Fatal Underfunding? Explaining COVID-19 Mortality in Spanish Nursing Homes.

The COVID-19 pandemic has exerted a disproportionate effect on older European populations living in nursing homes. This article discusses the 'fatal underfunding hypothesis', and reports an exploratory empirical analysis of the regional variation in nursing home fatalities during the first wave of the COVID-19 pandemic in Spain, one of the European countries with the highest number of nursing home fatalities. We draw on descriptive and multivariate regression analysis to examine the association between fatalities and measures of nursing home organisation, capacity and coordination plans alongside other characteristics. We document a correlation between regional nursing home fatalities (as a share of excess deaths) and a number of proxies for underfunding including nursing home size, occupancy rate and lower staff to a resident ratio (proxying understaffing). Our preliminary estimates reveal a 0.44 percentual point reduction in the share of nursing home fatalities for each additional staff per place in a nursing home consistent with a fatal underfunding hypothesis.

The association of leadership styles and nurses well-being: a cross-sectional study in healthcare settings.

INTRODUCTION: the nurses´ perception of their supervisors´ leadership styles has a substantial impact on their well-being. Effective leadership in health care is crucial in improving and enhancing the effectiveness of health care systems. This study aims to assess the leadership styles of nurse leaders as perceived by employees, and to explore the relationship between perceived leadership styles and the quality of life of nurses in Lebanese hospital settings. METHODS: it was a cross-sectional study conducted in 2017 and involved a sample of 250 nurses chosen randomly in eight hospitals. The survey included questions on socio-demographic and health-related characteristics, Multifactor Leadership Questionnaire 5X Short Form, and the Short Form Health Survey-12 V2 (SF-12v2). RESULTS: the managers used enough transformational leadership style, whereas they used fairly often transactional leadership. The Laissez-faire style was adopted from time to time by the managers. Male nurses perceive their managers as transformational significantly more than female nurses (2.94 vs. 2.73; p = 0.05). Transformational leadership style was statistically related to all scales scores of the SF-12v2 (p < 0.001) except the Social Functioning domain (p = 0.42). The transactional leadership style was associated with the Vitality scale scores (p < 0.001). The physical (p < 0.05) and Emotional Role (p < 0.001) and the mental health summary measure (p < 0.05) were lower in persons who perceived the leadership style of their manager as Laissez-faire. CONCLUSION: this study highlights the existence of a positive effect of leadership styles in the wellbeing of nurses, and confirms that nursing management has been identified as a challenge in the Lebanese hospitals.

Assessment of Changes in Rural and Urban Primary Care Workforce in the United States From 2009 to 2017.

Importance: Access to primary care clinicians, including primary care physicians and nonphysician clinicians (nurse practitioners and physician assistants) is necessary to improving population health. However, rural-urban trends in primary care access in the US are not well studied. Objective: To assess the rural-urban trends in the primary care workforce from 2009 to 2017 across all counties in the US. Design, Setting, and Participants: In this cross-sectional study of US counties, county rural-urban status was defined according to the national rural-urban classification scheme for counties used by the National Center for Health Statistics at the Centers for Disease Control and Prevention. Trends in the county-level distribution of primary care clinicians from 2009 to 2017 were examined. Data were analyzed from November 12, 2019, to February 10, 2020. Main Outcomes and Measures: Density of primary care clinicians measured as the number of primary care physicians, nurse practitioners, and physician assistants per 3500 population in each county. The average annual percentage change (APC) of the means of the density of primary care clinicians over time was calculated, and generalized estimating equations were used to adjust for county-level sociodemographic variables obtained from the American Community Survey. Results: The study included data from 3143 US counties (1167 [37%] urban and 1976 [63%] rural). The number of primary care clinicians per 3500 people increased significantly in rural counties (2009 median density: 2.04; interquartile range [IQR], 1.43-2.76; and 2017 median density: 2.29; IQR, 1.57-3.23; P < .001) and urban counties (2009 median density: 2.26; IQR. 1.52-3.23; and 2017 median density: 2.66; IQR, 1.72-4.02; P < .001). The APC of the mean density of primary care physicians in rural counties was 1.70% (95% CI, 0.84%-2.57%), nurse practitioners was 8.37% (95% CI, 7.11%-9.63%), and physician assistants was 5.14% (95% CI, 3.91%-6.37%); the APC of the mean density of primary care physicians in urban counties was 2.40% (95% CI, 1.19%-3.61%), nurse practitioners was 8.64% (95% CI, 7.72%-9.55%), and physician assistants was 6.42% (95% CI, 5.34%-7.50%). Results from the generalized estimating equations model showed that the density of primary care clinicians in urban counties increased faster than in rural counties (ß = 0.04; 95% CI, 0.03 to 0.05; P < .001). Conclusions and Relevance: Although the density of primary care clinicians increased in both rural and urban counties during the 2009-2017 period, the increase was more pronounced in urban than in rural counties. Closing rural-urban gaps in access to primary care clinicians may require increasingly intensive efforts targeting rural areas.

Task shifting of emergency caesarean section in south Ethiopia: are we repeating the brain drain.

INTRODUCTION: preventable mortality from complications which arise during pregnancy and childbirth continue to claim more than a quarter of million women´s lives every year, almost all in low- and middle-income countries. However, lifesaving emergency obstetric services, including caesarean section (CS), significantly contribute to prevention of maternal and newborn mortality and morbidity. Between 2009 and 2013, a task shifting intervention to train caesarean section (CS) teams involving 41 CS surgeons, 35 anesthetic nurses and 36 scrub nurses was implemented in 13 hospitals in southern Ethiopia. We report on the attrition rate of those upskilled to provide CS with a focus on the medium-term outcomes and the challenges encountered. METHODS: a cross-sectional study involving surveys of focal persons and a facility staff audit supplemented with a review of secondary data was conducted in thirteen hospitals. Mean differences were computed to appreciate the difference between numbers of CSs conducted for the six months before and after task shifting commenced. RESULTS: from the trained 112 professionals, only 52 (46.4%) were available for carrying out CS in the hospitals. CS surgeons (65.9%) and nurse anesthetists (71.4%) are more likely to have left as compared to scrub nurses (22.2%). Despite the loss of trained staff, there was an increase in the number of CSs performed after the task shifting (mean difference=43.8; 95% CI: 18.3-69.4; p=0.003). CONCLUSION: our study, one of the first to assess the medium-term effects of task shifting highlights the risk of ongoing attrition of well-trained staff and the need to reassess strategies for staff retention.

Newborn Service Readiness of Primary Level Health Facilities of Eastern Mountain Region of Nepal.

BACKGROUND: Newborn service readiness is facility's observed capacity to provide newborn services and a pre-requisite for quality. Newborn services are priority program of government and efforts are focused on infrastructure and supplies at peripheral health facilities. Study describes health facility readiness for newborn services in four domains of general requirements, equipment, medicines and commodities, and staffing and guidelines. METHODS: Convergent parallel mixed method using concurrent triangulation was done in public health facilities providing institutional deliveries of two randomly selected districts- Taplejung and Solukhumbu of Eastern Mountain Region of Nepal. Face to face interview and observation of facilities were done using structured questionnaire and checklist; in-depth interviews were done using interview guideline from November 2016 to January 2017. Ethical clearance was taken. Descriptive analysis and deductive thematic analysis were done. RESULTS: Mean score of newborn service readiness was 68.7±7.1 with range from 53.3 to 81.4 out of 100. Domains of general requirement, equipment, medicine and commodity, supervision, staffing and guideline were assessed. The gaps identified in general requirements were availability of uninterrupted power supply, means of communication and referral vehicle. Clean wrappers and heater for room temperature maintenance were identified during interviews to be part of the readiness. All health facilities had trained staff while retention of skill was of concern. There was felt need of enforcing adequate training coverage to suffice the need of human resources in remote. CONCLUSIONS: Efforts of improving transportation, heater for room temperature maintenance, trainings with skill retention strategy, utilization of guidelines, availability of skilled birth attendance could result increased and improved newborn service readiness.

COVID-19 pandemic preparedness: A practical guide from an operational pharmacy perspective.

PURPOSE: To describe our medical center's pharmacy services preparedness process and offer guidance to assist other institutions in preparing for surges of critically ill patients such as those experienced during the coronavirus disease 2019 (COVID-19) pandemic. SUMMARY: The leadership of a department of pharmacy at an urban medical center in the US epicenter of the COVID-19 pandemic proactively created a pharmacy action plan in anticipation of a surge in admissions of critically ill patients with COVID-19. It was essential to create guidance documents outlining workflow, provide comprehensive staff education, and repurpose non-intensive care unit (ICU)-trained clinical pharmacotherapy specialists to work in ICUs. Teamwork was crucial to ensure staff safety, develop complete scheduling, maintain adequate drug inventory and sterile compounding, optimize the electronic health record and automated dispensing cabinets to help ensure appropriate prescribing and effective management of medication supplies, and streamline the pharmacy workflow to ensure that all patients received pharmacotherapeutic regimens in a timely fashion. CONCLUSION: Each hospital should view the COVID-19 crisis as an opportunity to internally review and enhance workflow processes, initiatives that can continue even after the resolution of the COVID-19 pandemic.

The economic case for meeting employees' needs.

AIM: The purpose of this article was to demonstrate that health care organisations stand to benefit financially by accommodating the needs of nursing staff. BACKGROUND: Nurse turnover results in major financial losses in health care, and inadequate staffing resulting from turnover negatively affects patient outcomes, which further drives up health care costs. Strategies to limit nurse turnover are available and crucial in the quest for health care sustainability. EVALUATION: Economic theory was presented to underpin evidence from business, education, and health disciplines literature, and from case studies of industry best practices in employee retention. This multidisciplinary analysis was applied to the retention of nurses in health care organisations. CONCLUSION: Significant reductions in nurse turnover lead to considerable financial benefit to employers. Reductions can be achieved when employers accommodate the needs of their staff. Further investigation of specific incentive models, and the transferability of those models, is needed. Incentive programmes may be matched to specific nurse needs to decrease turnover. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing leaders have the opportunity to discover the unique need of their workforces and invest in incentive programmes to fulfil those needs.

Pediatric trainees systematically under-report duty hour violations compared to electronic health record defined shifts.

Duty hour monitoring is required in accredited training programs, however trainee self-reporting is onerous and vulnerable to bias. The objectives of this study were to use an automated, validated algorithm to measure duty hour violations of pediatric trainees over a full academic year and compare to self-reported violations. Duty hour violations calculated from electronic health record (EHR) logs varied significantly by trainee role and rotation. Block-by-block differences show 36.8% (222/603) of resident-blocks with more EHR-defined violations (EDV) compared to self-reported violations (SRV), demonstrating systematic under-reporting of duty hour violations. Automated duty hour tracking could provide real-time, objective assessment of the trainee work environment, allowing program directors and accrediting organizations to design and test interventions focused on improving educational quality.

Associations Between In-Hospital Mortality, Health Care Utilization, and Inpatient Costs With the 2011 Resident Duty Hour Revision.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) has mandated revisions to residents' work hours to improve patient safety and enhance resident education and wellness. The impact on clinical outcomes on a national level is poorly understood. OBJECTIVE: We examined data from before and after the ACGME 2011 duty hour revision and looked for differences between teaching and nonteaching US hospitals. METHODS: A retrospective observational study of patients admitted to hospitals in the 2-year periods before and after the 2011 duty hour revision was conducted, utilizing a nationally representative data set. We compared patient and hospital characteristics using standardized differences. With nonteaching hospitals serving as the control group, we used multiple group interrupted time series segmented regression analysis to test for postrevision level and trend changes in mortality, length of stay (LOS), and costs. RESULTS: We examined more than 117 million hospitalizations. At teaching and nonteaching hospitals, trends in mortality and LOS in prerevision and postrevision periods were not significantly different (all P > .05). A significant monthly reduction in cost per hospitalization was noted postrevision at teaching hospitals (P = .019) but not at nonteaching hospitals (P = .62). In the 2 years following the 2011 revision, there was a monthly reduction in cost per hospitalization (-$52.28; 95% confidence interval -$116.90 to -$12.32; P = .026) at teaching relative to nonteaching hospitals. CONCLUSIONS: There were no differences in mortality or LOS between teaching and nonteaching hospitals. However, there was a small decrease in cost per hospitalization at teaching hospitals following the 2011 revision.

Effects of a standardized emergency department protocol on after-hours use of venous duplex ultrasound.

OBJECTIVE: Vascular laboratory (VL) venous duplex ultrasound is the "gold standard" for diagnosis of lower extremity deep venous thrombosis (DVT), which is linked to many morbid conditions. Decreasing night and weekend use of VL services in the emergency department (ED) represents a potentially viable means of reducing costs as skilled personnel must remain on call and receive a wage premium when activated. We investigated the effects of workflow changes that required ED providers to use a computerized decision-making tool, integrated into the electronic medical record, to calculate a Wells score for each patient considered for an after-hours venous duplex ultrasound study for suspected DVT. METHODS: The rate of VL use and study positivity before and after implementation of the decision-making tool were examined in addition to measures of ED throughput, rate of concomitant pulmonary embolism, disposition of examined patients from the ED, observed thrombus distribution in duplex ultrasound studies positive for DVT, and calculated personnel costs of after-hours VL use. RESULTS: A total of 391 after-hours, ED-initiated venous duplex ultrasound studies were obtained during the 4-year study period (n = 213 before intervention, n = 178 after intervention; P = .12). Whereas the period immediately after the start of the intervention saw a decrease in VL use, this was not sustained. Studies performed after the intervention were not more likely to be positive for acute DVT (12.2% vs 18%; P = .1179). The average Wells score was 2.8 (range, 0-6). VL personnel were called in 347 times during the 4-year period, with a total cost of $14,643.40. Nurse-ordered studies were significantly more likely to be positive, with 22% revealing acute DVT compared with 12% for physician-ordered studies (P = .042). The intervention resulted in significant improvements in ED throughput, with time between triage and study request falling from 226 minutes to 165 minutes (P < .001). Observed thrombus distribution revealed involvement of the most proximal external iliac system in a minority of cases (11%), whereas most thrombi (89%) were limited to the femoropopliteal, calf, and superficial venous systems. CONCLUSIONS: A requirement for ED providers to document a Wells score before obtaining an after-hours venous duplex ultrasound study resulted in only a transient decrease in VL use but improved ED throughput. Studies ordered by nurses were significantly more likely to be positive, possibly as a result of consistent protocol adherence compared with the physicians. Future studies may warrant investigation into this provider variance.

Systematic review of the evidence related to mandated nurse staffing ratios in acute hospitals.

Objective The purpose of this systematic review was to evaluate and summarise available research on nurse staffing methods and relate these to outcomes under three overarching themes of: (1) management of clinical risk, quality and safety; (2) development of a new or innovative staffing methodology; and (3) equity of nursing workload. Methods The PRISMA method was used. Relevant articles were located by searching via the Griffith University Library electronic catalogue, including articles on PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Medline. Only English language publications published between 1 January 2010 and 30 April 2016 focusing on methodologies in acute hospital in-patient units were included in the present review. Results Two of the four staffing methods were found to have evidenced-based articles from empirical studies within the parameters set for inclusion. Of the four staffing methodologies searched, supply and demand returned 10 studies and staffing ratios returned 11. Conclusions There is a need to develop an evidence-based nurse-sensitive outcomes measure upon which staffing for safety, quality and workplace equity, as well as an instrument that reliability and validly projects nurse staffing requirements in a variety of clinical settings. Nurse-sensitive indicators reflect elements of patient care that are directly affected by nursing practice In addition, these measures must take into account patient satisfaction, workload and staffing, clinical risks and other measures of the quality and safety of care and nurses' work satisfaction. i. What is known about the topic? Nurse staffing is a controversial topic that has significant patient safety, quality of care, human resources and financial implications. In acute care services, nursing accounts for approximately 70% of salaries and wages paid by health services budgets, and evidence as to the efficacy and effectiveness of any staffing methodology is required because it has workforce and industrial relations implications. Although there is significant literature available on the topic, there is a paucity of empirical evidence supporting claims of increased patient safety in the acute hospital setting, but some evidence exists relating to equity of workload for nurses. What does this paper add? This paper provides a contemporary qualitative analysis of empirical evidence using PRISMA methodology to conduct a systematic review of the available literature. It demonstrates a significant research gap to support claims of increased patient safety in the acute hospital setting. The paper calls for greatly improved datasets upon which research can be undertaken to determine any associations between mandated patient to nurse ratios and other staffing methodologies and patient safety and quality of care. What are the implications for practitioners? There is insufficient contemporary research to support staffing methodologies for appropriate staffing, balanced workloads and quality, safe care. Such research would include the establishment of nurse-sensitive patient outcomes measures, and more robust datasets are needed for empirical analysis to produce such evidence.