Care practices and neonatal survival in 52 neonatal intensive care units in Telangana and Andhra Pradesh, India: A cross-sectional study.

BACKGROUND: The Indian government supports both public- and private-sector provision of hospital care for neonates: neonatal intensive care is offered in public facilities alongside a rising number of private-for-profit providers. However, there are few published reports about mortality levels and care practices in these facilities. We aimed to assess care practices, causes of admission, and outcomes from neonatal intensive care units (NICUs) in public secondary and private tertiary hospitals and both public and private medical colleges enrolled in a quality improvement collaborative in Telangana and Andhra Pradesh-2 Indian states with a respective population of 35 and 50 million. METHODS AND FINDINGS: We conducted a cross-sectional study between 30 May and 26 August 2016 as part of a baseline evaluation in 52 consenting hospitals (26 public secondary hospitals, 5 public medical colleges, 15 private tertiary hospitals, and 6 private medical colleges) offering neonatal intensive care. We assessed the availability of staff and services, adherence to evidence-based practices at admission, and case fatality after admission to the NICU using a range of tools, including facility assessment, observations of admission, and abstraction of registers and telephone interviews after discharge. Our analysis is adjusted for clustering and weighted for caseload at the hospital level and presents findings stratified by type and ownership of hospitals. In total, the NICUs included just over 3,000 admissions per month. Staffing and infrastructure provision were largely according to government guidelines, except that only a mean of 1 but not the recommended 4 paediatricians were working in public secondary NICUs per 10 beds. On admission, all neonates admitted to private hospitals had auscultation (100%, 19 of 19 observations) but only 42% (95% confidence interval [CI] 25%-62%, p-value for difference is 0.361) in public secondary hospitals. The most common single cause of admission was preterm birth (25%) followed by jaundice (23%). Case-fatality rates at age 28 days after admission to a NICU were 4% (95% CI 2%-8%), 15% (9%-24%), 4% (2%-8%) and 2% (1%-5%) (Chi-squared p = 0.001) in public secondary hospitals, public medical colleges, private tertiary hospitals, and private medical colleges, respectively, according to facility registers. Case fatality according to postdischarge telephone interviews found rates of 12% (95% CI 7%-18%) for public secondary hospitals. Roughly 6% of admitted neonates were referred to another facility. Outcome data were missing for 27% and 8% of admissions to private tertiary hospitals and private medical colleges. Our study faced the limitation of missing data due to incomplete documentation. Further generalizability was limited due to the small sample size among private facilities. CONCLUSIONS: Our findings suggest differences in quality of neonatal intensive care and 28-day survival between the different types of hospitals, although comparison of outcomes is complicated by differences in the case mix and referral practices between hospitals. Uniform reporting of outcomes and risk factors across the private and public sectors is required to assess the benefits for the population of mixed-care provision.

2015 American College of Rheumatology Workforce Study: Supply and Demand Projections of Adult Rheumatology Workforce, 2015-2030.

OBJECTIVE: To describe the character and composition of the 2015 US adult rheumatology workforce, evaluate workforce trends, and project supply and demand for clinical rheumatology care for 2015-2030. METHODS: The 2015 Workforce Study of Rheumatology Specialists in the US used primary and secondary data sources to estimate the baseline adult rheumatology workforce and determine demographic and geographic factors relevant to workforce modeling. Supply and demand was projected through 2030, utilizing data-driven estimations regarding the proportion and clinical full-time equivalent (FTE) of academic versus nonacademic practitioners. RESULTS: The 2015 adult workforce (physicians, nurse practitioners, and physician assistants) was estimated to be 6,013 providers (5,415 clinical FTE). At baseline, the estimated demand exceeded the supply of clinical FTE by 700 (12.9%). By 2030, the supply of rheumatology clinical providers is projected to fall to 4,882 providers, or 4,051 clinical FTE (a 25.2% decrease in supply from 2015 baseline levels). Demand in 2030 is projected to exceed supply by 4,133 clinical FTE (102%). CONCLUSION: The adult rheumatology workforce projections reflect a major demographic and geographic shift that will significantly impact the supply of the future workforce by 2030. These shifts include baby-boomer retirements, a millennial predominance, and an increase of female and part-time providers, in parallel with an increased demand for adult rheumatology care due to the growing and aging US population. Regional and innovative strategies will be necessary to manage access to care and reduce barriers to care for rheumatology patients.

Diversity and Similarity of Anesthesia Procedures in the United States During and Among Regular Work Hours, Evenings, and Weekends.

BACKGROUND: Anesthesiologists providing care during off hours (ie, weekends or holidays, or cases started during the evening or late afternoon) are more likely to care for patients at greater risk of sustaining major adverse events than when they work during regular hours (eg, Monday through Friday, from 7:00 AM to 2:59 PM). We consider the logical inconsistency of using subspecialty teams during regular hours but not during weekends or evenings. METHODS: We analyzed data from the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry (NACOR). Among the hospitals in the United States, we estimated the average number of common types of anesthesia procedures (ie, diversity measured as inverse of Herfindahl index), and the average difference in the number of common procedures between 2 off-hours periods (regular hours versus weekends, and regular hours versus evenings). We also used NACOR data to estimate the average similarity in the distributions of procedures between regular hours and weekends and between regular hours and evenings in US facilities. Results are reported as mean ± standard error of the mean among 399 facilities nationwide with weekend cases. RESULTS: The distributions of common procedures were moderately similar (ie, not large, <.8) between regular hours and evenings (similarity index .59 ± .01) and between regular hours and weekends (similarity index, .55 ± .02). For most facilities, the number of common procedures differed by <5 procedures between regular hours and evenings (74.4% of facilities, P < .0001) and between regular hours and weekends (64.7% of facilities, P < .0001). The average number of common procedures was 13.59 ± .12 for regular hours, 13.12 ± .13 for evenings, and 9.43 ± .13 for weekends. The pairwise differences by facility were .13 ± .07 procedures (P = .090) between regular hours and evenings and 3.37 ± .12 procedures (P < .0001) between regular hours and weekends. In contrast, the differences were -5.18 ± .12 and 7.59 ± .13, respectively, when calculated using nationally pooled data. This was because the numbers of common procedures were 32.23 ± .05, 37.41 ± .11, and 24.64 ± .12 for regular hours, evenings, and weekends, respectively (ie, >2x the number of common procedures calculated by facility). CONCLUSIONS: The numbers of procedures commonly performed at most facilities are fewer in number than those that are commonly performed nationally. Thus, decisions on anesthesia specialization should be based on quantitative analysis of local data rather than national recommendations using pooled data. By facility, the number of different procedures that take place during regular hours and off hours (diversity) is essentially the same, but there is only moderate similarity in the procedures performed. Thus, at many facilities, anesthesiologists who work principally within a single specialty during regular work hours will likely not have substantial contemporary experience with many procedures performed during off hours.

Standards for device implantation and follow-up: personnel, equipment, and facilities: results of the European Heart Rhythm Association Survey.

Cardiac device implantation is the most common of all invasive cardiac electrophysiological procedures. Over 250 000 devices are implanted each year in Europe. The purpose of this European Heart Rhythm Association (EHRA) survey was to assess the facilities, personnel, and protocols of members of the EHRA electrophysiology (EP) research network involved in device implantation. There were 68 responses to the questionnaire. The survey responses were mainly (84%) from medium- to high-volume device implanting centres, performing >200 implants per year, with over 50% performing >400 implants per year. Most consultants are male (85%), half of all centres had no female consultants, and only one in six had more than one female consultant. There is trend towards specialization in device implantation. The combination of device implantation and EP is still common (76% of all centres) but only 34% of centres have consultants performing device implantation and coronary intervention. Moreover, 23% of centres have all device implantation performed by consultants who do not perform any other types of procedure. Cardiac device implantation as a day case is the planned admission for routine elective device implantation in 30% of hospitals, 47% of hospitals have a single night stay, and 23% of hospitals have admission durations of two or more nights. Device implantation is available as a 24 h service, 365 days a year in 38% of hospitals. The commonest other model was as a daytime service on weekdays in 45% of hospitals.

Growth of an academic palliative medicine program: patient encounters and clinical burden.

CONTEXT: Information regarding the challenges of clinical growth and staffing of palliative care programs is limited. OBJECTIVES: Our aim was to describe the growth and staffing structure of a palliative care program at a comprehensive cancer center. METHODS: During fiscal years ending in 2000 through 2010, we recorded all billed palliative care consultations and follow-ups. To determine the yearly clinical burden per physician, advanced practice nurse (APN), and physician assistant (PA), we calculated the mean number of patient encounters per clinical full-time equivalents. Increase in absolute number of patient encounters and relative (%) growth from year to year were calculated. RESULTS: Over the 10-year history of the program, the number of outpatient consultations tripled, whereas the inpatient consultations increased from 73 to 1880. In all cases, with the exception of the first year of operation, the vast majority of clinical activity was in the inpatient hospital setting. Growth in the ratio of inpatient consultations per operational hospital beds was noted during the first five years of the program followed by a more modest increase in the succeeding five years. In fiscal year 2010, palliative care physicians had 6.2 patient encounters per working day, and APNs/PAs independently evaluated and treated 4.0 additional patients. CONCLUSION: Over the 10-year history, there has been an increase in the number of patient consultations seen by our palliative care program. The clinical burden was manageable during the first three years but quickly became too burdensome. Active recruitment of new faculty was required to sustain the increased clinical activity.

Creative models of spiritual care. As healthcare delivery changes, pastoral care departments must explore alternative staffing approaches.

Recognizing changes are coming to the healthcare delivery system, pastoral care departments are developing a new vision of spiritual care. As they educate and hire staff, many directors are finding that alternative staffing approaches can help them make the transition. Flexible schedules for pastoral care professionals improve the care they deliver and enhance morale. Restructuring responsibilities within the department and giving some patient populations priority can be helpful. Some facilities share chaplains' time to minimize on-call burden; others are increasingly using supervised volunteers. Pastoral care givers who are specialists in areas such as mental health and chemical dependency can often perform certain functions traditionally performed by other professionals. By assigning chaplains to a product or service line, pastoral care departments can improve the continuity of care patients receive. As parishes' role in the healing ministry takes on new meaning, healthcare institutions' pastoral care staff can help initiate and develop new parish services or provide assistance that complements existing parish efforts.

Canadian nurses head South.

What's going on with the Canadian Health System? Many nursing graduates are moving to the U.S. Example: one hospital in Texas is now operating with a 25 percent Canadian nursing staff.

The changing composition of the British hospital nursing workforce 1962-1984.

The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) recently undertook a major project aimed at identifying the most appropriate future nurse staffing patterns. The results presented here were produced at the request of the UKCC in order that the recommendations stemming from their deliberations could be set against a wider backcloth. It proved possible to secure nurse staffing data from three of the countries of the United Kingdom, namely, England, Wales and Scotland. Most were secured from government publications but the appropriate government agencies also provided valuable assistance. The main trends emerging from a processing of the data are a steadily falling ratio of student nurses and midwives to their qualified counterparts and a steadily increasing contribution by state enrolled nurses. A number of other ratios are presented pictorially accompanied, where appropriate, by a commentary. The actual growth in whole time equivalent nurses is seen to be somewhat less than many people imagine when account is taken of the reduction in both the number of weeks and the number of hours per week worked. Indeed, there has been a levelling off of this last figure over the past few years.