability and utilization of emergency care and hospital services, availability of outpatient services, changes in quality of care, and workforce and community members. However, significant heterogeneity existed within these findings. CONCLUSIONS: Given the significant heterogeneity within our findings across multiple domains of impact, we advocate for a tailored approach to mitigating the impacts of rural hospital closures for policymakers. We also discuss crucial knowledge gaps in the evidence base-especially with respect to quality measures beyond mortality. The synthesis of these findings will permit policymakers and researchers to understand, and mitigate, the harms of rural hospital closure.