RESUMO
BACKGROUND: Older patients with frailty syndrome have a greater risk of poor postoperative outcomes. In this study, we used a RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to implement an assessment tool to identify frail patients and targeted interventions to improve their outcomes. STUDY DESIGN: We implemented a 5-question frailty assessment tool for patients 65 years and older admitted to the general and vascular surgery services from January 1, 2018 to December 31, 2019. Identified frail patients received evidence-based clinical orders and nursing care plan interventions tailored to optimize recovery. A RE-AIM framework was used to assess implementation effectiveness through provider and nurse surveys, floor audits, and chart review. RESULTS: Of 1,158 patients included in this study, 696 (60.1%) were assessed for frailty. Among these, 611 patients (87.8%) scored as frail or intermediately frail. After implementation, there were significant increases in the completion rates of frailty-specific care orders for frail patients, including delirium precautions (52.1% vs 30.7%; p < 0.001), aspiration precautions (50.0% vs 26.9%; p < 0.001), and avoidance of overnight vitals (32.5% vs 0%). Floor audits, however, showed high variability in completion of care plan components by nursing staff. Multivariate analysis showed significant decreases in 30-day complication rates (odds ratio 0.532; p < 0.001) after implementation. CONCLUSIONS: A frailty assessment was able to identify elderly patients for provision of targeted, evidence-based frailty care. Despite limited uptake of the assessment by providers and completion of care plan components by nursing staff, implementation of the assessment and care interventions was associated with substantial decreases in complications among elderly surgical patients.
Assuntos
Fragilidade/diagnóstico , Avaliação Geriátrica/estatística & dados numéricos , Planejamento de Assistência ao Paciente/organização & administração , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Fragilidade/epidemiologia , Fragilidade/terapia , Implementação de Plano de Saúde/estatística & dados numéricos , Hospitais Urbanos/organização & administração , Hospitais Urbanos/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Planejamento de Assistência ao Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Provedores de Redes de Segurança/organização & administração , Provedores de Redes de Segurança/estatística & dados numéricos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The initial wave of the Covid-19 pandemic has hit Italy, and Lombardy in particular, with violence, forcing to reshape all hospitals' activities; this happened even in pediatric hospitals, although the young population seemed initially spared from the disease. "Vittore Buzzi" Children's Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), had to stop elective procedures-with the exception of urgent/emergent ones-between February and May 2020 to leave space and resources to adults' care. We describe the challenges of reshaping the hospital's identity and structure, and restarting pediatric surgery and anesthesia, from May on, in the most hit area of the world, with the purpose to avoid and contain infections. Both patients and caregivers admitted to hospital have been tested for Sars-CoV-2 in every case. METHODS: Observational cohort study via review of clinical charts of patients undergoing surgery between 16th May and 30th September 2020, together with SARS-CoV -2 RT-PCR testing outcomes, and comparison to same period surgeries in 2019. RESULTS: An increase of approximately 70% in pediatric surgeries (OR 1.68 [1.33-2.13], P < .001) and a higher increase in the number of surgeries were reported (OR 1.75 (1.43-2.15), P < .001). Considering only urgent procedures, a significant difference in the distribution of the type of surgery was observed (Chi-squared P-value < .001). Sars-CoV-2-positive patients have been 0.8% of total number; 14% of these was discovered through caregiver's positivity. CONCLUSION: We describe our pathway for safe pediatric surgery and anesthesia and the importance of testing both patient and caregiver.
Assuntos
Serviço Hospitalar de Anestesia/organização & administração , Agendamento de Consultas , Teste de Ácido Nucleico para COVID-19 , COVID-19/epidemiologia , Hospitais Pediátricos/organização & administração , Hospitais Universitários/organização & administração , Pandemias , SARS-CoV-2 , Centro Cirúrgico Hospitalar/organização & administração , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Centros de Atenção Terciária/organização & administração , Adolescente , Teste de Ácido Nucleico para COVID-19/estatística & dados numéricos , Cuidadores , Criança , Pré-Escolar , Estudos de Coortes , Grupos Diagnósticos Relacionados , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Emergências/epidemiologia , Feminino , Número de Leitos em Hospital/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Hospitais Universitários/estatística & dados numéricos , Hospitais Urbanos/organização & administração , Hospitais Urbanos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Controle de Infecções/métodos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Itália/epidemiologia , Masculino , Nasofaringe/virologia , Pacientes , SARS-CoV-2/isolamento & purificação , Avaliação de Sintomas , Centros de Atenção Terciária/estatística & dados numéricos , Adulto JovemAssuntos
COVID-19/epidemiologia , Planejamento em Desastres/organização & administração , Hospitais Urbanos/organização & administração , Conduta do Tratamento Medicamentoso/organização & administração , Serviço de Farmácia Hospitalar/organização & administração , Equipamentos e Provisões/provisão & distribuição , Humanos , Cidade de Nova Iorque/epidemiologia , Pandemias , Medicamentos sob Prescrição/provisão & distribuição , SARS-CoV-2 , Fluxo de TrabalhoRESUMO
BACKGROUND: Coronavirus disease 2019 (COVID-19) emerged as a public health crisis that disrupted normal patterns of health care in the New York City metropolitan area. In preparation for a large influx of critically ill patients, operating rooms (ORs) at NewYork-Presbyterian/Columbia University Irving Medical Center (NYP-Columbia) were converted into a novel intensive care unit (ICU) area, the operating room intensive care unit (ORICU). METHODS: Twenty-three ORs were converted into an 82-bed ORICU. Adaptations to the OR environment permitted the delivery of standard critical care therapies. Nonintensive-care-trained staff were educated on the basics of critical care and deployed in a hybrid staffing model. Anesthesia machines were repurposed as critical care ventilators, with accommodations to ensure reliable function and patient safety. To compare ORICU survivorship to outcomes in more traditional environments, we performed Kaplan-Meier survival analysis of all patients cared for in the ORICU, censoring data at the time of ORICU closure. We hypothesized that age, sex, and obesity may have influenced the risk of death. Thus, we estimated hazard ratios (HR) for death using Cox proportional hazard regression models with age, sex, and body mass index (BMI) as covariables and, separately, using older age (65 years and older) adjusted for sex and BMI. RESULTS: The ORICU cared for 133 patients from March 24 to May 14, 2020. Patients were transferred to the ORICU from other ICUs, inpatient wards, the emergency department, and other institutions. Patients remained in the ORICU until either transfer to another unit or death. As the hospital patient load decreased, patients were transferred out of the ORICU. This process was completed on May 14, 2020. At time of data censoring, 55 (41.4%) of patients had died. The estimated probability of survival 30 days after admission was 0.61 (95% confidence interval [CI], 0.52-0.69). Age was significantly associated with increased risk of mortality (HR = 1.05, 95% CI, 1.03-1.08, P < .001 for a 1-year increase in age). Patients who were ≥65 years were an estimated 3.17 times more likely to die than younger patients (95% CI, 1.78-5.63; P < .001) when adjusting for sex and BMI. CONCLUSIONS: A large number of critically ill COVID-19 patients were cared for in the ORICU, which substantially increased ICU capacity at NYP-Columbia. The estimated ORICU survival rate at 30 days was comparable to other reported rates, suggesting this was an effective approach to manage the influx of critically ill COVID-19 patients during a time of crisis.
Assuntos
COVID-19/mortalidade , COVID-19/terapia , Mortalidade Hospitalar , Hospitais Urbanos/organização & administração , Unidades de Terapia Intensiva/organização & administração , Salas Cirúrgicas/organização & administração , Idoso , COVID-19/diagnóstico , Estado Terminal/terapia , Feminino , Mortalidade Hospitalar/tendências , Hospitais Urbanos/tendências , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Salas Cirúrgicas/tendências , Organização e Administração , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
Doctor-patient trust is not strong in China, but studies examining this factor remain insufficient. The present study aimed to explore the effect of doctor-patient communication, medical service quality, and service satisfaction on patient trust in doctors. Five hundred sixty-four patients with tuberculosis participated in this cross-sectional study in Dalian, China. They completed questionnaires assessing socio-demographic characteristics, doctor-patient communication, medical service quality, service satisfaction and patient trust in medical staff. A structural equation model was applied to examine the hypotheses, and all the study hypotheses were supported: (1) doctor-patient communication, medical service quality and service satisfaction were positively associated with building doctor-patient trust; (2) service quality positively mediated the relationship between doctor-patient communication and trust; (3) medical service satisfaction positively mediated the relationship between doctor-patient communication and trust; (4) medical service satisfaction positively mediated the relationship between medical service quality and doctor-patient trust; and (5) medical service quality and service satisfaction were the positively sequential mediators between communication and doctor-patient trust. Based on these findings, improvements in doctor-patient communication, medical service quality, and service satisfaction are the important issues contributing to the rebuilding of doctor-patient trust in medical service delivery.
Assuntos
Atenção à Saúde/organização & administração , Relações Médico-Paciente , Confiança , Adulto , China , Feminino , Hospitais Rurais/organização & administração , Hospitais Urbanos/organização & administração , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Inquéritos e Questionários , Adulto JovemRESUMO
INTRODUCTION: The overload of the healthcare system and the organisational changes made in response to the COVID-19 pandemic may be having an impact on acute stroke care in the Region of Madrid. METHODS: We conducted a survey with sections addressing hospital characteristics, changes in infrastructure and resources, code stroke clinical pathways, diagnostic testing, rehabilitation, and outpatient care. We performed a descriptive analysis of results according to the level of complexity of stroke care (availability of stroke units and mechanical thrombectomy). RESULTS: The survey was completed by 22 of the 26 hospitals in the Madrid Regional Health System that attend adult emergencies, between 16 and 27 April 2020. Ninety-five percent of hospitals had reallocated neurologists to care for patients with COVID-19. The numbers of neurology ward beds were reduced in 89.4% of hospitals; emergency department stroke care pathways were modified in 81%, with specific pathways for suspected SARS-CoV2 infection established in 50% of hospitals; and SARS-CoV2-positive patients with acute stroke were not admitted to neurology wards in 42%. Twenty-four hour on-site availability of mechanical thrombectomy was improved in 10 hospitals, which resulted in a reduction in the number of secondary hospital transfers. The admission of patients with transient ischaemic attack or minor stroke was avoided in 45% of hospitals, and follow-up through telephone consultations was implemented in 100%. CONCLUSIONS: The organisational changes made in response to the SARS-Co2 pandemic in hospitals in the Region of Madrid have modified the allocation of neurology department staff and infrastructure, stroke units and stroke care pathways, diagnostic testing, hospital admissions, and outpatient follow-up.
Assuntos
Betacoronavirus , Infecções por Coronavirus , Procedimentos Clínicos/organização & administração , Atenção à Saúde/organização & administração , Pandemias , Pneumonia Viral , Reabilitação do Acidente Vascular Cerebral , Acidente Vascular Cerebral/terapia , Doença Aguda , Assistência Ambulatorial/organização & administração , Agendamento de Consultas , Conversão de Leitos , COVID-19 , Infecções por Coronavirus/diagnóstico , Atenção à Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Número de Leitos em Hospital , Departamentos Hospitalares/organização & administração , Hospitais Urbanos/organização & administração , Hospitais Urbanos/estatística & dados numéricos , Humanos , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/terapia , Trombólise Mecânica/estatística & dados numéricos , Neurologia/organização & administração , Admissão do Paciente/estatística & dados numéricos , Pneumonia Viral/diagnóstico , SARS-CoV-2 , Espanha/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Reabilitação do Acidente Vascular Cerebral/estatística & dados numéricos , Telemedicina , Terapia Trombolítica/estatística & dados numéricosRESUMO
The purpose of this article is to report the experience of the Department of Hospital Pharmacy of a mid-size hospital during the peak of the COVID-19 pandemic. The human and material resources available in a mid-size hospital were more limited than in larger hospitals of the region. In this article, we describe how this Department of Hospital Pharmacy was reorganized to meet the increase in activity, the strategies developed and the lessons learned for future pandemics. The COVID-19 pandemic had a higher impact in Leganes, a city in the south of Madrid, with a population of 190,000. In the face of the dramatic increase in the proportion of patients attending our hospital between March and April 2020, the Severo Ochoa University Hospital increased the number of beds by 24.5% and fitted out new premises inside and outside the hospital (sports centers). The mean number of patients seen in our Emergency Department every day passed from 70-80 to a peak of 286 patients, with 652 hospitalized patients. The situation of emergency created by this infectious disease, with management protocols changing constantly, had a dramatic impact on the activity of hospital pharmacies. Thus, the pandemic has affected areas of economic management, magistral preparation, dispensing of medication to inpatients, ambulatory patients, patients monitored at home, institutionalized patients, and patients from private hospitals and field hospitals. Other areas affected include training, clinical trials, pharmacovigilance, and counseling boards. Two strategies were adopted to overcome these problems: a strategy centered on human resources (staff reinforcement, reallocation of responsibilities), and a strategy centered on processes (some processes were reinforced to meet the increase in activity, whereas other were temporarily suspended or reduced to the minimum).Conclusions: The Department of Hospital Pharmacy plays a key role in hospitals and has been significantly reinforced to meet the dramatic impact of the pandemic on this service. This Department has been able to reorganize its processes and take over new responsibilities such as telepharmacy and home dispensing. Hospital pharmacies play a crucial role in pharmacotherapeutic decisions in hospitals. As in other Departments, training is the area more significantly affected by the pandemic.
El objetivo de este artículo es describir la experiencia del servicio de farmacia de un hospital mediano, en el período álgido de la pandemia de COVID-19, con recursos humanos y materiales más limitados que otros hospitales de su entorno de mayor tamaño. Se analiza cómo afrontó su reorganización, debido al incremento de su actividad, así como las estrategias desarrolladas y las lecciones aprendidas para afrontar el futuro. La pandemia por COVID-19 tuvo especial repercusión en el municipio de Leganés, una ciudad de 190.000 habitantes al sur de Madrid. Ante el incremento de la afluencia de pacientes entre los meses de marzo y abril de 2020, el Hospital Universitario Severo Ochoa llegó a asumir un 24,5% más de camas, incluyendo nuevas ubicaciones tanto dentro como fuera del hospital (pabellón deportivo). Siendo la media de frecuentación del Servicio de Urgencias de 70-80 pacientes, se llegó a alcanzar un pico de 286 pacientes y 652 pacientes ingresados. Esta situación de emergencia y el abordaje de una patología infecciosa, con protocolos de tratamiento en continua revisión, impactó en todas las áreas y actividades del servicio de farmacia: adquisiciones, gestión económica, elaboración de medicamentos y dispensación a pacientes hospitalizados, pacientes externos y ambulantes, domiciliaria, a centros geriátricos, hospitales de gestión privada y hospitales de campaña. Se vieron afectadas áreas como la formación, los ensayos clínicos, la farmacovigilancia y las comisiones hospitalarias. Para superar los problemas, se aplicaron dos estrategias: una centrada en los recursos humanos (reforzamiento de áreas, reasignación de responsabilidades) y otra focalizada en los procesos (procesos que se reforzaron por un aumento de la actividad, procesos que se suspendieron temporalmente por la pandemia y procesos que se redujeron al mínimo).Conclusiones: El servicio de farmacia es una pieza clave en el hospital cuyas funciones principales son las primeras perjudicadas, pero a la vez las más reforzadas durante la pandemia. Ha tenido la capacidad de reorganizar sus procesos para asimilar nuevas actividades, como la telefarmacia y la dispensación domiciliaria. Juega un papel importante en las decisiones farmacoterapéuticas del hospital. Al igual que otros servicios clínicos, la formación ha sido el área más perjudicada.
Assuntos
Betacoronavirus , Infecções por Coronavirus/tratamento farmacológico , Pandemias , Serviço de Farmácia Hospitalar/organização & administração , Pneumonia Viral/tratamento farmacológico , COVID-19 , Ensaios Clínicos como Assunto , Planejamento em Desastres , Composição de Medicamentos , Prescrições de Medicamentos/estatística & dados numéricos , Previsões , Necessidades e Demandas de Serviços de Saúde , Número de Leitos em Hospital , Hospitais Universitários/organização & administração , Hospitais Urbanos/organização & administração , Humanos , Pacientes Internados/estatística & dados numéricos , Sistemas de Medicação no Hospital/organização & administração , SARS-CoV-2 , Espanha , Desenvolvimento de Pessoal , Tratamento Farmacológico da COVID-19RESUMO
On the 20th of March 2020, triggered by the public health emergency declared, the Health Authorities in Madrid reported a legal instruction (Orden 371/2020) indicating the organization of a provisional hospital to admit patients with COVID-19 at the Trade Fair Institution (IFEMA). Several pharmacists working in the Pharmacy and Medical Devices Department of the Madrid Regional Health Service were called to manage the Pharmacy Department of the abovementioned hospital. Required permissions to set up a PD were here authorized urgently. Tackling human and material resources, and computer systems for drug purchase and electronic prescription, were some of the initial issues that hindered the pharmaceutical provision required for patients from the very day one. Once the purchase was assured, mainly by direct purchase from suppliers, drug dispensing up to 1,250 hospitalized patients (25 nursing units) and 8 ICU patients was taken on. Dispensing was carried out through either drug stocks in the nursing units or individual patient dispensing for certain drugs. Moreover, safety issues related to prescription were considered, and as the electronic prescription was implemented we attained 100% prescriptions review and validation. The constitution of a multidisciplinary Pharmacy and Therapeutics Committee let agree to a pharmacotherapy guide, pres cription protocols, therapeutic equivalences, interactions, and drug dispensing circuits. The Pharmacy Department strategy was to ensure a very quick response to basic tasks keeping the aim to offer a pharmaceutical care of the highest quality whenever possible. Working under a health emergency situation, with many uncertainties and continuous pressure was a plight. However, the spirit of collaboration in and out of the Pharmacy Department was aligned with the whole hospital motivation to offer the highest quality of healthcare. These were possibly the keys to allow caring for almost 4,000 patients during the 42 days that the hospital lasted.
El día 20 de marzo de 2020 la Consejería de Sanidad publicó una Orden (371/2020) para la apertura de un centro hospitalario provisional para atender a pacientes COVID-19 en la Institución Ferial de Madrid (IFEMA), por razón de emergencia sanitaria. Se dispuso un equipo de farmacéuticos de la Subdirección General de Farmacia y Productos Sanitarios para la apertura de un Servicio de Farmacia, que obtuvo la autorización correspondiente por el órgano competente, con carácter de urgencia. La gestión de recursos humanos, materiales y de herramientas informáticas para la adquisición y prescripción electrónica fueron unas de las primeras dificultades que se solaparon con el primer reto de garantizar la prestación farmacéutica a los pacientes que atendía el hospital desde el mismo día uno. Asegurada la adquisición, fundamentalmente mediante la compra directa a proveedores, se planteó la dispensación para un máximo de 1.250 pacientes de hospitalización (25 controles de enfermería) y una Unidad de Cuidados Intensivos de 8 pacientes; se establecieron botiquines en las unidades de enfermería y circuitos individualizados de dispensación para determinados medicamentos. A su vez, desde el primer momento se trabajó en la seguridad en la prescripción, llegando a la revisión y validación del 100% de los tratamientos, una vez instaurada la prescripción electrónica. La creación de una Comisión de Farmacia y Terapéutica multidisciplinar permitió consensuar la guía farmacoterapéutica, protocolos de prescripción, equivalencias terapéuticas, interacciones y circuitos de dispensación de medicamentos. La estrategia del Servicio de Farmacia se basó en asegurar una respuesta rápida en las funciones básicas, sin perder la visión de incorporar una atención farmacéutica de la máxima calidad posible a medida que iba siendo factible. A pesar de un escenario adverso, de incertidumbre y presión continuas por la emergencia sanitaria, se ha mantenido un espíritu de colaboración y contribución dentro y fuera del Servicio de Farmacia, alineado con un objetivo común de trabajo en equipo para brindar una atención sanitaria rápida y de la mayor calidad posible. Posiblemente éstas han sido las claves del éxito que han permitido atender a casi 4.000 pacientes en los 42 días de vida del hospital.
Assuntos
Infecções por Coronavirus , Atenção à Saúde/organização & administração , Hospitais Urbanos/organização & administração , Modelos Teóricos , Pandemias , Serviço de Farmácia Hospitalar/organização & administração , Pneumonia Viral , Betacoronavirus , COVID-19 , Atenção à Saúde/legislação & jurisprudência , Atenção à Saúde/métodos , Prescrição Eletrônica/normas , Fiscalização e Controle de Instalações/legislação & jurisprudência , Previsões , Planejamento de Instituições de Saúde , Necessidades e Demandas de Serviços de Saúde , Hospitalização , Hospitais Urbanos/legislação & jurisprudência , Humanos , Comunicação Interdisciplinar , Segurança do Paciente , Serviço de Farmácia Hospitalar/legislação & jurisprudência , Comitê de Farmácia e Terapêutica/organização & administração , Garantia da Qualidade dos Cuidados de Saúde , SARS-CoV-2 , EspanhaRESUMO
The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.
Assuntos
Betacoronavirus , Infecções por Coronavirus , Alocação de Recursos para a Atenção à Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Hospitais Urbanos/organização & administração , Serviços de Saúde Materna/organização & administração , Unidade Hospitalar de Ginecologia e Obstetrícia/organização & administração , Pandemias , Pneumonia Viral , COVID-19 , Parto Obstétrico , Feminino , Humanos , New York , Gravidez , SARS-CoV-2 , Telemedicina/métodos , Telemedicina/organização & administração , Saúde da População Urbana , Serviços Urbanos de Saúde/organização & administraçãoRESUMO
BACKGROUND AND PURPOSE: The purpose of the study is to analyze how the coronavirus disease 2019 (COVID-19) pandemic affected acute stroke care in a Comprehensive Stroke Center. METHODS: On February 28, 2020, contingency plans were implemented at Hospital Clinic of Barcelona to contain the COVID-19 pandemic. Among them, the decision to refrain from reallocating the Stroke Team and Stroke Unit to the care of patients with COVID-19. From March 1 to March 31, 2020, we measured the number of emergency calls to the Emergency Medical System in Catalonia (7.5 million inhabitants), and the Stroke Codes dispatched to Hospital Clinic of Barcelona. We recorded all stroke admissions, and the adequacy of acute care measures, including the number of thrombectomies, workflow metrics, angiographic results, and clinical outcomes. Data were compared with March 2019 using parametric or nonparametric methods as appropriate. RESULTS: At Hospital Clinic of Barcelona, 1232 patients with COVID-19 were admitted in March 2020, demanding 60% of the hospital bed capacity. Relative to March 2019, the Emergency Medical System had a 330% mean increment in the number of calls (158 005 versus 679 569), but fewer Stroke Code activations (517 versus 426). Stroke admissions (108 versus 83) and the number of thrombectomies (21 versus 16) declined at Hospital Clinic of Barcelona, particularly after lockdown of the population. Younger age was found in stroke admissions during the pandemic (median [interquartile range] 69 [64-73] versus 75 [73-80] years, P=0.009). In-hospital, there were no differences in workflow metrics, angiographic results, complications, or outcomes at discharge. CONCLUSIONS: The COVID-19 pandemic reduced by a quarter the stroke admissions and thrombectomies performed at a Comprehensive Stroke Center but did not affect the quality of care metrics. During the lockdown, there was an overload of emergency calls but fewer Stroke Code activations, particularly in elderly patients. Hospital contingency plans, patient transport systems, and population-targeted alerts must act concertedly to better protect the chain of stroke care in times of pandemic.
Assuntos
Betacoronavirus , Infecções por Coronavirus , Hospitais Especializados/organização & administração , Hospitais Urbanos/organização & administração , Pandemias , Pneumonia Viral , Acidente Vascular Cerebral/terapia , Doença Aguda , Distribuição por Idade , COVID-19 , Infecções por Coronavirus/epidemiologia , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência , Número de Leitos em Hospital/estatística & dados numéricos , Hospitais Especializados/estatística & dados numéricos , Hospitais Urbanos/normas , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Neuroimagem/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde , Admissão do Paciente/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Alocação de Recursos , SARS-CoV-2 , Espanha/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/cirurgia , Trombectomia/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Children continue to suffer from the impact of the human immunodeficiency virus-acquired immunodeficiency syndrome (HIV/AIDS) pandemic. In Cape Town, these children receive medical care including antiretroviral therapy from facilities like Tygerberg Hospital's Paediatric Infectious Diseases Clinic. HIV-infected children may experience an increased caries experience when compared with their healthy peers. AIM: The aim of this study was to determine the oral health status of HIV-infected children younger than 12 years receiving antiviral drugs at the Paediatric Infectious Diseases Clinic. DESIGN: A cross-sectional survey was conducted among children aged between 2 and 12 years presenting at this clinic. Caregivers were interviewed to obtain information regarding health seeking behaviour, oral hygiene practices and dietary habits. A single clinician undertook a standardized clinical intraoral examination according to the World Health Organization guidelines, with modifications. RESULTS: Sixty-six children were recruited. A high prevalence of dental caries (78.8%) and an unmet treatment need of 90.4% were recorded among the participants. Most children had never visited the dentist, and those who did had mainly received emergency dental care. CONCLUSION: The high prevalence of severe dental caries in this population highlights the need for oral health awareness and the inclusion of oral health care in the comprehensive care of children with HIV. WHY THIS PAPER IS IMPORTANT TO PAEDIATRIC DENTISTS: The study highlights the importance of collaborating with health professions outside of dentistry. Doctors and nurses are often the first health professionals to come into contact with children with special needs. They should therefore be made aware of the early signs of decay so that these patients can be referred for dental treatment timeously. Holistic management of children with special healthcare needs is essential to improve their overall well-being.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Assistência Integral à Saúde/organização & administração , Assistência Odontológica/organização & administração , Cárie Dentária/epidemiologia , Infecções por HIV/complicações , Criança , Pré-Escolar , Assistência Integral à Saúde/métodos , Estudos Transversais , Índice CPO , Cárie Dentária/diagnóstico , Cárie Dentária/imunologia , Cárie Dentária/prevenção & controle , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/imunologia , Necessidades e Demandas de Serviços de Saúde , Hospitais Urbanos/organização & administração , Humanos , Masculino , Saúde Bucal , Ambulatório Hospitalar/organização & administração , Prevalência , Encaminhamento e Consulta/organização & administração , Índice de Gravidade de Doença , África do Sul/epidemiologiaRESUMO
STUDY OBJECTIVE: We examine the effects of a front-end flow model designated the rapid assessment zone on multiple emergency department (ED) operational metrics. METHODS: This was a retrospective, before-after study of consecutive patient visits at an urban community ED. Six-month periods were compared before and after an intervention in 2017 that changed patient flow and the intake process. A lead nurse role splits patient flow immediately on patient arrival according to only age and chief complaint, allowing direct bedding without the bottlenecks of vital sign measurement, full triage assessment, or Emergency Severity Index assignment. A new patient care area (designated rapid assessment zone) preferentially expedites treatment of patients likely to remain ambulatory and serves as flexible acute care space when needed by individual cases and the ED. The outcomes measured were ED length of stay, arrival-to-provider time, the rate of leaving before treatment completion, and the rate of leaving before being seen. Data were analyzed with nonparametric testing, χ2 analysis, and multiple linear regression, controlling for patient visit characteristics, ED daily census volumes, and measurements of boarding patients. RESULTS: We analyzed 43,847 visits in the preintervention and 44,792 visits in the postintervention periods. The intervention was associated with the following changes: median ED length of stay from 203 to 171 minutes (-15.8%), median arrival-to-provider time from 28 to 13 minutes (-53.6%), leaving before treatment completion from 1.0% to 0.8% (-20%), and leaving before being seen from 3.1% to 0.5% (-84%). Regression analysis accounting for multiple confounders demonstrated that the reduced length of stay after rapid assessment zone implementation persisted across Emergency Severity Index levels 2 to 5 and all ED daily census levels. CONCLUSION: The rapid assessment zone model aims to decrease front-end bottlenecks and minimize serial intake assessments at a high-volume, urban ED. It was associated with improved patient throughput and decreased early patient departure. It may represent a useful model for similar centers.
Assuntos
Serviço Hospitalar de Emergência/organização & administração , Triagem/organização & administração , Fluxo de Trabalho , Eficiência Organizacional , Arquitetura Hospitalar , Hospitais Urbanos/organização & administração , Humanos , Tempo de Internação , Modelos Lineares , Massachusetts , Estudos Retrospectivos , Triagem/métodosRESUMO
This article demonstrates effects on utilization of a clinical transformation: changing locus of care from a dedicated sickle cell day unit to an approach that "fast-tracks" patients through the emergency department (ED) into an observation unit with 24/7 access. Retrospective quantitative analyses of claims and Epic electronic medical record data for patients with sickle cell disease treated at Thomas Jefferson University (inpatient and ED) assessed effects of the clinical transformation. Additionally, case studies were conducted to confirm and deepen the quantitative analyses. This study was approved by the Thomas Jefferson University Institutional Review Board. The quantitative analyses show significant decreases in ED and inpatient utilization following the transformation. These effects likely were facilitated by increased observation stays. This study demonstrated the impact on utilization of transformation in care (from dedicated day unit to an approach that fast-tracks patients into an observation unit). Additional case studies support the quantitative findings.
Assuntos
Centros Médicos Acadêmicos/organização & administração , Anemia Falciforme/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Equipe de Assistência ao Paciente/organização & administração , Melhoria de Qualidade/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Hospitais Urbanos/organização & administração , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Assistentes SociaisRESUMO
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.
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Tratamento Farmacológico da COVID-19 , Conduta do Tratamento Medicamentoso/organização & administração , Serviço de Farmácia Hospitalar/organização & administração , Guias de Prática Clínica como Assunto , Centros Médicos Acadêmicos/organização & administração , Centros Médicos Acadêmicos/normas , COVID-19/epidemiologia , Hospitais Urbanos/organização & administração , Hospitais Urbanos/normas , Humanos , Liderança , New York/epidemiologia , Pandemias/prevenção & controle , Admissão e Escalonamento de Pessoal/organização & administração , Admissão e Escalonamento de Pessoal/normas , Farmacêuticos/organização & administração , Serviço de Farmácia Hospitalar/normas , Centros de Atenção Terciária/organização & administração , Centros de Atenção Terciária/normas , Fluxo de Trabalho , Recursos Humanos/organização & administração , Recursos Humanos/normasRESUMO
BACKGROUND: Healthcare reform in China has attracted worldwide interest and reached a new juncture. In an attempt to improve healthcare quality and patient satisfaction, the government of Beijing introduced comprehensive reform of urban public hospitals in 2016 and implemented new policies on personnel, compensation, management, and diagnosis and treatment. As the agents of healthcare service, and a target of reform measures, healthcare workers were greatly affected by these reforms but have not been carefully studied. METHODS: This study used mean value analysis, variance analysis, and qualitative content analysis to investigate the status of healthcare workers after comprehensive reform of urban public hospitals in Beijing. RESULTS: We found a gradual but constant increase in the number of healthcare workers in poor health in Beijing public hospitals. After the reforms, this population reported high challenge stress, public service motivation, job satisfaction, job performance and quality of healthcare, moderate presenteeism, and low hindrance stress and turnover intention. The status of healthcare workers differed by subgroup and changed during the reform process. CONCLUSIONS: Our study provides data useful for policy recommendations regarding the implementation and extension of future reforms and offers important lessons for developing and developed countries that are reforming public hospitals to improve efficiency and reduce costs.
Assuntos
Atitude do Pessoal de Saúde , Reforma dos Serviços de Saúde/métodos , Pessoal de Saúde/psicologia , Hospitais Públicos/organização & administração , Reorganização de Recursos Humanos/estatística & dados numéricos , Desempenho Profissional/estatística & dados numéricos , Adulto , Pequim , Feminino , Pessoal de Saúde/estatística & dados numéricos , Hospitais Urbanos/organização & administração , Humanos , Satisfação no Emprego , Masculino , Pessoa de Meia-Idade , Motivação , Presenteísmo/estatística & dados numéricosRESUMO
BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a bridge to definitive hemostasis in select patients with noncompressible torso hemorrhage. The number of patients who might benefit from this procedure, however, remains incompletely defined. We hypothesized that we could quantify the number of patients presenting to our center over a 2-year period who may have benefited from REBOA. METHODS: All patients presenting to our trauma center from 2014 to 2015 were included. Potential REBOA patients were identified based on anatomic injuries. We used ICD-9 codes to identify REBOA-amenable injury patterns and physiology. We excluded patients with injuries contraindicating REBOA. We then used chart review by two REBOA-experienced independent reviewers to assess each potential REBOA candidate, evaluate the accuracy of our algorithm, and to identify a cohort of confirmed REBOA candidates. RESULTS: Four thousand eight hundred eighteen patients were included of which 666 had injuries potentially amenable to REBOA. Three hundred thirty-five patients were hemodynamically unstable, and 309 patients had contraindications to REBOA. Sixty-four patients had both injury patterns and physiology amenable to REBOA with no contraindications, and these patients were identified as potential REBOA candidates. Of these, detailed independent two physician chart review identified 29 patients (45%) as confirmed REBOA candidates (interrater reliability kappa = 0.94, P < 0.001). CONCLUSIONS: Our database query identified patients with indications for REBOA but overestimated the number of REBOA candidates. To accurately quantify the REBOA candidate population at a given center, an algorithm to identify potential patients should be combined with chart review. STUDY TYPE: Therapeutic study, level V.
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Hemorragia/cirurgia , Hospitais Urbanos/organização & administração , Avaliação das Necessidades/estatística & dados numéricos , Ressuscitação/métodos , Centros de Traumatologia/organização & administração , Adulto , Aorta/cirurgia , Oclusão com Balão/estatística & dados numéricos , Procedimentos Endovasculares/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Hemorragia/epidemiologia , Hemorragia/etiologia , Técnicas Hemostáticas/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ressuscitação/estatística & dados numéricos , Estudos Retrospectivos , Tronco , Centros de Traumatologia/estatística & dados numéricos , Adulto JovemRESUMO
PURPOSE: This study aimed to define the public-private partnership (PPP) model, eliciting the views and assessments of stakeholders and identifying associated health policies and planning issues. METHOD: It uses qualitative research methods to examine the extent to which PPPs promote or interfere with the provision of health services, equality, efficiency, quality, health tourism, and initiatives to strengthen the national economy. Having selected an appropriate sample, researchers approached bureaucrats and experts from the Ministry of Health, Social Security Institution, Ministry of Development, Ministry of Finance, NGOs, and other state institutions and organizations. A total of 83 people were asked to complete a semi-structured questionnaire. The qualitative research data were analyzed using a descriptive-analysis method; a content analysis was carried out using a computer-based qualitative research program, MAXQDA Versions 11. RESULTS: The majority of participants expressed positive opinions about PPPs, their applicability in Turkey, and the financial viability and scope of PPPs in the health sector. They also commented on the aims, advantages, and disadvantages of such partnerships. The majority of participants believed that a PPP was an appropriate finance model for the integrated health-campus substructure of Turkey's health sector. The most positive views were expressed by public and private sector-stakeholders, while some negative views were voiced by NGO representatives. CONCLUSION: This study identified and assessed integrated health-campus projects to determine the aim, suitability, advantages, and disadvantages of the model in the health sector, particularly in relation to the cost, quality, and availability of health services. This study discusses the current positive and negative effects of integrated health-campus implementation.
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Hospitais Urbanos/organização & administração , Parcerias Público-Privadas/organização & administração , Eficiência Organizacional , Feminino , Humanos , Masculino , Modelos Organizacionais , Qualidade da Assistência à Saúde , Inquéritos e Questionários , TurquiaRESUMO
BACKGROUND: China has a high burden of diabetes mellitus (DM), and a large proportion of DM patients remain untreated for various reasons, including low availability of primary health care providers. DM patient management is one of the priorities in China's national essential public health programs. Shortage of health workforce has been a major barrier to improving access to health care for DM patients. This study examines the impact of the health workforce on outpatient utilization of DM patients. METHODS: Data were collected from China National Health Service Surveys in 2008 and 2013, covering 94 rural counties and 156 urban districts, respectively, with a total of 15,984 DM patients. Household data and facility-based data at county/district level were merged. The health workforce was measured by number of physicians per 1,000 population in county hospitals and primary health centers (PHCs), respectively. Health care seeking behavior was measured by health care utilization and distribution of health providers of the DM patients. Multilevel zero-inflated negative binomial regression was used to analyze the impact of the health workforce on outpatient visits by DM patients, and a multilevel, multinomial logit model was used to examine the impact of the health workforce on choice of health providers by DM patients. RESULTS: An increase in the number of physicians at both county hospitals and PHCs was associated with increased outpatient visits by DM patients, particularly more physicians at PHCs. With increased numbers of physicians at PHCs, outpatient visits among residents with DM in rural and western areas of China increased more than those in urban and eastern areas. More physicians at PHCs had a positive impact on improving the likelihood of outpatient visits at PHCs. The positive influence of increasing the number of physicians available to DM patients in rural and western areas was greater than that for urban and eastern DM patients. CONCLUSIONS: The health workforce is a key component of any healthcare system and is critical in improving health care accessibility. Strategies to increase coverage of health workforce at PHCs are crucial to achieving adequate levels of health services for DM patients. Allocation of health workforce should focus on PHCs in rural and low-income areas.
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Diabetes Mellitus/terapia , Mão de Obra em Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Médicos/provisão & distribuição , China , Feminino , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde , Hospitais Rurais/organização & administração , Hospitais Urbanos/organização & administração , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/organização & administraçãoRESUMO
BACKGROUND: Delays in patient transfers are associated with worse outcomes for some neurosurgical conditions. One of the primary causes of transfer delay is lack of neurosurgery intensive care unit bed availability. In the present study, we characterize the results of implementing an interhospital transfer protocol to reduce unnecessary transfers and improve bed availability. METHODS: A transfer protocol was implemented in July 2012 at the Bellevue Hospital Department of Neurosurgery that screened for and prevented transfer of low-risk patients who were unlikely to require specialized inpatient neurosurgical care. The impact of this protocol was assessed with prospectively recorded data on all potential interhospital transfers from May 2011 through June 2016. RESULTS: Of the 1978 calls (regarding 1886 individual patients), 402 occurred before the implementation of the transfer protocol and 1576 occurred after. Before the protocol, 84.1% of transfer requests were accepted, but 15.2% were subsequently denied for bed unavailability. After the protocol, a smaller share of transfer requests were accepted after protocol screening (71.8%, P < 0.001), but only 1.9% (P < 0.001) were subsequently denied because of bed unavailability. The diagnosis demographics changed significantly (P < 0.001), with a larger share of arriving transfers suffering from aneurysms or tumors after the protocol and a smaller share suffering from stenosis/disc disease without neurological symptoms. CONCLUSIONS: The transfer protocol implemented in the present study allowed transfer determination based on the need for specialized neurosurgical care rather than chance unavailability of beds. Developing interhospital transfer protocols may be an effective strategy to efficiently allocate limited hospital resources and improve transfer systems.
Assuntos
Recursos em Saúde/organização & administração , Recursos em Saúde/provisão & distribuição , Número de Leitos em Hospital/estatística & dados numéricos , Hospitais Públicos/organização & administração , Hospitais Urbanos/organização & administração , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/provisão & distribuição , Procedimentos Neurocirúrgicos/estatística & dados numéricos , Transferência de Pacientes/organização & administração , Transferência de Pacientes/estatística & dados numéricos , Doenças do Sistema Nervoso Central/epidemiologia , Doenças do Sistema Nervoso Central/cirurgia , Estudos Transversais , Implementação de Plano de Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Hospitais Públicos/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Cidade de Nova Iorque , Avaliação de Resultados da Assistência ao PacienteRESUMO
BACKGROUND: Although adding convenience for both patients and providers, the proliferation of elective services and equipment in U.S. general hospitals contributes to higher costs and raises concerns about quality and overuse. PURPOSES: We assess the relationship of two forces-health system membership and market competition-with the diffusion of elective services and equipment. METHODOLOGY/APPROACH: The sample consists of all urban U.S. nonfederal general acute hospitals in 2010 (n = 2,467). Elective equipment and services are defined by 25 services offered by less than 33% of urban general hospitals. We relate the number of elective services to environmental and organizational conditions, adopting a contingency theory perspective. Ordinary least squares regression is used to estimate the associations among the key variables. FINDINGS: Market competition is positively associated with numbers of elective services. The effect of health system membership varies by system type, with the most developed integrated systems showing a positive relationship with the quantity of elective services, relative to freestanding hospitals. Members of less-developed integrated systems, however, have fewer elective services than freestanding hospitals. PRACTICE IMPLICATIONS: The evidence on market competition is consistent with a medical arms race scenario in which hospitals pursue elective services and equipment to compete with each other. Membership in highly integrated systems does not act as a constraint on the pursuit of elective services and equipment but instead may independently promote it. It may be unrealistic to expect hospitals to resist offering elective services in the face of competitive and organizational considerations that encourage proliferation.