Social Determinants of Hallway Bed Use.

INTRODUCTION: Hallway beds in the emergency department (ED) produce lower patient satisfaction and inferior care. We sought to determine whether socioeconomic factors influence which visits are assigned to hallway beds, independent of clinical characteristics at triage. METHODS: We studied 332,919 visits, across 189,326 patients, to two academic EDs from 2013-2016. We estimated a logistic model of hallway bed assignment, conditioning on payor, demographics, triage acuity, chief complaint, patient visit frequency, and ED volume. Because payor is not generally known at the time of triage, we interpreted it as a proxy for other observable characteristics that may influence bed assignment. We estimated a Cox proportional hazards model of hallway bed assignment on length of stay. RESULTS: Median patient age was 53. 54.0% of visits were by women. 42.1% of visits were paid primarily by private payors, 37.1% by Medicare, and 20.7% by Medicaid. A total of 16.2% of visits were assigned to hallway beds. Hallway bed assignment was more likely for frequent ED visitors, for lower acuity presentations, and for psychiatric, substance use, and musculoskeletal chief complaints, which were more common among visits paid primarily by Medicaid. In a logistic model controlling for these factors, as well as for other patient demographics and for the volume of recent ED arrivals, Medicaid status was nevertheless associated with 22% greater odds of assignment to a hallway bed (odds ratio 1.22, [95% confidence interval, CI, 1.18-1.26]), compared to private insurance. Visits assigned to hallway beds had longer lengths of stay than roomed visits of comparable acuity (hazard ratio for departure 0.91 [95% CI, 0.90-0.92]). CONCLUSION: We find evidence of social determinants of hallway bed use, likely involving epidemiologic, clinical, and operational factors. Even after accounting for different distributions of chief complaints and for more frequent ED use by the Medicaid population, as well as for other visit characteristics known at the time of triage, visits paid primarily by Medicaid retain a disproportionate association with hallway bed assignment. Further research is needed to eliminate potential bias in the use of hallway beds. [West J Emerg Med. 2020;21(4)949-958.].

Observing the influence of the physical environment on family involvement in a rehabilitation setting.

INTRODUCTION: Health professionals and institutions need to understand how to facilitate family involvement within settings designed prior to the adoption of patient- and family-centered philosophies. This study sought to explore how the physical environment of an inpatient rehabilitation setting influenced family involvement in health care delivery. METHOD: We conducted this study on the inpatient acquired brain injury ward of a Canadian adult rehabilitation center. This study used a basic interpretive qualitative approach. We conducted observations of how the physical environment influenced the conversations, interactions, and activities, which were central to family involvement, in this setting. We used a systematic qualitative analysis method. This study received research ethics board approval prior to commencing. RESULTS: We conducted 26 2-hr observation sessions. Five sessions occurred in the morning, 17 in early and late afternoon, and 4 in the evening. Eighteen sessions occurred on a weekday and 8 on a weekend day. The following 6 categories emerged from the field data: (a) accessing health professionals, (b) awareness of family presence, (c) facilitating family presence, (d) facilitating patient-family activities, (e) providing information for families, and (f) facilitating family involvement in therapy. DISCUSSION: This study provided information to inform future discussions and strategies for facilitating family involvement within the existing physical environments of health care institutions. Initial steps should consider ways to help families feel welcomed, such as including additional seating in spaces, posting signage inviting families into spaces, having resources tailored to families readily available, and creating a visible sign-in/sign-out board for families. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Addressing Occupational Fatigue in Nurses: Current State of Fatigue Risk Management in Hospitals, Part 1.

OBJECTIVE: The aim of this study was to describe the current state of fatigue risk management systems (FRMS) to address nurse fatigue in hospitals. BACKGROUND: Although multiple studies have examined sources and consequences of fatigue, little is known about the current state of FRMS. METHODS: This study used a sequential exploratory mixed-method design including a survey of nurse leaders from across the United States. FINDINGS: Although healthcare organizations have implemented strategies to address fatigue, most participants' organizations did not have a formal FRMS in place. Monitoring individual nurses' levels of fatigue and using tools to predict fatigue risk were rare. CONCLUSIONS: Significant opportunities exist to implement formal FRMS in healthcare. Nursing leaders, in partnership with other organizational leaders, should develop a formal plan to monitor fatigue and implement multiple levels of interventions to prevent fatigue and mitigate its consequences.

The development of environmental assessment tools to support the creation of dementia friendly care environments: Innovative practice.

The need for more dementia friendly design in hospitals and other care settings is now widely acknowledged. Working with 26 NHS Trusts in England as part of a Department of Health commissioned programme, The King's Fund developed a set of overarching design principles and an environmental assessment tool for hospital wards in 2012. Following requests from other sectors, additional tools were developed for hospitals, care homes, health centres and housing with care. The tools have proven to be effective in both disseminating the principles of dementia friendly design and in enabling the case to be made for improvements that have a positive effect on patient outcomes and staff morale. This paper reports on the development, use and review of the environmental assessment tools, including further work that is now being taken forward by The Association for Dementia Studies, University of Worcester.

Impact of Environmental Factors on Differences in Quality of Medication Use: An Insight for the Medicare Star Rating System.

BACKGROUND: The Medicare star ratings system incentivizes health plan sponsors based on their performance across a measurement system that contains quality measures related to medication use. As health plan sponsors seek to further engage their network providers, specifically network pharmacies, to improve performance on these measures, it is important to consider the effect of environmental factors on the performance of network pharmacies. OBJECTIVE: To determine the effect of environmental factors on pharmacy quality as measured by (a) medication adherence for noninsulin diabetes medications, (b) medication adherence for renin angiotensin receptor antagonists (RASA), (c) medication adherence for cholesterol medications (statins), and (d) use of high-risk medications (HRM) in the elderly. METHODS: The EQuIPP database, which contains performance information for pharmacies for a nationwide sample of Medicare beneficiaries, was used for this analysis. Environmental factors included regions or characteristics of a community or county. County-level data was obtained from the Area Health Resource Files, a resource product available from the Health Resources & Service Administration. A logistic regression model was developed with performance as the dependent variable and regions and environmental factors as independent variables. Performance and county characteristics, such as proportion of patients in an age group, race, income, or number of outpatient visits, were classified as high and low based on a median cutoff of nationwide performance scores. RESULTS: A total of 28,950 pharmacies were included in this analysis. For most measures, the proportion of low-performing pharmacies was significantly higher in the East South Central, Mid-Atlantic, Mountain, Pacific, and West South Central regions. Pharmacies in counties with high median income, high proportion of elderly population (aged > 84 years), high proportion of elderly patients who were white or Hispanic, high proportion of elderly males, and high proportion of elderly urban patients were less likely to have low performance, whereas those with high proportion of elderly African Americans and high density of independent pharmacies were more likely to have low performance (P < 0.05-0.0001). CONCLUSIONS: This study found that environmental characteristics of a region, including pharmacy and sociodemographic characteristics, explained regional variation in quality measures related to medication use for patient populations served by pharmacies. This evaluation serves to further inform the discussion regarding case-mix adjustment of quality measures and provides information that may be important to further refine intervention strategies for pharmacies and pharmacists who serve certain regional populations. Additionally, pharmacies in greatest need of support for quality improvement may be those who serve populations that are predominantly low income and elderly African American. DISCLOSURES: Desai's postdoctoral fellowship was funded by Pharmacy Quality Solutions for conducting this study and writing the manuscript. Nau and Conklin are employed by Pharmacy Quality Solutions. An earlier version of this research was presented as a poster at the Annual Meeting of the Academy of Managed Care Pharmacy; San Diego, CA; April 7-10, 2015. Study concept and design were contributed by Conklin, Nau, Desai, and Heaton. Desai and Conklin took the lead in data collection, assisted by Nau and Heaton. The manuscript was primarily written by Desai and Heaton, with assistance from Conklin and Nau. All authors contributed to data interpretation and manuscript revision.

Microbiological Assessment of Indoor Air of Teaching Hospital Wards: A case of Jimma University Specialized Hospital.

BACKGROUND: Hospital environment represents a congenial situation where microorganisms and susceptible patients are indoors together. Thus, the objective of this study is to provide fundamental data related to the microbial quality of indoor air of Jimma University Specialized Hospital wards, to estimate the health hazard and to create standards for indoor air quality control. METHODS: The microbial quality of indoor air of seven wards of Jimma University Specialized Hospital was determined. Passive air sampling technique, using open Petri-dishes containing different culture media, was employed to collect sample twice daily. RESULTS: The concentrations of bacteria and fungi aerosols in the indoor environment of the wards ranged between 2123 - 9733 CFU/m(3). The statistical analysis showed that the concentrations of bacteria that were measured in all studied wards were significantly different from each other (p-value=0.017), whereas the concentrations of fungi that were measured in all sampled wards were not significantly different from each other (p-value=0.850). Moreover, the concentrations of bacteria that were measured at different sampling time (morning and afternoon) were significantly different (p-value =0.001). CONCLUSION: All wards that were included in the study were heavily contaminated with bacteria and fungi. Thus, immediate interventions are needed to control those environmental factors which favor the growth and multiplication of microbes, and it is vital to control visitors and students in and out the wards. Moreover, it is advisable that strict measures be put in place to check the increasing microbial load in the hospital environment.

Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors.

BACKGROUND: Unlike direct contact with patients' body, hand hygiene practice is often neglected by healthcare workers (HCWs) and visitors after contact with patients' environment. Contact with hospital environmental items may increase risk of pathogen transmission. AIM: To enumerate the number of hand-touch contacts by patients, HCWs and visitors with any hospital environmental items. METHODS: All contact-episodes between person and item were recorded by direct observation in a six-bed cubicle of acute wards for 33 working days. High-touch and mutual-touch items with high contact frequencies by HCWs, patients, and visitors were analysed. FINDINGS: In total, 1107 person-episodes with 6144 contact-episodes were observed in 66 observation hours (average: 16.8 person-episodes and 93.1 contact-episodes per hour). Eight of the top 10 high-touch items, including bedside rails, bedside tables, patients' bodies, patients' files, linen, bed curtains, bed frames, and lockers were mutually touched by HCWs, patients, and visitors. Bedside rails topped the list with 13.6 contact-episodes per hour (mean), followed by bedside tables (12.3 contact-episodes per hour). Using patients' body contacts as a reference, it was found that medical staff and nursing staff contacted bedside tables [rate ratio (RR): 1.741, 1.427, respectively] and patients' files (RR: 1.358, 1.324, respectively) more than patients' bodies, and nursing staff also contacted bedside rails (RR: 1.490) more than patients' bodies. CONCLUSION: Patients' surroundings may be links in the transmission of nosocomial infections because many are frequently touched and mutually contacted by HCWs, patients, and visitors. Therefore, the focus of hand hygiene education, environmental disinfection, and other system changes should be enhanced with respect to high-touch and mutual-touch items.

Part 1: Evidence-based facility design using Transforming Care at the Bedside principles.

An academic hospital used Transforming Care at the Bedside (TCAB) principles as the framework for generating evidence-based recommendations for the design of an expansion of the current hospital. The interdisciplinary team used the table of evidence-based data to advocate for a patient- and family-centered, safe, and positive work environment. A nurse project manager acted as liaison between the TCAB design team, architects, and facilities and design consultants. Part 2 of this series describes project evaluation outcomes.

'Lean' approach gives greater efficiency.

Adapting the 'Lean' methodologies used for many years by many manufacturers on the production line - such as in the automotive industry - and deploying them in healthcare 'spaces' can, Roger Call, an architect at Herman Miller Healthcare in the US, argues, 'easily remedy many of the inefficiencies' found within a healthcare facility. In an article that first appeared in the September 2013 issue of The Australian Hospital Engineer, he explains how 'Lean' approaches such as the 'Toyota production system', and 'Six Sigma', can be harnessed to good effect in the healthcare sphere.

A proper strategy for combating mould.

managing director of Mycologia & Mould Worx, MSc, B.(Env. Sci.), TAE40110, examines the topic of mould exposure in healthcare facilities, and the associated duty of care for hospital facility managers and engineers. The article, published here in slightly adapted form, also focuses on the need for additional training of key personnel on the risks associated with exposure to environmental microbial contamination.

CHP project brings substantial savings.

With the NHS having committed to reduce its carbon footprint by 10% by 2015, Alan Newman, a partner at building services engineers, Troup Bywaters + Anders (TB+A), describes how, with the company's expertise and help, customer, the East and North Hertfordshire NHS Trust, 'surpassed the targets two years in advance'. As he explains, the key element of an ambitious carbon reduction scheme that won the 2013 IHEEM Healthcare Estates Sustainability Award (HEJ - November 2013) was a new combined heat and power-based energy centre at the Trust's Lister Hospital in Stevenage.

Dementia-friendly design resource.

Although estimates suggest that, on average, some 30 per cent of all patients in general acute medical wards may have some form of dementia, Stirling University's Dementia Services Development Centre (DSDC), one of the leading international knowledge centres working to improve the lives of dementia sufferers, says progress in designing healthcare facilities that address such patients' needs has been 'patchy at best'. With the number of individuals living with dementia expected to double in the next 25 years, the DSDC has recently worked with Edinburgh-based architects, Burnett Pollock Associates, to develop an online resource that clearly illustrates, via 15 simulated 'dementia-friendly' healthcare 'spaces', some of the key principles to consider when designing effectively for this fast-growing group. HEJ editor, Jonathan Baillie, attended the launch of the so-called 'Virtual Hospital'.