Unfinished nursing care in intensive care units and the mediating role of the association between nurse working environment, and quality of care and nurses' wellbeing.

OBJECTIVES: Unfinished care refers to the situation in which nurses are forced to delay or omit necessary nursing care. The objectives was: 1) to measure the prevalence of unfinished nursing care in intensive care units during the COVID-19 pandemic; 2) to examine whether unfinished nursing care has a mediating role in the relationship between nurse working environment and nurse-perceived quality of care and risk of burnout among nurses. DESIGN: A national cross-sectional survey. SETTING: Seventy-five intensive care units in Belgium (December 2021 to February 2022). MAIN OUTCOME MEASURES: The Practice Environment Scale of the Nursing Work Index was used to measure the work environment. The perception of quality and safety of care was evaluated via a Likert-type scale. The risk of burnout was assessed using the Maslach Burnout Inventory scale. RESULTS: A total of 2,183 nurse responses were included (response rate of 47.8%). Seventy-six percent of nurses reported at least one unfinished nursing care activity during their last shift. The staffing and resource adequacy subdimension of the Practice Environment Scale of the Nursing Work Index had the strongest correlation with unfinished nursing care. An increase in unfinished nursing care led to significantly lower perceived quality and safety of care and an increase in high risk of burnout. Unfinished nursing care appears to be a mediating factor for the association between staffing and resource adequacy and the quality and safety of care perceived by nurses and risk of burnout. CONCLUSIONS: Unfinished nursing care, which is highly related to staffing and resource adequacy, is associated with increased odds of nurses being at risk of burnout and reporting a lower level of perceived quality of care. IMPLICATIONS FOR CLINICAL PRACTICE: The monitoring of unfinished nursing care in the intensive care unit is an important early indicator of problems related to adequate staffing levels, the well-being of nurses, and the perceived quality of care.

RSV Burden and Its Impact on Pediatric Inpatient Bed Occupancy in Belgium: An Analysis of National Hospital Claims Data.

BACKGROUND: Respiratory syncytial virus (RSV) infections represent a substantial burden on pediatric services during winter. While the morbidity and financial burden of RSV are well studied, less is known about the organizational impact on hospital services (ie, impact on bed capacity and overcrowding and variation across hospitals). METHODS: Retrospective analysis of the population-wide Belgian Hospital Discharge Data Set for the years 2017 and 2018 (including all hospital sites with pediatric inpatient services), covering all RSV-associated (RSV-related International Classification of Diseases, 10th Version, Clinical Modification diagnoses) inpatient hospitalization by children under 5 years old as well as all-cause acute hospitalizations in pediatric wards. RESULTS: RSV hospitalizations amount to 68.3 hospitalizations per 1000 children less than 1 year and 5.0 per 1000 children 1-4 years of age and are responsible for 20%-40% of occupied beds during the peak period (November-December). The mean bed occupancy rate over the entire year (2018) varies across hospitals from 22.8% to 85.1% and from 30.4% to 95.1% during the peak period. Small-scale pediatric services (<25 beds) are more vulnerable to the volatility of occupancy rates. Forty-six hospital sites have daily occupancy rates above 100% (median of 9 days). Only in 1 of 23 geographically defined hospital networks these high occupancy rates are on the same calendar days. CONCLUSIONS: Pediatric services tend to be over-dimensioned to deal with peak activity mainly attributable to RSV. RSV immunization can substantially reduce pediatric capacity requirements. Enhanced collaboration in regional networks is an alternative strategy to deal with peaks and reduce capacity needs.

Association of burnout and intention-to-leave the profession with work environment: A nationwide cross-sectional study among Belgian intensive care nurses after two years of pandemic.

BACKGROUND: Intensive care unit (ICU) nurses are at an increased risk of burnout and may have an intention-to-leave their jobs. The COVID-19 pandemic may increase this risk. OBJECTIVE: The objective of this study was to describe the prevalence of burnout risk and intention-to-leave the job and nursing profession among ICU nurses and to analyse the relationships between these variables and the work environment after two years of the COVID-19 pandemic. DESIGN: A national cross-sectional survey of all nurses working in Belgian ICUs was conducted between December 2021 and January 2022 during the 4th and 5th waves of the COVID-19 pandemic in Belgium. The Practice Environment Scale of the Nursing Work Index (PES-NWI) was used to measure the work environment, intention-to-leave the hospital and/or the profession was assessed. The risk of burnout was assessed using the Maslach Burnout Inventory scale including emotional exhaustion, depersonalisation, and reduced personal accomplishment. SETTING: Nurses in 78 out of 123 Belgian hospital sites with an ICU participated in the survey. PARTICIPANTS: 2321 out of 4851 nurses (47.8%) completed the entire online survey. RESULTS: The median overall risk of burnout per hospital site (high risk in all three subdimensions) was 17.6% [P25: 10.0 - P75: 28.8] and the median proportion of nurses with a high risk in at least one subdimension of burnout in Belgian ICUs was 71.6% [56.7-82.7]. A median of 42.9% [32.1-57.1] of ICU nurses stated that they intended-to-leave the job and 23.8% [15.4-36.8] stated an intent-to-leave the profession. The median overall score of agreement with the presence of positive aspects in the work environment was 49.0% [44.8-55.8]. Overall, nurses working in the top 25% of best-performing hospital sites with regard to work environment had a statistically significant lower risk of burnout and intention-to-leave the job and profession compared to those in the lowest performing 25% of hospital sites. Patient-to-nurse ratio in the worst performing quartile was associated with a higher risk for emotional exhaustion (OR = 1.53, 95% CI:1.04-2.26) and depersonalisation (OR = 1.48, 95% CI:1.03-2.13) and intention-to-leave the job (OR = 1.46, 95% CI:1.03-2.05). CONCLUSIONS: In this study, a high prevalence of burnout risk and intention-to-leave the job and nursing profession was observed after two years of the COVID-19 pandemic. Nevertheless, there was substantial variation across hospital sites which was associated with the quality of the work environment. TWEETABLE ABSTRACT: "Burnout & intention to leave was high for Belgian ICU nurses after 2 years of COVID, but wellbeing was better with high quality work environments and more favourable patient to nurse ratios".

Improving hospital nurse staffing during the pandemic: Implementation of the 2019 Fund for Health Care Staff in Belgium.

Chronic hospital nurse understaffing is a pre-existing condition of the COVID-19 pandemic. With nurses on the frontline against the pandemic, safe nurse staffing in hospitals is high on the political agenda of the responsible ministers of Health. This paper presents a recent Belgian policy reform to improve nurse staffing levels. Although the reform was initiated before the pandemic, its roll-out took place from 2020 onwards. Through a substantial increase of the hospital budget, policy makers envisaged to improve patient-to-nurse ratios. Yet, this ambition was considerably toned down during the implementation. Due to a shortage of nurses in the labour market, hospital associations successfully lobbied to allocate part of the budget to hire non-nursing staff. Moreover, other healthcare settings claimed their share of the pie. Elements of international best-practice examples such as ward managers supernumerary to the team and increasing the transparency on staffing decisions were adopted. Other measures, such as mandated patient-to-nurse ratios, nurse staffing committees, or the monitoring or public reporting of ratios, were not retained. Additional measures were taken to safeguard that bedside staffing levels would improve, such as the requirement to demonstrate a net increase in staff to obtain additional budget, staffing plan's approval by local work councils and recommendation to base staff allocation on patient acuity measures. This policy process makes clear that the engagement of budgets is only a first step towards safe staffing levels, which needs to be embedded in a comprehensive policy plan. Future evaluation of bedside nurse staffing levels and nurse wellbeing is needed to conclude about the effectiveness of these measures and the intended and unintended effects they provoked.

Can people afford to pay for health care? New evidence on financial protection in Belgium

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimension of health system performance. The incidence of catastrophic health spending is higher in Belgium than in most other countries in western Europe. It is heavily concentrated in the poorest fifth of the population and among households headed by unemployed or inactive people. Rates of unmet need for health care and dental care in Belgium are similar to the European Union average, but there is a significant gap in unmet need between the richest and poorest people. The factors that undermine financial protection in Belgium include gaps in all three dimensions of health coverage (population coverage, service coverage and user charges) and administrative barriers. At least 1% of the population is uninsured, rising to at least 2% in the Brussels region and among younger adults and self-employed people. On average, catastrophic spending is driven by out-of-pocket payments for medical products (owing to gaps in the benefits package) and inpatient care (reflecting widespread balance billing). In the poorest consumption quintile, however, it is mainly driven by outpatient medicines, diagnostic tests and outpatient care. The Government has recently taken steps to strengthen financial protection, but more can be done to simplify Belgium’s unusually complex coverage policy and reduce co-payments and other out-of-pocket payments, particularly for low-income households – for example, abolishing retrospective reimbursement for all health services; extending the annual cap on co-payments to all health services and lowering it for people with very low incomes; granting automatic entitlement to everyone eligible for increased reimbursement (reduced co-payments); limiting balance billing in outpatient and inpatient care; and strengthening regulation of the price of non-covered medical products.

An EQ-5D-5L Value Set for Belgium.

OBJECTIVE: This study aimed to establish a Belgian EQ-5D-5L value set based on the preferences of the adult Belgian general population. METHODS: The most recent EuroQol Valuation Technology (EQ-VT 2.1) protocol for EQ-5D-5L valuation studies was followed. Computer-assisted personal interviews were carried out in a representative sample of the adult Belgian population. Potential respondents were randomly selected from the National Register using a multistage, stratified, cluster sampling with unequal probability design. Each respondent valued 10 or 11 health states using composite time trade-off (cTTO) and 14 health states in seven paired choice tasks using a discrete choice experiment (DCE). Different model specifications were explored and assessed based on logical consistency, goodness of fit, predictive accuracy and theoretical considerations. RESULTS: A total of 892 respondents were included in the analyses. The sample was representative of the Belgian adult population in terms of age, sex, region of residence, educational attainment, labour market status, self-assessed health status and health-related quality of life (HRQoL). The preferred model specification was a hybrid (DCE and cTTO data combined) multiplicative eight-coefficient model with intercept random effects and correction for heteroskedasticity. Values range from - 0.532 to 1. Loss of HRQoL is highest in the dimension pain/discomfort, closely followed by anxiety/depression. CONCLUSIONS: This study developed a Belgian EQ-5D-5L value set, based on the preferences of the Belgian adult general population. It provides opportunities for future clinical and economic evaluations in healthcare, for the measurement of patient-reported outcomes and for population health assessments.

Economies of scale and optimal size of maternity services in Belgium: A Data Envelopment Analysis.

This article uses a Data Envelopment Analysis to measure scale efficiency of maternity services in Belgium and estimate the minimum efficient scale in this context. Using administrative data for all maternity services in Belgium in 2016, the minimum efficient scale is estimated at 557 deliveries per year, which is above the currently prevailing norm of 400 deliveries per year. In particular, the closure of 17 small maternity services could improve efficiency without reducing accessibility. In addition to that, further efficiency gains could be attained by increasing the scale of maternity services up to at least 900 deliveries per year. Although most services are close to scale efficiency, the mean scale inefficiency level is 13% and low scores are mainly concentrated among the smallest services. These results are robust to changes in model specifications, bootstrapping and removal of outliers. In the current context of reform of the hospital and maternity landscape in Belgium, this study shows room for improvement and the possibility to generate substantial efficiency gains that could be reinvested in the healthcare system.

It runs in the family - Influenza vaccination and spillover effects.

We study a population-based influenza vaccination program in the Netherlands, and the spillovers it has within families. Individuals aged 65 years and over qualify for the program and receive a personal invitation for a free flu shot, while ineligible individuals have to pay out-of-pocket and face additional barriers to getting vaccinated. The quasi-random variation at age 65 is exploited to analyse program impact on vaccination behavior of cohabiting partners and adult children. We find that the program induced a 10 percentage points increase in vaccination coverage among individuals at age 65. The program further led to a similar effect on vaccination take-up by cohabiting younger partners, but spillovers on children were negative. These asymmetric patterns of vaccination uptake are consistent with partners and children learning about influenza mortality risk, target group membership, and cost and benefits of vaccination, as well as salience. We conclude that public health campaigns should pay attention to the effects on voluntary preventive care participation as within-family spillovers impact the program's overall public health impact.

Safe nurse staffing policies for hospitals in England, Ireland, California, Victoria and Queensland: A discussion paper.

OBJECTIVE: The association between higher registered nurses (RN) staffing (educational level and number) and better patient and nurse outcomes is well-documented. This discussion paper aims to provide an overview of safe staffing policies in various high-income countries to identify reform trends in response to recurring nurse workforce challenges. METHODS: Based on a scan of the literature five cases were selected: England (UK), Ireland, California (USA), Victoria and Queensland (Australia). Information was gathered via a review of the grey and peer-reviewed literature. Country experts were consulted for additional information and to review country reports. RESULTS: The focus of safe staffing policies varies: increasing transparency about staffing decisions (England), matching actual and required staffing levels based on patient acuity measurement (Ireland), mandated patient-to-nurse ratios at the level of the nurse (California) or the ward (Victoria, Queensland). Calibration of the number of patients by the number of nurses varies across cases. Nevertheless, positive effects on the nursing workforce (increased bedside staffing) and staff well-being (increased job satisfaction) have been consistently documented. The impact on patient outcomes is promising but less well evidenced. CONCLUSION: Countries will have to set safe staffing policies to tackle challenges such as the ageing population and workforce shortages. Various approaches may prove effective, but need to be accompanied by a comprehensive policy that enhances bedside nurse staffing in an evidence-based, objective and transparent way.

The Dutch influenza vaccination policy and medication use, outpatient visits, hospitalization and mortality at age 65.

BACKGROUND: Our objective was to obtain estimates of the impact of the Dutch vaccination programme on medication use, outpatient visits, hospitalization and mortality at age 65. METHODS: We linked population-wide mortality, hospitalization and municipality registries to identify influenza-related deaths and hospitalizations, and used health interview surveys to identify medication use and outpatient visits during 1996-2008. We applied a regression discontinuity design to estimate the intention-to-treat effect of the personal invitation for a free influenza vaccination sent to every Dutch inhabitant at age 65 years on each of the outcomes, separately in influenza-epidemic and non-epidemic months. RESULTS: Invitation receipt for free influenza vaccination at age 65 led to a 9.8 percentage points [95% confidence interval (CI) = 3.5 to16.1; P < 0.01] rise in influenza vaccination. During influenza-epidemic months, it was associated with 1.5 fewer influenza/pneumonia deaths per 100 000 individuals (95% CI = -3.1 to -0.0; P = 0.05), a 15 percentage point lower probability to use prescribed medicines (95% CI = -28 to -3; P = 0.02) and 0.13 fewer General Practitioner (GP) visits per month (95% CI = -0.28 to 0.02; P = 0.09), while the association with hospitalizations due to influenza/pneumonia was small and imprecisely estimated (seven more hospitalizations per 100 000 individuals, 95% CI = -20 to 33; P = 0.63). No associations were found with any outcomes during non-epidemic months. CONCLUSIONS: Personal invitations for a free influenza vaccination sent to every Dutch inhabitant at age 65 took pressure off primary health care but had small effects on hospitalizations and mortality.

Trends in the utilisation rates and acute hospital capacity needs for total hip replacements: results of an analysis of administrative data.

Total hip replacement surgery is the mainstay of treatment for end-stage hip arthritis. In 2014, there were 28227 procedures (incidence rate 252/100000 population). Using administrative data, we projected the future volume of total hip replacement procedures and incidence rates using two models. The constant rate model fixes utilisation rates at 2014 levels and adjusts for demographic changes. Projections indicate 32248 admissions by 2025 or an annual growth of 1.22% (incidence rate 273). The time trend model additionally projects the evolution in age-specific utilisation rates. 34895 admissions are projected by 2025 or an annual growth of 1.95% (incidence rate 296). The projections show a shift in performing procedures at younger age. Forecasts of length of stay indicate a substantial shortening. By 2025, the required number of hospital beds will be halved. Despite more procedures, capacity can be reduced, leading to organisational change (e.g. elective orthopaedic clinics) and more labour intensive stays.

Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data.

BACKGROUND: We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003-2014. METHODS: A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS. RESULTS: Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%. CONCLUSIONS: Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS.

The impact of an ageing population on the required hospital capacity: results from forecast analysis on administrative data.

PURPOSE: In this study, we evaluate the impact of population ageing on the required hospital capacity. METHODS: We used hospital discharge (years 2003-2014) and population data to estimate the required hospital capacity by 2025 for older inpatients (≥ 75 years) taking into account population changes and trends in hospital admission rates and length of stay. In addition, we developed an alternative scenario to evaluate the impact of accelerated ageing based on the peaks in population ageing from 2030 onwards. RESULTS: The number of inpatient stays for our study population is expected to increase from 478,027 in 2014 to 590,313 in 2025 (+ 23.5%). The average length of stay is expected to decrease by 18.4% (- 2.3 days). As a consequence, the number of inpatient days and the required bed capacity will only increase by 42,709 days (+ 0.7%) and 72 beds (+ 0.4%), respectively. The accelerated ageing scenario shows that the increase between 2014 and 2025 is more pronounced for inpatient stays (+ 50.5%), inpatient days (+ 21.9%) and hospital beds (+ 21.1%). CONCLUSIONS: Ageing will, if no drastic policy actions are taken, impact the required hospital capacity. This can initially (by 2025) be more or less controlled by further reductions in length of stay. From 2030, it is expected that the required hospital bed capacity will increase exponentially with a pronounced shift between general acute care beds towards geriatric and chronic care beds. If policy makers want to revert this trend, substantial investments in hospital alternatives will be required.

Improving the forecasting of hospital services: A comparison between projections and actual utilization of hospital services.

OBJECTIVES: To compare projected and observed hospital inpatient use in Belgium and to draw lessons from that comparison. METHODS: In 2005, projections for hospital service use were generated up to 2015, based on demographic change, substitution from inpatient to day care, and, the evolution of the average length of stay (LOS). The accuracy of the forecasts was assessed by comparing projected and observed population size, admissions and inpatient days, average LOS and percentage change in case mix. RESULTS: The demographic growth was underestimated. Overall, the baseline projection for hospital admissions was remarkably close to the observed figures but the underlying case mix diverged importantly. With substitution between inpatient and day care, the number of admissions was underestimated by 15%-40%. The number of days was projected to increase in every scenario, whereas a decreasing trend was observed mainly due to the faster decline in average LOS than projected. CONCLUSION: Hospital capacity planning is an important component of evidence informed policymaking. Projection results benefit from a well-designed methodology: choice of forecast groups, estimation models, selection criteria, and a sensitivity analysis of the results. To cope with the dynamic and continuously evolving context in which hospitals operate, regular updates to incorporate new data and to reassess estimated trends should be an integral part of the projection framework.

Differing types of medical prevention appeal to different individuals.

We analyze participation in medical prevention with an expected utility model that is sufficiently rich to capture diverging features of different prevention procedures. The predictions of the model are not rejected with data from SHARE. A decrease in individual health decreases participation in breast cancer screening and dental prevention and increases participation in influenza vaccination, cholesterol screening, blood pressure screening, and blood sugar screening. Positive income effects are most pronounced for dental prevention. Increased mortality risk is an important predictor in the model for breast cancer screening, but not for the other procedures. Targeted screening and vaccination programs increase participation.