Feed First, Ask Questions Later: Alleviating and Understanding Caregiver Food Insecurity in an Urban Children's Hospital.

OBJECTIVES: We estimated the prevalence of caregiver hospital food insecurity (defined as not getting enough to eat during a child's hospitalization), examined associations between food insecurity and barriers to food access, and propose a conceptual framework to inform remedies to this problem. METHODS: We conducted a cross-sectional study of 200 caregivers of hospitalized children in Chicago, Illinois (June through December 2011). A self-administered questionnaire assessed sociodemographic characteristics, barriers to food, and caregiver hospital food insecurity. RESULTS: Caregiver hospital food insecurity was prevalent (32%). Caregivers who were aged 18 to 34 years, Black or African American, unpartnered, and with less education were more likely to experience hospital food insecurity. Not having enough money to buy food at the hospital, lack of reliable transportation, and lack of knowledge of where to get food at the hospital were associated with hospital food insecurity. The proposed conceptual framework posits a bidirectional relationship between food insecurity and health, emphasizing the interdependencies between caregiver food insecurity and patient outcomes. CONCLUSIONS: Strategies are needed to identify and feed caregivers and to eradicate food insecurity in homes of children with serious illness.

Implementation and impact of an automated group monitoring and feedback system to promote hand hygiene among health care personnel.

BACKGROUND: Despite substantial evidence to support the effectiveness of hand hygiene for preventing health care-associated infections, hand hygiene practice is often inadequate. Hand hygiene product dispensers that can electronically capture hand hygiene events have the potential to improve hand hygiene performance. A study on an automated group monitoring and feedback system was implemented from January 2012 through March 2013 at a 140-bed community hospital. METHODS: An electronic system that monitors the use of sanitizer and soap but does not identify individual health care personnel was used to calculate hand hygiene events per patient-hour for each of eight inpatient units and hand hygiene events per patient-visit for the six outpatient units. Hand hygiene was monitored but feedback was not provided during a six-month baseline period and three-month rollout period. During the rollout, focus groups were conducted to determine preferences for feedback frequency and format. During the six-month intervention period, graphical reports were e-mailed monthly to all managers and administrators, and focus groups were repeated. RESULTS: After the feedback began, hand hygiene increased on average by 0.17 events/patient-hour in inpatient units (interquartile range = 0.14, p = .008). In outpatient units, hand hygiene performance did not change significantly. A variety of challenges were encountered, including obtaining accurate census and staffing data, engendering confidence in the system, disseminating information in the reports, and using the data to drive improvement. CONCLUSIONS: Feedback via an automated system was associated with improved hand hygiene performance in the short-term.

Evaluation of hospital medication inventory policies.

As supply chain costs constitute a large portion of hospitals' operating expenses and with $27.7 billion spent by the US hospitals on drugs alone in 2009, improving medication inventory management provides a great opportunity to decrease the cost of healthcare. This study investigates different management approaches for a system consisting of one central storage location, the main pharmacy, and multiple dispensing machines located in each department. Each medication has a specific unit cost, availability from suppliers, criticality level, and expiration date. Event-driven simulation is used to evaluate the performance of several inventory policies based on the total cost and patient safety (service level) under various arrangements of the system defined by the number of drugs and departments, and drugs' criticality, availability, and expiration levels. Our results show that policies that incorporate drug characteristics in ordering decisions can address the tradeoff between patient safety and cost. Indeed, this study shows that such policies can result in higher patient safety and lower overall cost when compared to traditional approaches. Additional insights from this study allow for better understanding of the medication inventory system's dynamics and suggest several directions for future research in this topic. Findings of this study can be applied to help hospital pharmacies with managing their inventory.

Initiation of an emergency department pharmacy program during economically challenging times.

PURPOSE: The initiation of a medication reconciliation program and other pharmacy services in the emergency department (ED) of a community hospital is described. SUMMARY: Despite a lack of funding for additional staff, the pharmacy department of a community hospital led an initiative to establish an ED pharmacy program; a major goal of the program was to address errors and inconsistencies in ED admission and discharge medication reconciliations. Implementing the program in a cost-neutral manner required the realignment of staff duties and schedules and an arrangement with the hospital's off-site central order-entry pharmacy contractor for expanded coverage hours. Other challenges during program implementation included securing ED workspace that afforded high visibility and easy access to the pharmacist and ensuring that pharmacy staff were qualified to provide critical care services (e.g., advanced life support, attendance at code responses, critical care drug information). After two months of operation, a review of a random sample (n = 102) of admission medication reconciliations indicated that those performed by pharmacists were significantly (p < 0.05) more likely than those conducted by nurses to meet specified accuracy criteria. An informal survey of ED physicians and nurses indicated that pharmacist involvement on the ED team was generally well received and viewed as integral to optimal ED services. CONCLUSION: Implementation of an ED pharmacist program improved the admission medication reconciliation process and provided additional services to improve patient safety and quality of care.

The costs of adverse drug events in community hospitals.

BACKGROUND: Adverse drug events (ADEs) occur often in hospitals, causing high morbidity and a longer length of stay (LOS), and are costly. However, most studies on the impact of ADEs have been conducted in tertiary referral centers, which are systematically different than community hospitals, where the bulk of care is delivered, and most available data about ADE costs in any setting are dated. Costs in community settings are generally lower than in academic hospitals, and the costs of ADEs might be as well. To assess the additional costs and LOS associated with patients with ADEs, a multicenter retrospective cohort study was conducted in six community hospitals with 100 to 300 beds in Massachusetts during a 20-month observation period (January 2005-August 2006). METHODS: A random sample of 2,100 patients (350 patients per study site) was drawn from a pool of 109,641 patients treated within the 20-month observation period. Unadjusted and adjusted cost of ADEs as well as LOS were calculated. RESULTS: ADEs were associated with an increased adjusted cost of $3,420 and an adjusted increase in length of stay (LOS) of 3.15 days. For preventable ADEs, the respective figures were +$3,511 and +3.37 days. The severity of the ADE was also associated with higher costs--the costs were +$2,852 for significant ADEs (LOS +2.77 days), +$3,650 for serious ADEs (LOS +3.47 days), and +$8,116 for life-threatening ADEs (LOS +5.54 days, all p < .001). CONCLUSIONS: ADEs in community hospitals cost more than $3,000 dollars on average and an average increase of LOS of 3.1 days--increments that were similar to previous estimates from academic institutions. The LOS increase was actually greater. A number of approaches, including computerized provider order entry and bar coding, have the potential to improve medication safety.

Effectiveness of a high end users program for persons with psychiatric disorders.

To evaluate the effectiveness of an intensive system of case management for high end users of inpatient care in reducing psychiatric inpatient utilization. A prepost study design with a contemporaneous comparison group was employed to determine the effects of a State designed intervention to reduce inpatient care for adults with a mental health disorder who had high utilization of inpatient psychiatric care between 2004 and 2007. Logit and negative binomial regression models were used to determine the likelihood, frequency and total days of inpatient utilization in the post period as a function of the intervention. Data from administrative reporting forms and Medicaid claims were used to construct inpatient utilization histories and characteristics of 176 patients. Patients in both groups had a significant reduction in mean inpatient days. However, being in the intervention program did not result in lower odds of being re-hospitalized or in fewer episodes during the study period.

[Alzheimer's disease and care needs: what do nurses know?]. / Doença de Alzheimer e demandas de cuidados: o que os enfermeiros sabem?

The aim of this study is to show what nurses from hospitalization units know about Alzheimer's disease (AD) and the demands of care for patients and their families. This is a descriptive and exploratory study with a qualitative approach. The data were collected through semistructured interviews. Data saturation occurred after interviewing eleven nurses in two private hospitals. Six categories emerged from the content analysis: AD characterization, risk factors, ways to diagnose, complications, treatment medication, patient and family care. It was observed that nurses have partial knowledge regarding AD, focusing their care actions only on the clinical change that caused admission. They recognize signs and symptoms but only show themselves as supporting assistants, instead of acting more autonomously in dealing with care needs and family support.

Trialling diagnosis-related groups classification in the Iranian health system: a case study examining the feasibility of introducing casemix.

This paper examines the quality of routinely collected information in an Iranian hospital in a trial of casemix classification. Australian Refined Diagnosis Related Groups (AR-DRG) were used to classify patient episodes. There were 327 DRGs identified, of which 20% had only 1 case. The grouper program identified invalid records for 4% of total separations. Approximately 4.5% of cases were classified into error DRGs and 3.4% were ungroupable. No complication and comorbidity effects were identified with 93% of total cases. R2 (variance in length of stay explained) was 44% for untrimmed cases, increasing to 63%, 57% and 58% after trimming by L3H3, IQR and 10th-95th percentile methods respectively.

Gearing service quality into public and private hospitals in small islands: empirical evidence from Cyprus.

PURPOSE: The purpose of this research is to develop and compare some determinants of service quality in both the public and private hospitals of Northern Cyprus. There is considerable lack of literature with respect to service quality in public and private hospitals. DESIGN/METHOD/APPROACH: Randomly, 454 respondents, who have recently benefited from hospital services in Famagusta, were selected to answer a modified version of the SERVQUAL Instrument. The instrument contained both service expectations and perceptions questions. FINDINGS: This study identifies six factors regarding the service quality as perceived in both public and private Northern Cyprus hospitals. These are: empathy, giving priority to the inpatients needs, relationships between staff and patients, professionalism of staff, food and the physical environment. Research results revealed that the various expectations of inpatients have not been met in either the public or the private hospitals RESEARCH IMPLICATIONS/LIMITATIONS: At the micro level, the lack of management commitment to service quality in both hospital settings leads doctors and nurses to expend less effort increasing or improving inpatient satisfaction. Hospital managers should also satisfy their employees, since job satisfaction leads to customer satisfaction and loyalty. Additionally, hospital administrations need to gather systematic feedback from their inpatients, establish visible and transparent complaint procedures so that inpatients' complaints can be addressed effectively and efficiently. ORIGINALITY/VALUE: The hospitals need to organize training sessions based on the critical importance of service quality and the crucial role of inpatient satisfaction in the health care industry. Future studies should include the remaining regions in Cyprus in order to increase research findings' generalizability. Additionally, including other dimensions such as hospital processes and discharge management and co-ordination may provide further insights into understanding inpatients' perceptions and intentions.

Nurse absenteeism and workload: negative effect on restraint use, incident reports and mortality.

AIM: This paper is a report of a study to assess the impact of nurse absenteeism on the quality of patient care. BACKGROUND: Nurse absenteeism is a growing management concern. It can contribute to understaffed units, staffing instability, and other factors that could have a negative impact on patient care. The impacts of absenteeism on the quality of nursing care have rarely been studied. METHOD: Retrospective monthly data from incident reports and staffing records in six inpatient units for 2004 were analysed. Dependent variables were the numbers of restraints, alternatives to restraints, incident reports, deaths, and length of stay. Explanatory variables were nurse absenteeism hours, patient days per nursing staff, and interaction between these variables. Controls were patient acuity and unit characteristics. Fixed effects regressions were analysed as regular or negative binomial models. FINDINGS: Neither high Registered Nurse absenteeism nor high patient load was related to restraint use when taken separately. However, high Registered Nurse absenteeism was related to restraint use when patient load was high. Registered Nurse absenteeism was related to a lower use of alternatives to restraints. Incident reports were increased by high patient load, but not absenteeism, or absenteeism given patient load. When both patient load and absenteeism were high, deaths were higher also. CONCLUSION: Absenteeism alone may not be a strong factor in lowering quality, but the combination of high Registered Nurse absenteeism and high patient load could be a factor. Staffing and absenteeism may be part of a vicious cycle in which low staffing contributes to unit absenteeism, which contributes to low staffing, and so on.

Gender disparities: a medical detoxification program.

Significant gaps exist in health care regarding gender in the United States. Health status, social roles, culturally patterned behavior and access to health care can be influenced by gender. Women have been the primary users of health care and minority women usually have received poorer quality care than Non-Hispanic White (NHW) females. The objectives of this study were to identify gender, racial and ethnic disparities in access to substance abuse treatment in a Texas hospital. Secondary data collected on 1,309 subjects who underwent detoxification were studied. Gender, race/ethnicity, drug of abuse, relapse and financial classification were included in the analysis. Results indicate Hispanic females and Non-Hispanic Black (NHB) females were about 5 and 3.5 more likely than NHW females to use Medicaid services respectively (p < .05). NHW and NHB males were more likely to use Medicare than females (p < .05). NHB and Hispanic females were 5.8 and 2.1 times more likely to receive care for abuse of cocaine when compared to NHW females respectively (p < .05). Hispanic females were 2.3 times more likely to relapse than Non-Hispanic females, and uninsured NHB females were 7.1 times at a higher risk to abuse multiple drugs compare to NHW females (p < .05). Socio-economic factors, lower labor force participation rates, and less financial independence can explain females utilizing more often Medicaid regardless of their race/ethnicity. These results can be also explained by aggressive case management utilization, socio cultural barriers and/or discriminatory practices, both intentional and unintentional.

Award-winning integrated campaign raises awareness, fills beds for rural hospital.

Being a small hospital in a rural region does not mean that competing with metropolitan facilities is out of the question. Just ask Sumter Regional Hospital, a 143-bed acute-care facility located in Americus, GA, 134 miles south of Atlanta.

Zero lift programs in small rural hospitals in Washington state: reducing back injuries among health care workers.

In Washington State, health care workers have the highest rate of compensable back injuries. Washington Hospital Services, a self-insured workers' compensation program, implemented a zero lift program in 31 of its 38 hospitals. Zero lift was defined as replacing manual lifting, transferring, and re-positioning of patients with mechanical lifting or use of other patient assist devices. This program included two trusts, two pools of hospitals that self-insure workers' compensation. The pools are governed by elected boards of trustees from the pool memberships and regulated by the State Department of Labor and Industries. This pretest-posttest descriptive study compared patient-handling injury data prior to program implementation with those after program implementation. Patient-handling injury claims decreased by 43% in the participating hospitals from 2000 to 2004 (i.e., from 3.51 to 2.23). The time lost frequency rate decreased by 50% (i.e., from 1.91 to 1.03).

Alternative indicators for monitoring the quality of a continuous intervention program on antibiotic prescribing during changing healthcare conditions.

We recently published on the impact of a four-phase hospital-wide intervention program designed to optimize the quality of antibiotic use, where a multidisciplinary team (MDT) could modify prescription at the last phase. Because health care quality was changing during the last 5 years (late 1999 to early 2004), we developed certain indicators to monitor the quality of our intervention over time. Different periods were defined as baseline (pre-intervention), initial intervention-active control, pre-crisis control, crisis control, post-crisis control and end of crisis control. Major indicators were rates of prescription modification by the MDT; prescription for an uncertain infection and a novel index formula (RIcarb) to estimate the rationale for carbapenem use. We assessed 2115 antimicrobial prescriptions. Modification of prescription rate was 30% at the beginning and decreased thereafter up to stable levels. Rate of prescriptions ordered for cases of both uncertain infection and unknown source of infection decreased significantly after intervention (i.e. from baseline to active control). In contrast, a doubling of culture-directed prescriptions was observed between these periods. RIcarb values lower and higher than 60% (modal, cut-off) were assumed as carbapenem overuse and underuse, respectively. Overuse was observed at the pre-intervention, while pronounced underuse was shown during the crisis (RIcarb, 45% and 87%, respectively). The present study demonstrates that certain indicators, other than the widely adopted impact outcomes, are a suitable tool for monitoring the quality of a continuous, long-term, active intervention on antimicrobial prescribing practice, especially when applied in a changing healthcare setting.