Impact of Telemedicine on Mortality, Length of Stay, and Cost Among Patients in Progressive Care Units: Experience From a Large Healthcare System.

OBJECTIVES: To determine whether Telemedicine intervention can affect hospital mortality, length of stay, and direct costs for progressive care unit patients. DESIGN: Retrospective observational. SETTING: Large healthcare system in Florida. PATIENTS: Adult patients admitted to progressive care unit (PCU) as their primary admission between December 2011 and August 2016 (n = 16,091). INTERVENTIONS: Progressive care unit patients with telemedicine intervention (telemedicine PCU [TPCU]; n = 8091) and without telemedicine control (nontelemedicine PCU [NTPCU]; n = 8000) were compared concurrently during study period. MEASUREMENTS AND MAIN RESULTS: Primary outcome was progressive care unit and hospital mortality. Secondary outcomes were hospital length of stay, progressive care unit length of stay, and mean direct costs. The mean age NTPCU and TPCU patients were 63.4 years (95% CI, 62.9-63.8 yr) and 71.1 years (95% CI, 70.7-71.4 yr), respectively. All Patient Refined-Diagnosis Related Group Disease Severity (p < 0.0001) and All Patient Refined-Diagnosis Related Group patient Risk of Mortality (p < 0.0001) scores were significantly higher among TPCU versus NTPCU. After adjusting for age, sex, race, disease severity, risk of mortality, hospital entity, and organ systems, TPCU survival benefit was 20%. Mean progressive care unit length of stay was lower among TPCU compared with NTPCU (2.6 vs 3.2 d; p < 0.0001). Postprogressive care unit hospital length of stay was longer for TPCU patients, compared with NTPCU (7.3 vs 6.8 d; p < 0.0001). The overall mean direct cost was higher for TPCU ($13,180), compared with NTPCU ($12,301; p < 0.0001). CONCLUSIONS: Although there are many studies about the effects of telemedicine in ICU, currently there are no studies on the effects of telemedicine in progressive care unit settings. Our study showed that TPCU intervention significantly decreased mortality in progressive care unit and hospital and progressive care unit length of stay despite the fact patients in TPCU were older and had higher disease severity, and risk of mortality. Increased postprogressive care unit hospital length of stay and total mean direct costs inclusive of telemedicine costs coincided with improved survival rates. Telemedicine intervention decreased overall mortality and length of stay within progressive care units without substantial cost incurrences.

[The progressive patient care program as a model of field training of public health practitioners: the experience of the Roman Public Health Academy]. / L'ospedale ad Intensità di cura come modello di formazione condivisa sul campo: l'esperienza dell'Accademia Romana di Sanità Pubblica.

The management of healthcare facilities has become increasingly complex in recent years, leading to a greater demand for public health physicians in Italy. Public Health physicians are responsible for evaluating community needs, with particular attention to health determinants and, at the same time, to final user feedback. During their training, they must acquire the competencies to manage a wide range of problems. The Roman Public Health Academy (ARSP) was developed to motivate young residents in Public Health to acquire the knowhow, skills and abilities required of a public health practitioner. It therefore implemented a special training program offering different educational opportunities for residents. In particular, the program offers a team of three young residents field training opportunities, allowing them to become engaged in solving complex technical and management problems. In this paper we describe the methods through which, following a specific request by the director of a hospital in Rome, the team supported a project involving the reorganization of several hospital wards. The aim of the reorganization was to enhance the performance and efficiency of the wards, according to the Progressive Patients Care program.

Nurses' knowledge and comfort levels using the Physician Orders for Life-sustaining Treatment (POLST) form in the progressive care unit.

Many patients are admitted to the hospital with an active Physician Orders for Life-sustaining Treatment (POLST) Form; however, not all registered nurses (RNs) are familiar with the form or comfortable with initiating a discussion about end-of-life care. Evidence indicates that an education program increases RNs' knowledge and utilization of the POLST form. The purpose of this evidence-based practice project was to answer the question: among the RNs in a progressive care unit (PCU), does implementing a formal evidence-based practice POLST program compared to current practice increase RNs' knowledge and comfort level using the POLST form? A pre-post education survey was used. Results indicated a POLST education program increased PCU RNs' knowledge and comfort level in using the POLST form. It is recommended to include POLST form education for PCU RNs in workplace education programs.

[Progressive Patient Care Model and its application into hospital organization: a narrative review]. / Progressive Patient Care e organizzazione ospedaliera per intensità di cure: revisione narrativa della letteratura.

Aim of this article is to review the literature about the Progressive Patient Care Model, in particular its conceptual and practical characteristics, its implementation and effects on the current health care organization. Was conducted by an integrative-narrative literature review. The Progressive Patient Care is a model which aims at group patients according to their complexity in order to place patients in the most appropriate care setting. The original model consists on five care levels: intensive care, intermediate care, self-care, long term care, home care.In Italy the above mentioned model can be considered as a contextualization of Progressive Patient Care in the light of similarities both in terms of model purposes and care levels classification. The organization for intensive care levels is an opportunity for Italian healthcare facilities to reach continuity of care. This model emphazises care processes looking to patients' needs rather than a division according to criteria of specialties.

Pediatric mass critical care in a pandemic.

OBJECTIVES: Previous simulation studies suggest that temporary pediatric mass critical care approaches would accommodate plausible hypothetical sudden-impact public health emergencies. However, the utility of sustained pediatric mass critical care responses in prolonged pandemics has not been evaluated. The objective of this study was to compare the ability of a typical region to serve pediatric intensive care unit needs in hypothetical pandemics, with and without mass critical care responses sufficient to triple usual pediatric intensive care unit capacity. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: The Monte Carlo simulation method was used to model responses to hypothetical pandemics on the basis of national historical evidence regarding pediatric intensive care unit admission and length of stay in pandemic and nonpandemic circumstances. Assuming all ages are affected equally, federal guidelines call for plans to serve moderate and severe pandemics requiring pediatric intensive care unit care for 457 and 5,277 infants and children per million of the population, respectively. MEASUREMENTS AND MAIN RESULTS: A moderate pandemic would exceed ordinary surge capacity on 13% of pandemic season days but would always be accommodated by mass critical care approaches. In a severe pandemic, ordinary surge methods would accommodate all the patients on only 32% of pandemic season days and would accommodate 39% of needed patient days. Mass critical care approaches would accommodate all the patients on 82% of the days and would accommodate 64% of all patient days. CONCLUSION: Mass critical care approaches would be essential to extend care to the majority of infants and children in a severe pandemic. However, some patients needing critical care still could not be accommodated, requiring consideration of rationing.

SBAR: electronic handoff tool for noncomplicated procedural patients.

Awareness for patient safety led a team to develop an electronic handoff communication tool for noncomplicated routine patients. The structure of SBAR (situation, background, assessment, and recommendation) was used when transferring patients to and from the progressive care unit and cardiac laboratories. The electronic SBAR gave staff a reliable and standard way to provide a patient handoff.

Intermediate care for homeless people: results of a pilot project.

A year-long, nurse-led intermediate care pilot project was undertaken at a 120-bed homeless hostel in south London to improve healthcare outcomes among the clients involved, and to reduce emergency department (ED) attendance, ambulance call outs and use of acute care services. By the end of the year, the number of ED and hospital admissions had dropped significantly. The project was recognised by the Department of Health in 2010 as an example of innovative practice in work with 'at-risk' groups, and was awarded the 2011 Nursing Standard Community Nursing Award. This article considers reasons for the success of the project and the lessons that can be learned from it.

Strategies for transitioning to adult care for youth with Lennox-Gastaut syndrome and related disorders.

Transition is the process of preparing children with chronic illness and their families for the adult health care system. In patients with Lennox-Gastaut syndrome (LGS) and related disorders, the process of transition is complicated by the presence of intellectual handicap, treatment-resistant epilepsy, and behavioral issues. Patients who are not successfully transitioned to adult care may end up without specialty care, may not receive satisfactory adult services, may lack adequate follow-up and access to newer therapies, and may lack appropriate management of comorbid conditions. Several family related and clinician-related barriers can inhibit the transition process. Transition strategies that maximize each patient's ability to achieve his or her potential and optimize self-sufficiency may lead to better social outcomes. Adolescent clinics that include members of the pediatric and adult neurology teams may help ensure a smooth transition to adult care, although studies are needed to objectively establish the best model. Results are reported from a survey of 133 symposium attendees on the topic of practice characteristics and issues related to transitioning care. Results suggested a great deal of dissatisfaction about the process of transition, especially for patients with intellectual handicap. We provide suggestions for developing a transition program, including identifying a willing adult service, adapting a multidisciplinary approach, addressing legal and psychosocial issues, and celebrating rites of passage.

[The complex prophylaxis of thromboembolism in oncourologic patients].

One of the major complications in oncourological patients in the hospital is the development of thromboembolic complications. This article is devoted to analysis of the results of the comprehensive prevention of thromboembolic complications in 1006 patients that have received surgical treatment in the Scientific research institute of urology in the period 2009-2011. Carried out the comparative estimation of efficiency of elastic bandaging and elastic compressive knitted wear as a means of non-medicamental prevention of thromboembolic complications in of oncourology. In the study, in addition to assessing the impact of elastic compression on various aspects of the state of the venous system of patients and the hemostasis system is shown that the use of elastic compression hosiery compared with elastic bandaging allows to reduce the incidence of thromboembolic complications.

Demand and supply-based operating modes--a framework for analyzing health care service production.

CONTEXT: The structure of organizations that provide services should reflect the possibilities of and constraints on production that arise from the market segments they serve. Organizational segmentation in health care is based on urgency and severity as well as disease type, bodily function, principal method, or population subgroup. The result is conflicting priorities, goals, and performance metrics. A managerial perspective is needed to identify activities with similar requirements for integration, coordination, and control. METHODS: The arguments in this article apply new reasoning to the previous literature. FINDINGS: The method used in this article to classify health care provision distinguishes different types of health problems that share generic constraints of production. CONCLUSIONS: The analysis leads to seven different demand-supply combinations, each with its own operational logic. These are labeled demand and supply-based operating modes (DSO modes), and constitute the managerial building blocks of health care organizations. The modes are Prevention, Emergency, One visit, Project, Elective, Cure, and Care. As analytical categories the DSO modes can be used to understand current problems. Several operating modes in one unit create managerial problems of conflicting priorities, goals, and performance metrics. The DSO modes are constructed as managerially homogeneous categories or care platforms responding to general types of demand, and supply constraints. The DSO modes bring methods of industrial management to bear on efforts to improve health care.

In-theater peritoneal dialysis for combat-related renal failure.

BACKGROUND: Complications of renal failure may prevent timely evacuation of injured soldiers. Conventional renal replacement therapy is not available in forward surgical units. METHODS: Records of in-theater improvised peritoneal dialysis (IPD) in level III hospitals or forward surgical units in Iraq or Afghanistan were reviewed to determine the following: cause of renal failure and associated injuries; type of dialysate, peritoneal access, and exchange technique; and patient outcome. These data were used to propose method for IPD using commonly available materials. RESULTS: IPD is described in four patients. Abdominal or chest drains were used with either improvised dextrose-electrolyte solution or commercial dialysate. Exchanges were successful, despite fresh surgical wounds including full laparotomy, removed excess fluid and restored acid and electrolyte balance, but did not correct azotemia. Open abdominal packing prevented continuation of IPD after 48 hours. Two patients fully recovered, one died, and one patient with a poor prognosis was lost to follow-up. CONCLUSION: IPD can be delivered effectively using readily available materials in forward surgical units and level III combat support hospitals.

Developing and maintaining competency with circulatory assist devices: how to meet the challenge.

Heart failure is the only cardiovascular disease that is increasing in prevalence in developing countries. As a result, circulatory assist devices are being used more both as a bridge to heart transplantation and as destination therapy in patients with a failing heart. Nurses must become knowledgeable about these options for their patients. Developing and maintaining competency can be challenging as more devices become available. The principles of adult learners were used by one academic medical center to set up a new circulatory assist program and to maintain ongoing competency among staff working with patients who have these devices.

Lived experiences of eating after esophagectomy: a phenomenological study.

BACKGROUND: Esophagectomy is the most common treatment for esophageal cancer (Pierie, Goedegebuure, Schuerman, & Leguit, 2000). Dysphagia is the most common symptom, after esophagectomy (Easterling et al., 2000; Ludwig, Thirlby, & Low, 2001; Pierie et al., 2000; Verschuur et al., 2006). The aim of this study was to describe patients' experiences of eating after esophagectomy. METHOD: A phenomenology approach was used to describe and understand eating experiences after esophagectomy. FINDINGS: Three major categories of experiences were extrapolated from informant verbal reports: physical, psychosocial, and psychological. Within these categories main themes were identified and included gastrointestinal feelings, fear of going home, and positive feelings toward eating. CONCLUSION: Most patients may not be able to eat exactly as they did prior to their operation (Ludwig et al., 2001). Findings from this study illustrate patients should be provided with a diet they perceive as socially acceptable with minimal eating discomforts.

[Integrated care for patients with advanced chronic obstructive pulmonary disease]. / Zintegrowana opieka medyczna u chorych na zaawansowana przewlekla obturacyjna chorobe pluc.

Chronic obstructive pulmonary disease (COPD) is the third cause of mortality and disability (assessed by DALY) among patients above 60 year old. Severe and very severe COPD (FEV(1) = equal or less than 50% and 30% of expected value, respectively) is estimated at 20% of all COPD patients. Advanced COPD usually leads to physical and mental deterioration, the patients often manage with the problems caused by the disease and other comorbidities poorly. This leads to increased risk of COPD exacerbations and further deterioration of the patient's status, increased costs of medical care and eventually increased risk of death. Current organization of medical care for those patients does not provide adequate health and social support for them. However, it seems that introducing an integrated approach proposed by World Health Organization, could improve the situation of advanced COPD patients. In Poland, this kind of care has been provided in advanced cancer patients throughout stationary palliative care units and hospices during the last several years. This experience should be helpful in integrating actions of general practitioners and specialized nurses, as well as providing access for the specialists' consultations according to the individual needs of the patients. It should also allow for broad cooperation with auxiliary staff, such as social workers, medical assistants and volunteers, as well as psychologists and clergymen (especially in the terminal phase of the disease).

Rehospitalization from skilled nursing facilities: implications for policy.

(1) Between 2000 and 2006, rehospitalizations within 30 days following discharge to a skilled nursing facility increased by 29 percent. (2) Initial site of residence prior to a hospitalization affects the likelihood of a rehospitalization. (3) There is a significant variation across states in the rate of rehospitalizations following discharge to a skilled nursing facility.

Standardization of change-of-shift report.

This article describes a clinical nurse-led initiative that changed the traditional group shift report in the conference room to a combination of a written report with a nurse-to-nurse verbal exchange at the patient's bedside. The new process resulted in less time spent in shift report, financial savings from reduced overtime, and a decrease in the number of patient falls and call lights during change of shift.

A Slovenian model of integrated care for older people can offer solutions for NHS services.

The population in Britain is ageing and creating a burden on healthcare that will require the NHS and social care to deliver innovative strategies. This article outlines a visit to Slovenia to view a model of care that fits in well with the Department of Health's integrated care approach to the care of older people and those with long term conditions.

The role of mental health staff in intermediate care.

Intermediate care enables older people to have access to a range of intermediate care services at home or in designated settings. This article outlines developments in health and social policy since the inception of intermediate care and then presents three case studies that explore the positive contribution that mental health staff have made to an intermediate care team in south west England.