The experiences of ethical conflict among critical care professionals in China: A qualitative study.

BACKGROUND: Ethical conflict is embedded in healthcare and is common in critical care setting. However, there is a paucity of research on the nature of ethical conflict in China. Ethical conflict has cultural and context sensitivity. Therefore, evidence is needed from different backgrounds to help discuss this issue across borders. AIM: This study aimed to qualitatively identify the experience of ethical conflict in critical care professionals in China. STUDY DESIGN: From December 2021 to February 2022, we performed semi-structured, face-to-face interviews with 21 critical care professionals from five intensive care units in a tertiary general hospital in China. A thematic analysis approach was used to analyse the data. RESULTS: Five themes and 14 sub-themes emerged from the data. Critical care professionals probably felt unable to navigate uncertainty, torn by family issues, outraged by unprofessional behaviours of medical staff, being trapped in a socioeconomic dilemma when having experience of ethical conflict. In addition, they also perceived that they could turn struggle into growth. CONCLUSIONS: The experience of ethical conflict in critical care professionals involved a mixture of feelings. This study builds a comprehensive understanding of how ethical conflict affected their perceptions of themselves and their profession and provides implications to develop effective coping strategies. RELEVANCE TO CLINICAL PRACTICE: The identification of critical care professionals' experience of ethical conflict would help identify what might trigger the ethical issues and what would be the potential target to optimize in critical practice.

Ethical conflict in nursing: A concept analysis.

AIMS AND OBJECTIVES: The purpose of this paper was to clarify the concept of ethical conflict in nursing and highlight the importance of tackling this issue. BACKGROUND: Ethical conflict is on the rise in the nursing context. It is associated with the compromise of nurses' well-being and patient care. However, there is no thorough conceptual understanding of this concept. DESIGN: Concept analysis. METHODS: Databases (PubMed, PsycINFO, CINAHL, Scopus, Embase, Web of Science and SocINDEX) were searched for studies between 1984 and 2021. Both quantitative and qualitative studies related to ethical conflict in nursing were included. Walker and Avant's method of concept analysis was used to identify the defining attributes, antecedents and consequences of the concept of ethical conflict in nursing. We followed the PRISMA-ScR checklist to report the study. RESULTS: Thirty studies were included for conceptualization. Defining attributes were divided into four categories: (1) emotional responses, (2) incompatible values, (3) competing interests and (4) ambiguous obligations. The antecedents were (1) ethical sensitivity, (2) negative ethical climate, (3) insufficient authority, (4) unrealistic expectations, (5) poor collaboration and (6) inadequate resources. The consequences were identified as (1) moral residue, (2) loss of identity, (3) professional burnout and (4) poor patient care. CONCLUSIONS: A unified conceptual model of ethical conflict in nursing shed light on the ethical issues nurses might come across in practice. Despite the fact that ethical conflict is inherently negative, we conceptualised this concept as a neutral fact and an opportunity for nursing action. The construct identification provides basis for both the development of practice and the development of staff support and education. RELEVANCE TO CLINICAL PRACTICE: A clearer understanding of such an important facet of nursing practice helps nurses raise awareness of ethical conflict and implement effective coping strategies to improve their well-being and patient care. NO PATIENT OR PUBLIC CONTRIBUTION: This is a review article conducted by the researchers, so there is no patient or public contribution.

The experiences of intensive care nurses coping with ethical conflict: a qualitative descriptive study.

BACKGROUND: The critical conditions and life risk scenarios make intensive care nurses susceptible to ethical conflict. Negative consequences were recognized at both the individual level and the professional level which highly compromised the patient care and nurses' well-being. Therefore, ethical conflict has become a major concern in nursing practice. However, the experience of coping with ethical conflict among intensive care nurses remains unclear. AIMS: This study aims to explore the experience of intensive care nurses coping with ethical conflict in China. METHODS: From December 2021 to February 2022, in- depth interviews with 15 intensive care nurses from five intensive care units in a tertiary general hospital in China was performed using purposive sampling. An inductive thematic analysis approach was used to analyze the data. We applied the consolidated criteria for reporting qualitative research for this study. RESULTS: Two distinctive themes were found: detachment and engagement, which contained four subthemes: ignoring ethical problems in the workplace, seeking ways to express emotions, perspective-taking, and identifying positive assets. Theses coping strategies demonstrated an ongoing process with different essential features. CONCLUSION: This study provides a new insight into the experience of intensive care nurses coping with ethical conflict in clinical nursing. Intensive care nurses demonstrated differential experience of coping with ethical conflict including problem-focused, emotion-focused and meaning-making strategies. These findings have implications for policymakers and nursing administrators to develop ethical education and training and supportive environment for intensive care nurses to tackle this issue.

Critical care nurses' knowledge, attitudes, and practices of pressure injury prevention in China: A multicentric cross-sectional survey.

Pressure injury is a serious and preventable problem in intensive care units. Translating guidelines into clinical practice can reduce the incidence of pressure injury. Identifying clinical status, barriers and facilitators contribute to guideline implementation. To identify the knowledge, attitudes, and practices of pressure injury prevention in Chinese critical care nurses. Secondary data were extracted from a multicentric clinical trial. Knowledge and attitudes toward pressure injury prevention were assessed by a fourteen-item questionnaire. The observed practices were recorded using a case report form. The report complies with the STROBE statement. A total of 950 critical care nurses in 15 hospitals from six provinces of China were investigated. A total of 53.1% of nurses received a median score of 6 points or less. Knowledge regarding the repositioning procedure, risk assessment, and heel pressure injury prevention was insufficient. Over 99% of nurses strongly or somewhat agreed that pressure injury prevention was very important and that they were willing to take measures to prevent pressure injury. A total of 27 781 patient days of pressure injury prevention practice were recorded. Repositioning was the most commonly used prevention measure, followed by support surfaces and prophylactic dressings. A combination of repositioning, support surface, and prophylactic dressing was lacking. Chinese critical nurses showed a low level of knowledge and a positive attitude toward pressure injury prevention. Practices of pressure injury prevention were unsatisfactory. There is a clear gap between the guidelines and clinical practices. The barrier (low-level knowledge) and facilitator (positive attitude) were identified in this study. According to these findings, strategies need to be developed to promote guideline implementation.

Values and preferences of health care professionals, policy-makers, patients and family members regarding recommendations of adapted physical restraint guidelines in critical care: A survey research.

BACKGROUND: The values and preferences of stakeholders are crucial in the development of guidelines. AIM: The aim of this study was to investigate stakeholders' values and preferences regarding draft recommendations for adapted physical restraint guidelines in China. STUDY DESIGN: This survey research was carried out at four university-affiliated comprehensive hospitals based in the eastern, central, western, and north eastern zones of China from January 5-30, 2022. A 48-item self-report questionnaire was distributed, and values and preferences were assessed on a 10-point Likert scale. One-way ANOVA was used to compare values and preference scores among stakeholders. As effect-size measures, partial η2 and Cohen's f values are reported for ANOVA results. RESULTS: A total of 1155 stakeholders were enrolled in the study. The mean value and preference scores were higher than seven for 46 draft recommendations. There was either no significant difference in the values and preferences of the stakeholders for the draft recommendations or there was a significant difference (p values ranged from <0.001 ∼ .048), but the effect size was small or very small (partial η2 value ranged from 0.011 ∼ .044; Cohen's f value ranged from 0.101 ∼ .214). The mean scores of patients for items related to cyber therapy and early tracheotomy were 6.84 and 6.60, respectively, which were lower than those of family members, policy-makers, and health care professionals and were statistically significant (p < 0.001). The partial η2 and Cohen's f values of the effect size were 0.083/0.062 and 0.302/0.256, respectively, which indicated that the differences were moderate. CONCLUSION: These recommendations were in line with the values and preferences of stakeholders. Patients were more supportive of implementing cyber therapy or hypnosis for pain management but did not support early tracheotomy to reduce the duration of mechanical ventilation. Guideline panels could use value and preference information to revise and endorse recommendations of adapted physical restraint guidelines in critical care. RELEVANCE TO CLINICAL PRACTICE: Practitioners should implement recommendations based on the values and preferences of stakeholders.

Association between Frailty and 90-Day Outcomes amongst the Chinese Population: A Hospital-Based Multicentre Cohort Study.

INTRODUCTION: Frailty has gained increasing attention as it is by far the most prevalent geriatric condition amongst older patients which heavily impacts chronic health status. However, the relationship between frailty and adverse health outcomes in China is far from clear. This study explored the relation between frailty and a panel of adverse health outcomes. METHODS: We performed a multicentre cohort study of older inpatients at 6 large hospitals in China, with two-stage cluster sampling, from October 2018 to April 2019. Frailty was measured according to the FRAIL scale and categorized into robust, pre-frail, and frail. A multivariable logistic regression model and multilevel multivariable negative binomial regression model were used to analyse the relationship between frailty and adverse outcomes. Outcomes were length of hospitalization, as well as falls, readmission, and mortality at 30 and 90 days after enrolment. All regression models were adjusted for age, sex, BMI, surgery, and hospital ward. RESULTS: We included 9,996 inpatients (median age 72 years and 57.8% male). The overall mortality at 30 and 90 days was 1.23 and 1.88%, respectively. At 30 days, frailty was an independent predictor of falls (odds ratio [OR] 3.19; 95% CI 1.59-6.38), readmission (OR 1.45; 95% CI 1.25-1.67), and mortality (OR 3.54; 95% confidence interval [CI] 2.10-5.96), adjusted for age, sex, BMI, surgery, and hospital ward clustering effect. At 90 days, frailty had a strong predictive effect on falls (OR 2.10; 95% CI 1.09-4.01), readmission (OR 1.38; 95% CI 1.21-1.57), and mortality (OR 6.50; 95% CI 4.00-7.97), adjusted for age, sex, BMI, surgery, and hospital ward clustering effect. There seemed to be a dose-response association between frailty categories and fall or mortality, except for readmission. CONCLUSIONS: Frailty is closely related to falls, readmission, and mortality at 30 or 90 days. Early identification and intervention for frailty amongst older inpatients should be conducted to prevent adverse outcomes.

The relationships of ethical climate, physician-nurse collaboration and psychological empowerment with critical care nurses' ethical conflict in China: A structural equation model.

AIMS: To explore the relationships of ethical climate, physician-nurse collaboration and psychological empowerment with ethical conflict in critical care nurses. BACKGROUND: Ethical conflict is a major ethical issue in nursing practice. Little research has been done on the associated factors from both organizational and personal perspectives, especially in China. METHODS: From October 2021 to March 2022, we collected the data from 342 critical care nurses in three tertiary general hospitals in China via questionnaires about four variables (ethical climate, physician-nurse collaboration, psychological empowerment and ethical conflict). Data were analysed using Spearman's correlation and a structural equation model through statistical product and service solutions (SPSS) and analysis of moment structure (AMOS). RESULTS: Critical care nurses' ethical conflict showed a negative correlation with ethical climate (r = -0.351), physician-nurse collaboration (r = -0.347) and psychological empowerment (r = -0.259) (all p < 0.001). Physician-nurse collaboration partially mediated the relationship between ethical climate and ethical conflict. Additionally, physician-nurse collaboration and psychological empowerment served as sequential mediators in the association. CONCLUSIONS: These findings suggested that negative ethical climate can lead to poor physician-nurse collaboration and ultimately ethical conflict. The intermediary role of psychological empowerment and physician-nurse collaboration was also identified. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers should use the study as a fundamental basis to evaluate factors that can affect nurses' ethical conflict and develop effective strategies to mitigate this issue, which may help improve nurses' wellbeing and quality of patient care.

Validation of E-PRE-DELIRIC in cardiac surgical ICU delirium: A retrospective cohort study.

BACKGROUND: The early prediction model for delirium in intensive care units (ICUs)-E-PRE-DELIRIC-has been created to predict delirium development during the length of stay in ICUs. However, there have been few early predictive models for delirium in the cardiac surgical ICU (CSICU), and the predictive ability of the E-PRE-DELIRIC among patients following cardiac surgeries is still unknown. AIMS AND OBJECTIVES: To validate the performance of E-PRE-DELIRIC in CSICU. DESIGN: A retrospective cohort study. METHODS: Data were retrospectively extracted from the electronic records for patients admitted in CSICU from January 2018 to December 2018 in a tertiary teaching hospital in China. Adult patients were included following the criteria of the E-PRE-DELIRIC model. Predictors, including age, history of cognitive impairment, history of alcohol abuse, urgent admission, use of corticosteroids, respiratory failure, blood urea nitrogen, and mean arterial pressure, at the time of ICU admission were retrieved, and delirium was assessed twice a day using the Confusion Assessment Method for the ICU. The performance of the E-PRE-DELIRIC model was evaluated by area under receiver operator characteristic curve, precision-recall curve (AUPRC), Hosmer-Lemeshow (HL) test, and calibration belt. RESULTS: Of the 725 patients included, 120 (16.6%) developed delirium. The AUROC was 0.54 (95% confidence interval [CI], 0.48-0.59), and the AUPRC was 0.18 (95% CI, 0.12-0.20). The HL test showed a significant difference between predicted probability and delirium occurrence (χ2 = 17.326, P = .027), and the overestimation chance of the E-PRE-DELIRIC score was 0.24 to 0.43. CONCLUSION: The E-PRE-DELIRIC model has poor-to-fair predictive value in this study; thus, its application among the CSICU patients is limited. Development of reliable and validated tools for early prediction of delirium in CSICU is required. RELEVANCE TO CLINICAL PRACTICE: Early prediction of delirium risk at CSICU admission is of vital importance and could provide timely information to caregivers. However, the E-PRE-DELIRIC model should be applied cautiously in the CSICU because of the significant probability of over-estimating the risk of developing delirium.

An early predictive model of frailty for older inpatients according to nutritional risk: protocol for a cohort study in China.

BACKGROUND: Previous reports suggest that the attributes of frailty are multidimensional and include nutrition, cognition, mentality, and other aspects. We aim to develop an early warning model of frailty based on nutritional risk screening and apply the frailty early warning model in the clinic to screen high-risk patients and provide corresponding intervention target information. METHODS: The proposed study includes two stages. In the first stage, we aim to develop a prediction model of frailty among older inpatients with nutritional risk. Study data were collected from a population-based aging cohort study in China. A prospective cohort study design will be used in the second stage of the study. We will recruit 266 older inpatients (age 65 years or older) with nutritional risk, and we will apply the frailty model in the clinic to explore the predictive ability of the model in participants, assess patients' health outcomes with implementation of the frailty model, and compare the model with existing frailty assessment tools. Patients' health outcomes will be measured at admission and at 30-day follow-up. DISCUSSION: This project is the first to develop an early prediction model of frailty for older inpatients according to nutritional risk in a nationally representative sample of Chinese older inpatients of tertiary hospitals. The results will hopefully help to promote the development of more detailed frailty assessment tools according to nutritional risk, which may ultimately lead to reduced health care costs and improvement in independence and quality of life among geriatric patients. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1800017682 , registered August 9, 2018; and ChiCTR2100044148 , registered March 11, 2021.

Prevalence of cognitive impairment in Chinese older inpatients and its relationship with 1-year adverse health outcomes: a multi-center cohort study.

BACKGROUND: Previous studies on the relationship between cognitive impairment and adverse outcomes among geriatric inpatients are not representative of older inpatients in China because of insufficient sample sizes or single-center study designs. The purpose of our study was to examine the prevalence of cognitive impairment and the relationship between cognitive impairment and 1-year adverse health outcomes in older inpatients. METHODS: This study was a large-scale multi-center cohort study conducted from October 2018 to February 2020. Six tertiary hospitals across China were selected using a two-stage cluster sampling method, and eligible older inpatients were selected for the baseline survey and follow-up. The Mini Cognitive Scale and the FRAIL scale were used to screen for cognitive impairment and frailty, respectively. The EuroQol-5 Dimension-5 Level questionnaire was used to assess health-related quality of life (HRQoL). We used a generalized estimating model to evaluate the relationship between cognitive impairment and adverse outcomes. RESULTS: The study included 5008 men (58.02%) and 3623 women (41.98%), and 70.64% were aged 65-75 years, and 26.27% were aged 75-85 years. Cognitive impairment was observed in 1756 patients (20.35%). There were significant differences between participants with cognitive impairment and those with normal cognitive function for age, gender, surgery status, frailty, depression, handgrip strength and so on. After adjusting for multiple covariates, compared with patients with normal cognitive function, the odds ratio for 1-year mortality was 1.216 (95% confidence interval [CI]: 1.076-1.375) and for 1-year incidence of frailty was 1.195 (95% CI: 1.037-1.376) in patients with cognitive impairment. Similarly, the regression coefficient of 1-year HRQoL was - 0.013 (95% CI: - 0.024-- 0.002). In the stratified analysis, risk of adverse outcome within 1 year was higher in older patients with cognitive impairment aged over 75 years than those aged 65-74 years. CONCLUSIONS: We revealed that cognitive impairment was highly correlated with occurrence of 1-year adverse health outcomes (death, frailty, and decreased HRQoL) in older inpatients, which provides a basis for formulating effective intervention measures. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1800017682 , registered 09 August 2018.

Psychometric properties of the ethical conflict in nursing questionnaire critical care version among Chinese nurses: a cross-sectional study.

BACKGROUND: Ethical conflicts are common in the critical care setting, and have compromised job satisfaction and nursing care quality. Using reliable and valid instruments to measure the ethical conflict is essential. This study aimed to translate the Ethical Conflict in Nursing Questionnaire - Critical Care Version into Chinese and determine the reliability and validity in the population of Chinese nurses. METHODS: Researchers obtained permission and followed the translation-backward method to develop the Chinese version of the Ethical Conflict in Nursing Questionnaire - Critical Care Version (ECNQ-CCV-C). Relevant psychometric properties were selected according to the Consensus-based standards for the selection of health status measurement instruments checklist. Critical care nurses were recruited from two tertiary public hospitals in Hangzhou, Zhejiang Province, and Kunming, Yunnan Province. Of the 264 nurses we approached, 248 gave their consent and completed the study. RESULTS: The ECNQ-CCV-C achieved Cronbach's alphas 0.902 and McDonald's omega coefficient 0.903. The test-retest reliability was satisfactory within a 2-week interval (intraclass correlation coefficient = 0.757). A unidimensional structure of the ECNQ-CCV-C was determined. Confirmatory factor analysis supported acceptable structure validity. Concurrent validity was confirmed by a moderate relation with a measure for hospital ethical climate (r = - 0.33, p < 0.01). The model structure was invariant across different gender groups, with no floor/ceiling effect. CONCLUSIONS: The ECNQ-CCV-C demonstrated acceptable reliability and validity among Chinese nurses and had great clinical utility in critical care nursing.

Do-not-resuscitate decision making for terminally ill older patients in the emergency department: An explorative, descriptive inquiry of Chinese family members.

Many terminally ill older adults depend on family members to make medical decisions in China. Many family members find it difficult to make do-not-resuscitate (DNR) decisions in emergency departments (ED). Currently, factors that affect DNR decision making by family members for older adults needing emergency care have not been well studied. This qualitative inquiry explores factors influencing DNR decision-making among family members of terminally ill older adults in ED. Semi-structured in-depth interviews were conducted for a 12-family member of terminally ill older adults at ED in China. Results of the conventional content analysis showed that family members made DNR decisions based on a wide of reasons: (a) subjective perception of family members, (b) conditions of the terminally ill older adults, (c) external environmental factors, and (d) internal family factors. The findings of this study expand our knowledge and understanding of factors influencing DNR decision-making by family members of terminally ill older adults in ED.

Prevalence and associated factors for frailty among elder patients in China: a multicentre cross-sectional study.

BACKGROUND: To date, most previous studies of frailty among hospitalized elderly Chinese patients have been conducted based on small samples, which cannot represent the elderly patient population. The aim of this study was to identify the prevalence of and risk factors for frailty among elderly patients in China. STUDY DESIGN AND SETTING: This cross-sectional study surveyed 9996 elderly patients from 6 tertiary-level hospitals in China. The prevalence of frailty among patients from selected wards was surveyed by trained investigators. A mixed-effects Poisson regression model was used to analyse the factors associated with frailty among elderly patients. RESULTS: The mean age of all subjects was 72.47 ± 5.77 years. The prevalence rate of frailty in this study was 18.02%. After adjustments were made for the confounding effect of the clustering of hospital wards, a mixed-effects Poisson regression model showed that the associated factors of frailty included the following: age (OR: 1.016, 95% CI: 1.012-1.020), BMI < 18.5 (OR: 1.248, 95% CI: 1.171-1.330), female gender (OR: 1.058, 95% CI: 1.004-1.115), ethnic minority (OR: 1.152, 95% CI: 1.073-1.236), admission to hospital by the emergency department (OR: 1.104, 95% CI: 1.030-1.184), transit from another hospital (OR: 1.159, 95% CI: 1.049-1.279), former alcohol use (OR: 1.094, 95% CI: 1.022-1.171), fall history in the past 12 months (OR: 1.257, 95% CI: 1.194-1.323), vision dysfunction (OR: 1.144, 95% CI: 1.080-1.211), cognition impairment (OR: 1.182, 95% CI: 1.130-1.237), sleeping dysfunction (OR: 1.215, 95% CI: 1.215-1.318), urinary dysfunction (OR: 1.175, 95% CI: 1.104-1.251), and defecation dysfunction (OR: 1.286, 95% CI: 1.217-1.358). The results also showed some of the following protective effects: BMI > 28 (OR: 0.897, 95% CI: 0.856-0.940); higher education level, including middle school (OR: 0.915, 95% CI: 0.857, 0.977) and diploma and above (OR: 0.891, 95% CI: 0.821, 0.966); and current alcohol use (OR: 0.869, 95% CI: 0.815, 0.927). CONCLUSION: We identified a relatively high prevalence of frailty among elderly patients, and there are several associated factors among the population derived from this investigation of a large-scale, multicentre, nationally representative Chinese elderly inpatient population. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1800017682, registered 09 August 2018.

Potential associated factors of functional disability in Chinese older inpatients: a multicenter cross-sectional study.

BACKGROUND: There is still controversy about the relationship between aging and changes in functional ability. This study aims to describe the level of basic activities of daily living (ADL) and higher-level instrumental activities of daily living (IADL) in different age groups and explore the factors associated with functional disability in Chinese older inpatients. METHODS: This cross-sectional study surveyed 9996 older inpatients aged 65 years and older from six tertiary hospitals in China from October 2018 to February 2019. The levels of ADL and IADL were measured by scores of the Barthel index and Instrumental Activities of Daily Living Scale. A mixed-effect generalized linear model was used to examine the association between functional disability and covariates. RESULTS: The average ADL score was 89.51 ± 19.29 and the mean IADL score 6.76 ± 2.01 for all participants. There was a trend of decreasing scores along with aging, and significant differences between age groups were also observed (P < 0.001). The most affected ADL and IADL was stair climbing and shopping, respectively. Sociodemographic characteristics (such as age), physical health variables (frailty, emaciation, hearing dysfunction, urinary dysfunction, defecation dysfunction, falling accidents in the past 12 months), and mental health variables (cognitive dysfunction, depression) were associated with functional disability. Patients from the emergency department or transferred from other hospitals and former alcohol drinkers are at risk of ADL disability. Former smoking is a risk factor for IADL disability, whereas current drinking, higher-level education, and residing in a building without elevators were likely to maintain a better IADL performance. CONCLUSIONS: Functional ability declines with aging, older inpatients are low dependency upon ADL and IADL. There are several associated factors among the participants derived from this investigation of a large-scale, multicenter, nationally representative Chinese older inpatient population. These findings potentially have major importance for the planning of hospital services, discharge planning, and post-discharge care. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1800017682 , registered August 9, 2018.

Hospitalization costs among immobile patients with hemorrhagic or ischemic stroke in China: a multicenter cross-sectional study.

BACKGROUND: In this study, we aimed to analyze the hospitalization costs for immobile patients with hemorrhagic stroke (IHS) or ischemic stroke (IIS) in China and to determine the factors associated with hospitalization costs. METHODS: We evaluated patients with IHS and IIS hospitalized between November 2015 and July 2016 in six provinces or municipality cities of China. Linear regression analysis was used to examine the association with hospitalization costs and predictors. RESULTS: In total, 1573 patients with IHS and 3143 with IIS were enrolled and analyzed. For IHS and IIS, the average length of stay (LoS) was 17.40 ± 12.3 and 14.47 ± 11.55 days. The duration of immobility was 12.11 ± 9.98 and 7.36 ± 9.77 days, respectively. Median hospitalization costs were RMB 47000.68 (interquartile range 19,827.37, 91,877.09) for IHS and RMB 16578.44 (IQR 7020.13, 36,357.65) for IIS. In both IHS and IIS groups, medicine fees accounted for more than one-third of hospitalization costs. Materials fees and medical service fees accounted for the second and third largest proportions of hospital charges in both groups. Linear regression analysis showed that LoS, hospital level, and previous surgery were key determinants of hospitalization costs in all immobile patients with stroke. Subgroup analysis indicated that hospital level was highly correlated with hospitalization costs for IHS whereas pneumonia and deep vein thrombosis were key factors associated with hospitalization costs for IIS. CONCLUSIONS: We found that hospitalization costs were notably higher in IHS than IIS, and medicine fees accounted for the largest proportion of hospitalization costs in both patient groups, perhaps because most patients ended up with complications such as pneumonia thereby requiring more medications. LoS and hospital level may greatly affect hospitalization costs. Increasing the reimbursement ratio of medical insurance for patients with IHS is recommended. Decreasing medicine fees and LoS, preventing complications, and improving treatment capability may help to reduce the economic burden of stroke in China.

Nursing resources and major immobility complications among bedridden patients: A multicenter descriptive study in China.

BACKGROUND: Being bedridden, which is a common clinical phenomenon, causes a series of complications related to immobilization. Effective management of immobility complications requires a reasonable allocation of nursing resources. Unit-level evidence about the relationship between nursing resources and immobility complications is lacking. OBJECTIVES: To gain insight into nursing resources in China and explore the relationship between nursing resources and the incidence of major immobility complications among bedridden patients. The major immobility complications included in our study were pressure ulcers, deep vein thrombosis, pneumonia and urinary tract infection. DESIGN: A nationwide, multicenter, cross-sectional survey. SETTING: From November 2015 to June 2016, 18 hospitals (six tertiary and 12 secondary) from six provinces and cities in different geographic regions (eastern, southern, western, northern and central) in China participated in our study. PARTICIPANT: Intensive care units, internal medicine and surgery wards with high proportions of bedridden patients were chosen as investigation sites. Of the total of 23,637 available patients in the selected wards, 19,530 were recruited. METHODS: Data on nursing resources and ward characteristics were collected mainly by questionnaire. The incidence of major immobility complications among bedridden patients was measured by trained investigators. Data on patient characteristics were collected from the patient record system of each hospital. Multilevel regression analysis was used to estimate the impact of nursing resources on the incidence of major immobility complications, adjusting for patient and ward characteristics. RESULTS: The study included 23,637 patients in 213 wards, and 19,530 were recruited. The incidence of the four complications was 0.77% (pressure ulcers), 0.82% (deep vein thrombosis), 3.39% (pneumonia) and 0.86% (urinary tract infection), and the overall incidence of major immobility complications was 5.41%. The incidence of major immobility complications was higher in wards not attaining the target bed-to-nurse ratios than in those that met these criteria (ß = 0.44, 95% confidence interval [CI]: 0.02-0.87; OR = 1.553, 95% CI: 1.002-2.387). The incidence of major immobility complications was negatively associated with the proportion of nurses with intermediate or senior job titles (ß = -2.12, 95% CI: -3.78 to -0.45; OR = 0.120, 95% CI: 0.023-0.638). However, the incidence of major immobility complications was unexpectedly positively associated with the proportion of nurses with a bachelor's degree or higher (ß = 1.06, 95% CI: 0.31-1.81; OR = 2.886, 95% CI: 1.363-6.110). CONCLUSIONS: Sufficient nurse staffing and higher professional titles of nurses might contribute to reducing the incidence of major immobility complications. Nurse experience was not related to the incidence of major immobility complications. However, the association between nurse education level and the incidence of major immobility complications requires further investigation. IMPLICATIONS FOR NURSING MANAGEMENT: More nurses,especially nurses with higher professional titles may reduce the incidence of major immobility complications.

The prevalence, incidence, and associated factors of pressure injuries among immobile inpatients: A multicentre, cross-sectional, exploratory descriptive study in China.

The aim of this study was to assess the prevalence, incidence, and the associated factors of pressure injuries (PIs) among immobile hospitalised patients in China. Being immobile during hospitalisation put these patients at a higher risk of PIs. There is little literature about pressure injury (PI) prevalence or PI incidence in immobile hospitalised patients in hospitals in China. This was a multicentre, cross-sectional, exploratory descriptive study. A total of 23 985 immobile patients were recruited from 25 general hospitals in six provinces of China from November 1, 2015 to March 18, 2016. Information was collected on demographic characteristics, physical assessment information, and treatment and nursing care measures. The PI period prevalence was 3.38%, and the PI cumulative incidence was 1.23%. Most PIs (84.03%) were Stage 1 or Stage 2. A total of 48.22% of PIs occurred in the sacrum or heel region. In the multivariate analysis, the following factors were associated with higher PI prevalence: age, gender, length of immobility, type of hospital, modified Braden Scale score, urinary incontinence, faecal incontinence, low serum albumin, the usage of fixation or restraint devices, and patient's discharge diagnosis (lower limb fracture, malnutrition, and spinal cord injury). PI prevalence for immobile hospitalised patients in the study was lower than those reported in literature. However, because of the large population in China, the number of patients who suffer with PIs can be very high. The relating factors of higher PI prevalence identified in this study were consistent with current literature. Patients with a higher number of these associated factors should be monitored more closely, and preventative measures should be taken to prevent PI occurrence in high-risk populations.

Nurses' knowledge and attitudes regarding major immobility complications among bedridden patients: A prospective multicentre study.

AIMS AND OBJECTIVES: To gain insight into nurses' knowledge and attitudes regarding major immobility complications (pressure ulcers, pneumonia, deep vein thrombosis and urinary tract infections) and explore the correlation of nurses' knowledge and attitudes with the incidence of these complications. BACKGROUND: Immobility complications have adverse consequences, and effective management requires appropriate knowledge, attitudes and skills. Evidence about nurses' knowledge and attitudes regarding immobility complications is lacking. DESIGN: Cross-sectional study. METHODS: A total of 3,903 nurses and 21,333 bedridden patients from 25 hospitals in China were surveyed. Nurses' knowledge and attitudes regarding major immobility complications were assessed using researcher-developed questionnaires. The content validity, reliability and internal consistency of the questionnaires were validated through expert review and a pilot study. The incidence of major immobility complications among bedridden patients from selected wards was surveyed by trained investigators. Correlations between knowledge, attitudes and the incidence of major immobility complications were evaluated with multilevel regression models. RESULTS: Mean knowledge scores were 64.07% for pressure ulcers, 72.92% for deep vein thrombosis, 76.54% for pneumonia and 83.30% for urinary tract infections. Mean attitude scores for these complications were 86.25%, 84.31%, 85.00% and 84.53%, respectively. Knowledge and attitude scores were significantly higher among nurses with older age, longer employment duration, higher education level, previous training experience and those working in tertiary hospitals or critical care units. Nurses' knowledge about pressure ulcers was negatively related to the incidence of pressure ulcers, and attitude towards pneumonia was negatively correlated with the incidence of pneumonia. CONCLUSION: Clinical nurses have relatively positive attitudes but inadequate knowledge regarding major immobility complications. Improved knowledge and attitudes regarding major immobility complications may contribute to reducing these complications. RELEVANCE TO CLINICAL PRACTICE: Nursing managers should implement measures to improve nurses' knowledge and attitudes regarding major immobility complications to reduce the incidence of these complications in bedridden patients.

Clinical evaluation of the use of an intracardiac electrocardiogram to guide the tip positioning of peripherally inserted central catheters.

The use of peripherally inserted central catheters (PICCs) provides important central venous accesses for clinical treatments, tests and monitoring. Compared with the traditional methods, intracardiac electrocardiogram (ECG)-guided method has the potential to guide more accurate tip positioning of PICCs. This study aimed to clinically evaluate the effectiveness of an intracardiac ECG to guide the tip positioning by monitoring characteristic P-wave changes. In this study, eligible patients enrolled September 2011 to May 2012 according to the inclusion and exclusion criteria received the catheterization monitored by intracardiac ECG. Then chest radiography was performed to check the catheter position. The results revealed that, with 117 eligible patients, all bar one patient who died (n = 116) completed the study, including 60 males and 56 females aged 51.2 ± 15.1 years. Most (n = 113, > 97%) had characteristic P-wave changes. The intracardiac ECG-guided positioning procedure achieved correct placement for 112 patients (96.56%), demonstrating 99.12% sensitivity and 100% specificity. In conclusion, the intracardiac ECG can be a promising technique to guide tip positioning of PICCs. However, since the sample size in this study is limited, more experience and further study during clinical practice are needed to demonstrate achievement of optimal catheterization outcomes.