Application of Hospital-Community-Family "Trinity" Remote Rehabilitation Guidance Based on Internet + WeChat Platform in Patients with Stroke After Discharge.

Objective: To investigate the impact of an Internet + WeChat platform-based "trinity" remote rehabilitation model involving the hospital, community, and family on stroke patient rehabilitation nursing. Methods: 159 patients with stroke who were discharged from Beijing Luhe Hospital of Capital Medical University from January 1, 2018, to December 31, 2019, were selected and divided into a control group (79 cases) and an experimental group (80 cases) by the random drawing method. The control group was given routine nursing, and the experimental group was given remote rehabilitation nursing intervention by using the WeChat network platform based on the control group. Limb function [Fugl-Meyer Assessment Scale (FMA)] and activities of daily living [Modified Barthel Index (MBI)] were evaluated at enrollment and at the end of 3 months, 6 months and 12 months in both groups. The compliance and satisfaction surveys in the two groups were evaluated after 6 months and 12 months of intervention. Results: (1) Before the intervention, there was no statistical significance in FMA score between the two groups (t = 0.798, P > .05). After 3 months, 6 months and 12 months of intervention, the FMA score in the two groups was increased compared with that before intervention (t = 2.463, P < .05), and the FMA scores in the experimental group at the above time points were higher than those in the control group (ts = 7.057, 14.285, Ps < .05). (2) There was no statistical difference in MBI scores between the two groups before intervention (t = 0.798, P > .05). After 3 months, 6 months, and 12 months of intervention, the MBI score in the two groups was increased compared with that before intervention (t = 0.232, P < .05), and MBI scores in the experimental group at the above time points were higher compared to the control group (ts = 4.959, 8.842, 8.131, Ps < .05). (3) The compliance scores in the experimental group were higher than those in the control group after 6 months and 12 months of intervention (ts = 4.959, 8.842, 8.131, Ps < .05). (4) The satisfaction survey scores in the experimental group after 6 months and 12 months of intervention were higher than those in the control group (ts = 2.120 ~ 14.554, Ps < .05). Conclusion: The Hospital-community-family "trinity" stroke rehabilitation model on the WeChat network platform holds significant importance. Enhancing limb function and daily living for stroke patients improves their quality of life and lessens reliance on caregivers. This positively impacts both survivors' well-being and healthcare resources. Increased patient satisfaction and compliance suggest a potential revolution in post-stroke care, favoring a more patient-centered approach. Overall, this model has transformative potential for stroke treatment, offering holistic and patient-focused strategies. Its success promises better rehabilitation outcomes, patient satisfaction, and cost reduction, while paving the way for innovative research in stroke treatment and rehabilitation.

Comparing hospital costs and length of stay for cancer patients in New York State Comprehensive Cancer Centers versus nondesignated academic centers and community hospitals.

OBJECTIVE: To explore differences in costs and lengths of stay for cancer patients admitted to National Cancer Institute-designated Comprehensive Cancer Centers, nondesignated academic medical centers, and community hospitals in New York State. DATA SOURCES: We use patient-level data from the New York State Statewide Planning and Research Cooperative System Hospital Inpatient Discharges dataset for the years 2017-2019. STUDY DESIGN: We employ ordinary least squares and Poisson regressions to compare hospital costs and length of stay for cancer patients, controlling for hospital type, patient demographics, and patient health. Our key outcomes are differences in costs and lengths of stay. DATA COLLECTION: We use data on patient demographics, total treatment costs, and lengths of stay for patients discharged from New York hospitals with cancer-related diagnoses between 2017 and 2019. PRINCIPAL FINDINGS: We determine that inpatient costs were 27% higher (95% CI 0.252, 0.285), but length of stay was 12% shorter (95% CI -0.131, -0.100), in Comprehensive Cancer Centers relative to community hospitals. CONCLUSIONS: The results imply that, in New York State, Comprehensive Cancer Centers are a magnet for more complex oncology cases and administer more expensive treatments. That expertise, however, seems to be responsible for more efficient care delivery and thorough discharge planning, allowing for shorter average lengths of stay.

Impact of COVID-19 pandemic on outpatient visit volume in cancer patients: Results of COMETA multicenter retrospective observational study.

Objective: To evaluate the impact of the COVID-19 pandemic on first and follow-up visits for cancer outpatients. Methods: This is a multicenter retrospective observational study involving three Comprehensive Cancer Care Centers (CCCCs): IFO, including IRE and ISG in Rome, AUSL-IRCCS of Reggio Emilia, and IRCCS Giovanni Paolo II in Bari) and one oncology department in a Community Hospital (Saint'Andrea Hospital, Rome). From 1 January 2020 and 31 December 2021, we evaluated the volume of outpatient consultations (first visits and follow-up), comparing them with the pre-pandemic year (2019). Results were analyzed by quarter according to the Rt (real-time indicator used to assess the evolution of the pandemic). IFO and IRCCS Giovanni Paolo II were "COVID-free" while AUSL-IRCCS RE was a "COVID-mixed" Institute. Depending on the Rt, Sain't Andrea Hospital experienced a "swinging" organizational pathway (COVID-free/ COVID-mixed). Results: Regarding the "first appointments", in 2020 the healthcare facilities operating in the North and Center of Italy showed a downward trend. In 2021, only AUSL-IRCCS RE showed an upward trend. Regarding the "follow-up", only AUSL IRCCS RE showed a slight up-trend in 2020. In 2021, IFO showed an increasing trend, while S. Andrea Hospital showed a negative plateau. Surprisingly, IRCCS Giovanni Paolo II in Bari showed an uptrend for both first appointment and follow-ups during pandemic and late pandemic except for the fourth quarter of 2021. Conclusions: During the first pandemic wave, no significant difference was observed amongst COVID-free and COVID-mixed Institutes and between CCCCs and a Community Hospital. In 2021 ("late pandemic year"), it has been more convenient to organize COVID-mixed pathway in the CCCCs rather than to keep the Institutions COVID-free. A swinging modality in the Community Hospital did not offer positive results in term of visit volumes. Our study about the impact of COVID-19 pandemic on visit volume in cancer outpatients may help health systems to optimize the post-pandemic use of resources and improve healthcare policies.

Assessment of a Peer Physician Coaching Partnership Between a Designated Cancer Center Genetics Service and a Community Cancer Network Hospital.

Background: Patients with cancer seen in rural and underserved areas disproportionately face barriers to access genetic services. Genetic testing is critical to inform treatment decisions, for early detection of another cancer, and to identify at-risk family members who may benefit from screening and prevention. Objective: To examine medical oncologists' genetic testing ordering trends for patients with cancer. Design, Setting, and Participants: This prospective quality improvement study was performed in 2 phases over 6 months between August 1, 2020, and January 31, 2021, at a community network hospital. Phase 1 focused on observation of clinic processes. Phase 2 incorporated peer coaching from cancer genetics experts for medical oncologists at the community network hospital. The follow-up period lasted 9 months. Main Outcomes and Measures: The number of genetic tests ordered was compared between phases. Results: The study included 634 patients (mean [SD] age, 71.0 [10.8] years [range, 39-90 years]; 409 women [64.5%]; 585 White [92.3%]); 353 (55.7%) had breast cancer, 184 (29.0%) had prostate cancer, and 218 (34.4%) had a family history of cancer. Of the 634 patients with cancer, 29 of 415 (7.0%) received genetic testing in phase 1, and 25 of 219 (11.4%) received genetic testing in phase 2. Of the 29 patients who received testing in phase 1, 20 (69.0%) had germline genetic testing; 23 of 25 patients (92.0%) had germline genetic testing in phase 2. Uptake of germline genetic testing increased by 23.0% between phases, but the difference was not statistically significant (P = .06). Uptake of germline genetic testing was highest among patients with pancreatic cancer (4 of 19 [21.1%]) and ovarian cancer (6 of 35 [17.1%]); the National Comprehensive Cancer Network (NCCN) recommends offering genetic testing to all patients with pancreatic cancer and ovarian cancer. Conclusions and Relevance: This study suggests that peer coaching from cancer genetics experts was associated with an increase in ordering of genetic testing by medical oncologists. Efforts made to (1) standardize gathering of personal and family history of cancer, (2) review biomarker data suggestive of a hereditary cancer syndrome, (3) facilitate ordering tumor and/or germline genetic testing every time NCCN criteria are met, (4) encourage data sharing between institutions, and (5) advocate for universal coverage for genetic testing may help realize the benefits associated with precision oncology for patients and their families seeking care at community cancer centers.

'Localism and intimacy, and other rather imponderable reasons of that sort': A qualitative study of patient experience of community hospitals in England.

Debates over the value and contribution of community hospitals are hampered by a lack of empirical assessment of the experience of patients using these services. This paper presents findings from a study which included a focus on patient and family-carer experiences of community hospitals in England. We adopted a qualitative design involving nine case study hospitals. Data collection included interviews with patients (n = 60), carers (n = 28) and staff (n = 89). Through patients and carers highlighting the value of community hospitals feeling 'close to home', providing holistic and personalised care and supporting them through difficult transitions, the study confirms the importance of functional and interpersonal aspects of care, while also highlighting the importance of social and psychological aspects. These included having family, friends and the community close, maintaining social connections during periods of hospital treatment, and feeling less anonymous and anxious when attending the hospital due to the high levels of familiarity and connectedness. Although the experiences uncovered in this study were not uniformly positive, patients and carers placed a high overall value on the care provided by community hospitals, often arguing that these were distinctive when compared to their experiences of using other health and care services. The study suggests the need to weigh the full range of these dimensions of patient experience-functional, interpersonal, social and psychological-when assessing the role and contribution of community hospitals.

Bringing Sickle Cell Disease Care Closer to Home: Feasibility and Efficacy of a Quality Improvement Initiative at a Community Hospital.

Comprehensive care for patients with sickle cell disease has been shown to improve morbidity. However, few studies have focused on community hospitals where the burden of disease is highest. From 2017 to 2019, a series of quality improvement interventions was implemented in Brampton, Toronto, ON, Canada, directed toward pediatric and adult sickle cell disease populations. This included a new adult clinic and education directed at patients and healthcare providers. There were 206 visits from 88 unique patients at the clinic and hydroxyurea (HU) uptake increased from 41.0 to 60.0% over that time (p < 0.001). The annual admission rate by adult patients before and after intervention was 90.0 and 75.0% respectively (p = 0.010). The length of stay of pediatric patients decreased from 3.5 to 2.9 days (p = 0.039). These interventions resulted in significant improvements in acute care utilization and HU use by sickle cell disease patients locally, but larger studies are required to confirm these findings.

Same day discharge after pediatric laparoscopic appendectomy in community hospitals.

INTRODUCTION: Same-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units. METHODS: Patients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units. RESULTS: There were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference. CONCLUSION: Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.

Survival Outcomes for Malignant Peritoneal Mesothelioma at Academic Versus Community Hospitals.

BACKGROUND: Malignant peritoneal mesothelioma is a rare disease with poor outcomes. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is the cornerstone of therapy. We aim to compare outcomes of malignant peritoneal mesothelioma treated at academic versus community hospitals. METHODS: This was a retrospective cohort study using the National Cancer Database to identify patients with malignant peritoneal mesothelioma from 2004 to 2016. Patients were divided according to treating facility type: academic or community. Outcomes were assessed using log-rank tests, Cox proportional-hazard modeling, and Kaplan-Meier survival statistics. RESULTS: In total, 2682 patients with malignant peritoneal mesothelioma were identified. A total of 1272 (47.4%) were treated at an academic facility and 1410 (52.6%) were treated at a community facility. Five hundred forty-six (42.9%) of patients at academic facilities underwent debulking or radical surgery compared to 286 (20.2%) at community facilities. Three hundred sixty-six (28.8%) of patients at academic facilities received chemotherapy on the same day as surgery compared to 147 (10.4%) of patients at community facilities. Unadjusted 5-year survival was 29.7% (95% CI 26.7-32.7) for academic centers compared to 18.3% (95% CI 16.0-20.7) for community centers. In multivariable analysis, community facility was an independent predictor of increased risk of death (HR: 1.19, 95% CI 1.08-1.32, p = 0.001). CONCLUSIONS: We demonstrate better survival outcomes for malignant peritoneal mesothelioma treated at academic compared to community facilities. Patients at academic centers underwent surgery and received chemotherapy on the same day as surgery more frequently than those at community centers, suggesting that malignant peritoneal mesothelioma patients may be better served at experienced academic centers.

Availability of Integrative Medicine Therapies at National Cancer Institute-Designated Comprehensive Cancer Centers and Community Hospitals.

Introduction: The authors compared the availability of integrative medicine therapies in National Cancer Institute-Designated Comprehensive Cancer Centers and community hospitals. Methods: The authors reviewed 51 Comprehensive Cancer Center and 100 community hospital websites and collected race and median household income data for community hospital populations. Results: Availability of acupuncture (56% vs. 76.5%, p = 0.01), meditation (63% vs. 82.4%, p = 0.02), and music therapy (55% vs. 74.5%, p = 0.02) was significantly lower at community hospitals compared with Comprehensive Cancer Centers. Integrative medicine availability was also significantly lower in community hospitals serving lower-income populations. Conclusion: Equitable access to evidence-based integrative medicine in community hospitals is needed.

Outcomes of a pharmacist-driven vancomycin monitoring initiative in a community hospital.

WHAT IS KNOWN AND OBJECTIVE: Vancomycin, an antibiotic commonly used to treat MRSA infections, can be nephrotoxic. Administering vancomycin requires close monitoring of serum vancomycin levels and appropriate dosing based on patients' renal function, underlying infection type and serum concentration levels. This article discusses the results and implications of a pharmacist-driven vancomycin monitoring initiative, which was implemented at Mercy Catholic Medical Center's Philadelphia Campus (MPC) in July 2016. METHODS: MPC pharmacists were trained on how to give appropriate vancomycin dosing recommendations based on patients' vancomycin trough levels, renal function and underlying infection. This retrospective observational study consisted of patients who presented to MPC and were administered vancomycin over a 3-month period in 2015 for pre-implementation cohort and over a 3-month period in 2018 for post-implementation cohort. Patients with age ≥18 and receiving vancomycin for a minimum of 48 hours were included, whereas ESRD patients were excluded. Primary goal evaluated whether the incidence of AKI decreased with the pharmacist-driven initiative. Secondary goal assessed whether vancomycin level monitoring and achievement of goal serum levels improved with the initiative. RESULTS AND DISCUSSION: A total of 214 patients were included in the final data analysis, with 110 patients in the pre-implementation cohort and 104 patients in the post-implementation cohort. Although not statistically significant, a higher incidence of AKI was observed in the post-implementation cohort. However, compared to pre-implementation cohort, post-implementation group had higher percentage of patients with underlying comorbidities (such as CKD), higher number of cases of severe sepsis and septic shock, and greater number of patients with concomitant exposure to CT contrast and piperacillin-tazobactam-all of which were confounding factors that likely increased the AKI incidence in post-implementation cohort. With the initiative, there was a significant increase in the number of patients with appropriate vancomycin trough level monitoring (27.3% vs 55.8%, p value < 0.001) in the post-implementation cohort and a decrease in the number of patients with no trough level monitoring (30% vs. 7.6%, p value < 0.001). WHAT IS NEW AND CONCLUSION: Pharmacist-driven vancomycin monitoring significantly improved the monitoring compliance of vancomycin trough levels. In patients who developed AKI during their hospital course, pharmacist interventions improved the total percentage of patients attaining desired trough goals and helped reduce further renal insult from supratherapeutic vancomycin level. Incorporation of AUC-guided dosing and monitoring has the potential to further optimize vancomycin efficacy and safety.

Association between type of phototherapy management and hospital and patient-related outcomes in neonates with non-haemolytic jaundice at an Australian community hospital.

AIM: To evaluate the associations between type of light-emitting diode phototherapy intervention and hospital and patient related outcomes in term neonates with non-haemolytic jaundice. METHODS: A retrospective observational study in a community hospital within a disadvantaged area in Australia was conducted. Data was extracted from hospital systems and medical records regarding the use of three types of phototherapy surface-area exposure for term neonates ≤28 days with non-haemolytic neonatal jaundice. Associations between type of phototherapy management and length of stay (LOS), rate of serum bilirubin (SBR) decline and duration of phototherapy were estimated using the general linear mixed model or linear regression. RESULTS: Of 102 neonates diagnosed with non-haemolytic jaundice between 1 June 2016 and 31 August 2017, 82 were included in final analyses. Neonates treated for jaundice during their first (birth) admission had a median LOS of 118 h for single-sided and 125 h for maximal double-sided phototherapy. Differences by phototherapy type were not statistically significant (P = 0.06). SBR rate of decline increased as surface-area of phototherapy increased (P < 0.001) with the fastest decline seen in maximal double-sided phototherapy. Estimated duration of phototherapy did not vary by phototherapy type but did vary by age at initiation of phototherapy (P = 0.006), with 16 fewer hours of phototherapy if commenced at ≥72 to <96 h versus ≥24 to 48 h of age (difference -16.4 h, 95% confidence interval -29.1 to -3.7 h). CONCLUSIONS: LOS and phototherapy duration were not associated with phototherapy type. Older neonates with neonatal jaundice required shorter phototherapy duration. Double-sided phototherapy was associated with faster reduction in SBR.

An Integrated Model to Accelerate Patient Satisfaction Improvement.

Patient satisfaction is gaining traction in the strategic direction and daily operations of hospital executives. The financial penalty/incentive tied to patient satisfaction scores creates a burning platform to accelerate progress. Previous studies have shown the effectiveness of various improvement strategies including leadership rounding and employee training, among others. There has not been a study utilizing an integrated model that incorporates known best practices into a holistic approach. The integrated model included service excellence training, nursing unit-specific action plans, and weekly leadership rounding. Implementation of the model led to significant and sustainable improvements in patient satisfaction in the community hospital setting. This approach can be leveraged and scaled in other organizations to accelerate the pace of change.

Comparison of Melatonin and Zolpidem for Sleep in an Academic Community Hospital: An Analysis of Patient Perception and Inpatient Outcomes.

Hospitalizations can significantly disrupt patient sleep patterns and contribute to insomnia, which places patients at a higher risk of altered mental status as well as other complications. Despite attempts to control environmental factors, deliriogenic medications are often prescribed for the management of hospital-related insomnia. The primary objective of this study is to compare patient-perceived effectiveness of zolpidem versus melatonin in hospitalized patients. All inpatients who received melatonin or zolpidem the previous night as asleep aid and had no acute psychological issues or history of substance abuse were eligible for participation in this single-center, prospective, observational cohort study. The Verran and Snyder-Halpern sleep scale was utilized to evaluate sleep perception in 3 domains: sleep disturbance, effectiveness, and supplementation. A total of 439 patients were screened and 100 patients met study criteria and consented to the study. In the melatonin and zolpidem groups, the estimated adjusted means for the total sleep effectiveness (206.8 mm, 95% confidence interval [CI], 168.7-253.5vs 187.4 mm, 95% CI, 152.8-229.7; P=.513), sleep disturbance(362.1 mm, 95% CI, 310.1-422.7 vs 339.54 mm, 95% CI, 290.8-396.4; P=.573), and sleep supplementation (111.4 mm, 95% CI, 86.3-143.8 vs 120.9 mm, 95% CI, 94.1-155.2; P=.661) domains were not statistically different. Both melatonin and zolpidem were well tolerated with grogginess and headache as the only reported adverse effects. Melatonin demonstrated no significant difference in patient-perceived sleep effectiveness, disturbance, supplementation, or adverse effects when compared to zolpidem.

Testing of a (Spiritual) Self-Assessment Tool ((S)SAT) in a Community Hospital Setting.

The (Spiritual) Self-Assessment Tool Study was designed to test the novel engagement tool's effectiveness. Providing the (Spiritual) Self-Assessment Tool Study to newly admitted medical patients led to few instances where the tool was completed. Nevertheless, the (Spiritual) Self-Assessment Tool Study patient questionnaire generated significant secondary findings: a third of responding patients consider their hospital care incomplete without their care team having access to (Spiritual) Self-Assessment Tool data. Nursing staff also desire this data, but are unable to access it without the (Spiritual) Self-Assessment Tool or an equivalent source.

Acute Stroke Presentation, Care, and Outcomes in Community Hospitals in Northern California During the COVID-19 Pandemic.

BACKGROUND AND PURPOSE: Shelter-in-place (SIP) orders implemented to mitigate severe acute respiratory syndrome coronavirus 2 spread may inadvertently discourage patient care-seeking behavior for critical conditions like acute ischemic stroke. We aimed to compare temporal trends in volume of acute stroke alerts, patient characteristics, telestroke care, and short-term outcomes pre- and post-SIP orders. METHODS: We conducted a cohort study in 21 stroke centers of an integrated healthcare system serving 4.4+ million members across Northern California. We included adult patients who presented with suspected acute stroke and were evaluated by telestroke between January 1, 2019, and May 9, 2020. SIP orders announced the week of March 15, 2020, created pre (January 1, 2019, to March 14, 2020) and post (March 15, 2020, to May 9, 2020) cohort for comparison. Main outcomes were stroke alert volumes and inpatient mortality for stroke. RESULTS: Stroke alert weekly volume post-SIP (mean, 98 [95% CI, 92-104]) decreased significantly compared with pre-SIP (mean, 132 [95% CI, 130-136]; P<0.001). Stroke discharges also dropped, in concordance with acute stroke alerts decrease. In total, 9120 patients were included: 8337 in pre- and 783 in post-SIP cohorts. There were no differences in patient demographics. Compared with pre-SIP, post-SIP patients had higher National Institutes of Health Stroke Scale scores (P=0.003), lower comorbidity score (P<0.001), and arrived more often by ambulance (P<0.001). Post-SIP, more patients had large vessel occlusions (P=0.03), and there were fewer stroke mimics (P=0.001). Discharge outcomes were similar for post-SIP and pre-SIP cohorts. CONCLUSIONS: In this cohort study, regional stroke alert and ischemic stroke discharge volumes decreased significantly in the early COVID-19 pandemic. Compared with pre-SIP, the post-SIP population showed no significant demographic differences but had lower comorbidity scores, more severe strokes, and more large vessel occlusions. The inpatient mortality was similar in both cohorts. Further studies are needed to understand the causes and implications of care avoidance to patients and healthcare systems.

Proactive C-L Psychiatry Beyond Academic Hospital Settings: A Pilot Study of Effectiveness in a Suburban Community Hospital.

BACKGROUND: Proactive consultation-liaison psychiatry improves identification of psychiatric needs and reduces time to psychiatric consultation and length of stay (LOS) among medical inpatients in academic clinical settings. OBJECTIVE: To evaluate the effect of a proactive model on LOS, consult rate, and consultation latency in a nonacademic community hospital. METHODS: We implemented a modified proactive consultation-liaison service (PCS) in a 32-bed acute care medical-surgical unit in a community hospital. We compared outcomes during a 90-day PCS intervention period to preintervention and postintervention cohorts receiving consultation-as-usual in the same unit. During the intervention, a psychiatrist reviewed the electronic medical record of patients admitted to the study unit to guide recommendations and collaborated with existing unit staff. Primary outcomes were LOS, consultation rate, and consultation latency. Secondary outcomes included restraint utilization, 1:1 companion utilization, and a survey completed by unit nursing staff. RESULTS: Half of patients on the study unit had psychiatric comorbidity. Median LOS in the PCS cohort was 3.0 days versus 5.0 days in the preintervention and postintervention cohorts. The consultation rate was higher in the PCS cohort (1.4% before intervention; 33% intervention; 6.5% after intervention), and median consultation latency was also reduced during the intervention (57.6 h before intervention; 19.2 h intervention; 48 h after intervention). CONCLUSIONS: Implementation of a modified PCS model is feasible in a community hospital setting and can reduce LOS, enhance psychiatric service utilization, and reduce consultation latency. This study demonstrates that proactive consultation-liaison may offer the same benefits to nonacademic community hospitals as it does to large academic centers.

Determinants of Evidence-based Practice Uptake in Rural Intensive Care Units. A Mixed Methods Study.

Rationale: Evidence-based practices promote quality care for intensive care unit patients but chronic evidence-to-practice gaps limit their reach.Objectives: To characterize key determinants of evidence-based practice uptake in the rural intensive care setting.Methods: A parallel convergent mixed methods design was used with six hospitals receiving a quality improvement intervention. Guided by implementation science principles, we identified barriers and facilitators to uptake using clinician surveys (N = 90), key informant interviews (N = 14), and an implementation tracking log. Uptake was defined as completion of eight practice change steps within 12 months. After completing qualitative and quantitative data analyses for each hospital, site, staff, and program delivery factors were summarized within and across hospitals to identify patterns by uptake status.Results: At the site level, although structural characteristics (hospital size, intensivist staffing) did not vary by uptake status, interviews highlighted variability in staffing patterns and culture that differed by uptake status. At the clinician team level, readiness and self-efficacy were consistently high across sites at baseline with time and financial resources endorsed as primary barriers. However, interviews highlighted that as initiatives progressed, differences across sites in attitudes and ownership of change were key uptake influences. At the program delivery level, mixed methods data highlighted program engagement and leadership variability by uptake status. Higher uptake sites had better training attendance; more program activities completed; and a stable, engaged, collaborative nurse and physician champion team.Conclusions: Results provide an understanding of the multiple dynamic influences on different patterns of evidence-based practice uptake and the importance of implementation support strategies to accelerate uptake in the intensive care setting.

A scope of practice that works 'out here': exploring the effects of a changing medical regulatory environment on a rural New Zealand health service.

INTRODUCTION: In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand's rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand's far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health. METHODS: A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants' views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately. RESULTS: Four themes capturing the main issues were identified: (1) 'What I do': articulating the scope of medical practice at Hokianga, (2) 'What we do': the role of the hospital at Hokianga, (3) 'On the fringes', and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-for-purpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care. CONCLUSION: In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs.

Communities as 'renewable energy' for healthcare services? a multimethods study into the form, scale and role of voluntary support for community hospitals in England.

OBJECTIVE: To examine the forms, scale and role of community and voluntary support for community hospitals in England. DESIGN: A multimethods study. Quantitative analysis of Charity Commission data on levels of volunteering and voluntary income for charities supporting community hospitals. Nine qualitative case studies of community hospitals and their surrounding communities, including interviews and focus groups. SETTING: Community hospitals in England and their surrounding communities. PARTICIPANTS: Charity Commission data for 245 community hospital Leagues of Friends. Interviews with staff (89), patients (60), carers (28), volunteers (35), community representatives (20), managers and commissioners (9). Focus groups with multidisciplinary teams (8 groups across nine sites, involving 43 respondents), volunteers (6 groups, 33 respondents) and community stakeholders (8 groups, 54 respondents). RESULTS: Communities support community hospitals through: human resources (average=24 volunteers a year per hospital); financial resources (median voluntary income = £15 632); practical resources through services and activities provided by voluntary and community groups; and intellectual resources (eg, consultation and coproduction). Communities provide valuable supplementary resources to the National Health Service, enhancing community hospital services, patient experience, staff morale and volunteer well-being. Such resources, however, vary in level and form from hospital to hospital and over time: voluntary income is on the decline, as is membership of League of Friends, and it can be hard to recruit regular, active volunteers. CONCLUSIONS: Communities can be a significant resource for healthcare services, in ways which can enhance patient experience and service quality. Harnessing that resource, however, is not straight forward and there is a perception that it might be becoming more difficult questioning the extent to which it can be considered sustainable or 'renewable'.

Turnover intention of hospital staff in Ontario, Canada: exploring the role of frontline supervisors, teamwork, and mindful organizing.

BACKGROUND: This study contributes to a small but growing body of literature on how context influences employee turnover intention. We examine the impact of staff perceptions of supervisory leadership support for safety, teamwork, and mindful organizing on turnover intention. Interaction effects of safety-specific constructs on turnover intention are also examined. METHODS: Cross-sectional survey data were collected from nurses, allied health professionals, and unit clerks working in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario. RESULTS: Hierarchical regression analyses showed that staff perceptions of teamwork were significantly associated with turnover intention (p < 0.001). Direct associations of supervisory leadership support for safety and mindful organizing with turnover intention were non-significant; however, when staff perceived lower levels of mindful organizing at the frontlines, the positive effect of supervisory leadership on turnover intention was significant (p < 0.01). CONCLUSIONS: Our results suggest that, in addition to teamwork perceptions positively affecting turnover intentions, safety-conscious supportive supervisors can help alleviate the negative impact of poor mindful organizing on frontline staff turnover intention. Healthcare organizations should recruit and retain individuals in supervisory roles who prioritize safety and possess adequate relational competencies. They should further dedicate resources to build and strengthen the relational capacities of their supervisory leadership. Moreover, it is important to provide on-site workshops on topics (e.g., conflict management) that can improve the quality of teamwork and consequently reduce employees' intention to leave their unit/organization.