Combined effect of intermittent hemostasis and a modified external hemorrhage control device in a lethal swine model.

Background: Non-compressible torso hemorrhage (NCTH) presents the ultimate challenge in pre-hospital care. While external hemorrhage control devices (EHCDs) such as the Abdominal Aortic and Junctional Tourniquet (AAJT) and SAM Junctional Tourniquet (SJT) have been invented, the current design and application strategy requires further improvement. Therefore, researchers devised a novel apparatus named Modified EHCD (M-EHCD) and implemented intermittent hemostasis (IH) as a preventive measure against ischemia-reperfusion injury. The objective of this study was to ascertain the combined effect of M-EHCD and IH on the hemostatic effect of NCTH. Methods: Eighteen swine were randomized to M-EHCD, AAJT or SJT. The NCTH model was established by inducing Class Ⅲ hemorrhagic shock and performing a hemi-transection of common femoral artery (CFA). EHCDs were rapidly fastened since the onset of free bleeding (T0min). The IH strategy was implemented by fully releasing M-EHCD at T40min, T70min and T100min, respectively, whereas AAJT and SJT maintained continuous hemostasis (CH) until T120min. All groups underwent CFA bridging at T110min, and EHCDs were removed at T120min. Reperfusion lasted for 60 min, after which euthanasia was performed. Hemodynamics, intra-vesical pressure (IVP), and blood samples were collected periodically. Histological examinations were also conducted. Results: M-EHCD demonstrated the fastest application time (M-EHCD: 26.38 ± 6.32s vs. SJT: 30.84 ± 5.62s vs. AAJT: 54.28 ± 5.45s, P < 0.001) and reduced free blood loss (M-EHCD: 17.77 ± 9.85g vs. SJT: 51.80 ± 33.70g vs. AAJT: 115.20 ± 61.36g, P = 0.011) compared to SJT and AAJT. M-EHCD exhibited inhibitory effects on heart rate (M-EHCD: 91.83 ± 31.61bpm vs. AAJT: 129.00 ± 32.32bpm vs. SJT: 135.17 ± 21.24bpm, P = 0.041) and shock index. The device's external pressure was lowest in M-EHCD and highest in SJT (P = 0.001). The resultant increase in IVP were still the lowest in M-EHCD (M-EHCD: -0.07 ± 0.45 mmHg vs. AAJT: 27.04 ± 5.03 mmHg vs. SJT: 5.58 ± 2.55 mmHg, P < 0.001). Furthermore, M-EHCD caused the least colonic injury (M-EHCD: 1.17 ± 0.41 vs. AAJT: 2.17 ± 0.41 vs. SJT: 2.17 ± 0.41, P = 0.001). The removal of M-EHCD showed the slightest impact on pH (P < 0.001), while AAJT group was more susceptible to the lethal triad based on the arterial lactate and thrombelastogram results. Conclusions: M-EHCD + IH protected the organs and reduced the risk of the lethal triad by decreasing disruptions to IVP, hemodynamics, acid-base equilibrium and coagulation. M-EHCD + IH was superior to the hemostatic safety and efficacy of AAJT/SJT + CH.

Epidemiology and outcomes of out of hospital cardiac arrest in Karachi, Pakistan - A longitudinal study.

Background: Out-of-hospital cardiac arrest (OHCA) is a major cause of morbidity and mortality globally, with survival outcomes remaining poor particularly in many low- and middle-income countries. We aimed to establish a pilot OHCA registry in Karachi, Pakistan to provide insights into OHCA patient demographics, pre-hospital and in-hospital care, and outcomes. Methods: A multicenter longitudinal study was conducted from August 2015-October 2019 across 11 Karachi hospitals, using a standardized Utstein-based survey form. Data was retrospectively obtained from medical records, patients, and next-of-kin interviews at hospitals with accessible medical records, while hospitals without medical records system used on-site data collectors. Demographics, arrest characteristics, prehospital events, and survival outcomes were collected. Survivors underwent follow-up at 1 month, 6 months, 1 year, and 5 years. Results: In total, 1068 OHCA patients were included. Mean age was 55 years, 61.1 % (n = 653) male. Witnessed arrests accounted for 94.9 % of the cases (n = 1013), whereas 89.4 % of the cases (n = 955) were transported via non-EMS. Bystander CPR was performed in 10.3 % (n = 110) cases whereas pre-hospital defibrillation performed in 0.4 % (n = 4). In-hospital defibrillation was performed in 9.9 % (n = 106) cases despite < 5 % shockable rhythms. Overall survival to discharge was 0.75 % (n = 8). Of these 8 patients, 7 patients survived to 1-year and 2 to 5-years. Neurological outcomes correlated with long-term survival. Conclusion: OHCA survival rates are extremely low, necessitating public awareness interventions like CPR training, developing robust pre-hospital systems, and improving in-hospital emergency care through standardized training programs. This pilot registry lays the foundation for implementing interventions to improve survival and emergency medical infrastructure.

CALL TO ECLS-Acronym for Reporting Patients for Extracorporeal Cardiopulmonary Resuscitation Procedure from Prehospital Setting to Destination Centers.

The acronym CALL TO ECLS has been proposed as a potential tool to support decision-making in critical communication moments when qualifying a patient for the ECPR procedure. The aim of this study is to assess the accuracy of the acronym and validate its content. Validation is crucial to ensure that the acronym is theoretically correct and includes the necessary information that must be conveyed by EMS during the qualification of a patient with out-of-hospital cardiac arrest for ECMO. A survey was conducted using the LimeSurvey platform through the Survey Research System of the Jagiellonian University Medical College over a 6-month period (from December 2022 to May 2023). Usefulness, importance, clarity, and unambiguity were rated on a 4-point Likert scale, from 1 (not useful, not important, unclear, ambiguous) to 4 (useful, important, clear, unambiguous). On the 4-point scale, the Content Validity Index (I-CVI) was calculated as the percentage of subject matter experts who rated the criterion as having a level of importance/clarity/validity/uniqueness of 3 or 4. The Scale-level Content Validity Index (S-CVI) based on the average method was computed as the average of I-CVI scores (S-CVI-AVE) for all considered criteria (protocol). The number of fully completed surveys by experts was 35, and partial completion was obtained in 63 cases. All criteria were deemed significant/useful, with I-CVI coefficients ranging from 0.87 to 0.97. Similarly, the importance of all criteria was confirmed, as all I-CVI coefficients were greater than 0.78 (ranging from 0.83 to 0.97). The average I-CVI score for the ten considered criteria in terms of usefulness/significance and importance exceeded 0.9, indicating high validity of the tool/protocol/acronym. Based on the survey results and analysis of responses provided by experts, a second version was created, incorporating additional explanations. In Criterion 10, an explanation was added-"Signs of life"-during conventional cardiopulmonary resuscitation (ROSC, motor response during CPR). It has been shown that the acronym CALL TO ECLS, according to experts, is accurate and contains the necessary content, and can serve as a system to facilitate communication between the pre-hospital environment and specialized units responsible for qualifying patients for the ECPR.

Multimorbidity-associated emergency hospital admissions: a "screen and link" strategy to improve outcomes for high-risk patients in sub-Saharan Africa: a prospective multicentre cohort study protocol.

Background: The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub-Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives: Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives: Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods: This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng'ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.

Background: In sub-Saharan Africa, multimorbidity (defined as people living with two or more chronic health conditions) is increasing due to high infectious ( e.g., human immunodeficiency virus (HIV)) and non-communicable ( e.g., high blood pressure and diabetes) disease burdens. Multimorbidity increases as people live longer and can be worsened by HIV and HIV-medications. Patients delay seeking help until they are severely ill, meaning hospitals are key to healthcare delivery for chronic diseases, however hospital clinicians often focus on a single disease. Failure to identify and treat multimorbidity may lead to frequent readmissions, high costs, preventable disability and death. Aim: This cohort study is the first in a three-phase study with the overarching goal to design and test a system to identify patients suffering from multimorbidity when they seek emergency care in sub-Saharan African hospitals. This could improve early disease treatment (reducing death), ensure better follow-up and prevent disability, readmission and excess costs. The cohort study aims to determine multimorbidity prevalence, outcomes and costs. The results will help us co-create with key stakeholders the most cost-effective way to deliver improved care for patients before testing this strategy in a randomised trial. Methods in Brief: In Malawi and Tanzania, we will identify multimorbidity among patients admitted to hospital (focusing on high blood pressure, diabetes, HIV and chronic kidney disease), by enhancing diagnostic tests in hospital departments treating acutely admitted medical patients. With the help of healthcare professional, patients and community groups we will find how best to link patients to long-term care and improve self-management. After mapping health system pathways, we will work with stakeholders (policymakers, healthcare worker representatives, community and patient groups) to co-develop an intervention to improve outcomes for patients with multimorbidity. This study will allow us to collect clinical, health economic and health system data to inform this process.

Causes, outcomes and diagnosis of acute breathlessness hospital admissions in Malawi: protocol for a multicentre prospective cohort study.

Background: Hospital admission due to breathlessness carries a significant burden to patients and healthcare systems, particularly impacting people in low-income countries. Prompt appropriate treatment is vital to improve outcomes, but this relies on accurate diagnostic tests which are of limited availability in resource-constrained settings. We will provide an accurate description of acute breathlessness presentations in a multicentre prospective cohort study in Malawi, a low resource setting in Southern Africa, and explore approaches to strengthen diagnostic capacity. Objectives: Primary objective: Delineate between causes of breathlessness among adults admitted to hospital in Malawi and report disease prevalence. Secondary objectives : Determine patient outcomes, including mortality and hospital readmission 90 days after admission; determine the diagnostic accuracy of biomarkers to differentiate between heart failure and respiratory infections (such as pneumonia) including brain natriuretic peptides, procalcitonin and C-reactive protein. Methods: This is a prospective longitudinal cohort study of adults (≥18 years) admitted to hospital with breathlessness across two hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Chiradzulu, Malawi. Patients will be consecutively recruited within 24 hours of emergency presentation and followed-up until 90 days from hospital admission. We will conduct enhanced diagnostic tests with robust quality assurance and quality control to determine estimates of disease pathology. Diagnostic case definitions were selected following a systematic literature search. Discussion: This study will provide detailed epidemiological description of adult hospital admissions due to breathlessness in low-income settings, which is currently poorly understood. We will delineate between causes using established case definitions and conduct nested diagnostic evaluation. The results have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve both patient care and outcomes.

BACKGROUND: People admitted to hospital with symptoms of breathlessness are often severely ill and need quick, accurate assessment to facilitate timely initiation of appropriate treatments. In low resource settings, such as Malawi, limited access to diagnostic equipment impedes patient assessment. Failure to identify and treat the underlying diagnosis may lead to preventable death. AIMS: This cohort study aims to delineate between common, treatable causes of breathlessness among adult patients admitted to hospital in Malawi and measure survival. We will also evaluate the performance of blood markers to diagnose and differentiate between conditions. The results will help us develop context-appropriate diagnostic and treatment algorithms based on resources available in the health system Methods in brief: We will recruit adult patients who present to hospital with breathlessness in a central national referral hospital (Queen Elizabeth Central Hospital, Blantyre), and a district hospital (Chiradzulu District Hospital, Chiradzulu). We will conduct enhanced diagnostic tests to determine causes of breathlessness against internationally accepted diagnostic guidelines. Patients will be followed up throughout their hospital admission and after discharge, until 90 days. INTERPRETATION: This study aligns with World Health Assembly resolutions on 'Strengthening diagnostics capacity' and on 'Integrated emergency, critical and operative care for universal health coverage and protection from health emergencies'. The results of this study will have the potential to facilitate development of interventions targeted to strengthen diagnostic capacity, enable prompt and appropriate treatment, and ultimately improve care and outcomes for acutely unwell patients.

Hospital at home worldwide: Program and clinician characteristics from the World Hospital at Home Congress survey.

BACKGROUND: Hospital at home (HaH) delivers hospital-level care to acutely ill patients at home as a substitute for brick-and-mortar hospital care. The clinician and program characteristics of HaH programs worldwide are relatively unknown. We sought to describe the world's HaH clinicians and their programs' characteristics. METHODS: We analyzed a survey administered to all attendees of the 2023 World Hospital at Home Congress. Clinician characteristics included age, years worked in HaH, profession, burnout, and experience. Program characteristics included location, daily census, types of care delivery, and clinical capabilities. RESULTS: Of 670 attendees, about 305 were clinicians and 129 responded (42% response rate for clinicians). The majority of clinicians were 30-49 years old (65.1%), new to the field (70.5% worked less than 10 years), and part-time (18% dedicated >74% effort to HaH). Clinicians reported overall satisfaction with their job and low burnout. About half of programs were in Europe (52.1%), newly operational (44.7% less than 5 years), mostly operated in urban environments (87.2%), and mostly had a daily census of less than 25 patients (62.8%). Most programs operated 7-days per week (88.3%), performed intermittent or continuous remote monitoring (81.4%), used video communication (63.8%), and had some advanced capabilities such as in-home imaging (47.9%) and advanced procedures (23.4%). Visit frequencies to the patient's home were variable: most programs had physicians visit the home, nearly all had nurses visit the home, and fewer performed virtual visits. CONCLUSIONS: HaH clinicians and programs have significant similarities but also a fair number of divergent practices, much like brick-and-mortar hospital care. Further standardization of the care model will help to unify the field across the globe.

Repeated radiological procedures in the last 6 months of life in old age: a retrospective study.

OBJECTIVES: This novel study looks at the use of radiological procedures in an elderly cohort of patients in their last 6 months of life. Radiological imaging plays a central part of clinical investigations, but too many may override the judgement of benefits, risks and resources. There is little information on the burden of radiological procedures performed towards the end of life in patients of old age. METHODS: Data from every fourth patient aged 80 years and over who died between 4 July 2021 and 30 December 2021 in a National Health Service (NHS) hospital were collected. All radiological procedures performed within the last 6 months of the patients' life were recorded from clinical documentation and related to their age. RESULTS: 96 patients were studied with a total of 699 radiological procedures performed. When scaled up, costs of CT and MRI scans alone are conservatively estimated as £312 000/annum in patients aged ≥80 years in their last 6 months of life for a single medium-sized NHS hospital. CONCLUSIONS: A very large number of radiological procedures were performed towards the end of life among patients of old age. This is consistent with the national trend of increased medicalisation and poor recognition of dying.

Clinical Services, Barriers, and Public Perspectives of Community Pharmacies in Saudi Arabia: A Cross-Sectional Study.

In the Kingdom of Saudi Arabia, there is an increasing demand for community pharmacists to provide the highest level of clinical knowledge and services. However, evidence regarding Saudi public awareness of the clinical services offered by community pharmacies (CPs) and the barriers to using them is limited. In this cross-sectional study, we used an online questionnaire developed by adapting the Consolidated Framework for Implementation Research. A total of 273 participants completed the survey. Half the participants were generally aware of the availability of some CP services but were not informed about the full range on offer, eg, medication reviews (84%) and online counseling (89%). Most of the participants (69.6%) did not identify differences in the care provided by community pharmacists versus hospital pharmacists (P = 0.02). A commonly reported barrier to using CP services was a general preference for other healthcare professionals to seek pharmaceutical help (85.7%). Many other barriers were also reported, impacting the participants' use of these services. The decision-making authorities should consider improvements to increase patients' awareness and utilization of clinical services and enhance community pharmacists' performance in clinical-oriented pharmaceutical care.

What influences ambulance clinician decisions to pre-alert emergency departments: a qualitative exploration of pre-alert practice in UK ambulance services and emergency departments.

BACKGROUND: Ambulance clinicians use pre-alerts to inform receiving hospitals of the imminent arrival of a time-critical patient considered to require immediate attention, enabling the receiving emergency department (ED) or other clinical area to prepare. Pre-alerts are key to ensuring immediate access to appropriate care, but unnecessary pre-alerts can divert resources from other patients and fuel 'pre-alert fatigue' among ED staff. This research aims to provide a better understanding of pre-alert decision-making practice. METHODS: Semi-structured interviews were conducted with 34 ambulance clinicians from three ambulance services and 40 ED staff from six receiving EDs. Observation (162 hours) of responses to pre-alerts (n=143, call-to-handover) was also conducted in the six EDs. Interview transcripts and observation notes were imported into NVIVO and analysed using thematic analysis. FINDINGS: Pre-alert decisions involve rapid assessment of clinical risk based on physiological observations, clinical judgement and perceived risk of deterioration, with reference to pre-alert guidance. Clinical experience (pattern recognition and intuition) and confidence helped ambulance clinicians to understand which patients required immediate ED care on arrival or were at highest risk of deterioration. Ambulance clinicians primarily learnt to pre-alert 'on the job' and via informal feedback mechanisms, including the ED response to previous pre-alerts. Availability and access to clinical decision support was variable, and clinicians balanced the use of guidance and protocols with concerns about retention of clinical judgement and autonomy. Differences in pre-alert criteria between ambulance services and EDs created difficulties in deciding whether to pre-alert and was particularly challenging for less experienced clinicians. CONCLUSION: We identified potentially avoidable variation in decision-making, which has implications for patient care and emergency care resources, and can create tension between the services. Consistency in practice may be improved by greater standardisation of guidance and protocols, training and access to performance feedback and cross-service collaboration to minimise potential sources of tension.

Nutritional support clinical efficacy in tuberculosis: quasi-experimental study.

OBJECTIVE: This study aimed to investigate the impact of nutritional support on the clinical efficacy in hospitalised tuberculosis patients with nutritional risk. METHODS: We selected a total of 266 eligible patients with tuberculosis for the experimental and 190 patients for control groups. The patients in intervention group received adjusted dietary structure, enteral nutrition via oral intake or gastric tube, total parenteral nutrition and combined enteral and parenteral nutrition. We recorded various factors, including age, sex, underlying disease, tuberculosis type, nutritional risk at admission, serum albumin (ALB), body mass index, complications during hospitalisation, nutritional support status, serum ALB before discharge and length of hospital stay. RESULTS: The incidences of nutritional risk in the control and experimental groups were 64.41% and 64.72%, respectively, with no statistically significant differences in baseline characteristics. The occurrence rates of complications and secondary infections in the experimental group were 57.89% and 51.5%, respectively, which were significantly lower than the control group's rates of 70.00% and 56.31%. These differences were statistically significant. The experimental group had a significantly shorter hospital stay (16.5±7.54 days) compared with the control group (19.55±7.33 days). Furthermore, the serum ALB levels of patients in the experimental group were higher on discharge than at admission. CONCLUSION: Hospitalised patients with tuberculosis often face a high incidence of nutritional risk. However, the implementation of standardised nutritional support treatment has shown promising results in improving the nutritional status of tuberculosis patients with nutritional risk. This approach not only helps reduce the occurrence of complications but also enhances short-term prognosis and improves overall clinical efficacy.

Factors associated with care partner identification and education among hospitalized persons living with dementia.

Objective: Care partners of persons living with dementia (PLWD) often feel unprepared to care for their loved ones. Improving PLWD care partner identification and education during hospital stays can improve preparedness. This retrospective EHR study investigated PLWD characteristics that may relate to care partner identification, education, and teaching methods during hospital stays. Methods: Encounters from a Midwestern academic healthcare system were used. Patients were over 18, had a documented dementia diagnosis, were admitted to the hospital for at least 24 h, and had information documented in care partner or education data fields (N = 7982). Logistic regressions assessed patient's demographics, care partner identification and education. Chi-square tests compared education teaching methods and patient discharge location. Results: PLWD's who were unmarried, discharged to other care facilities, or received the diagnosis "degeneration of nervous system due to alcohol" were associated with lacking care partner identification. Care partners of unmarried PLWDs or those with the diagnosis "Alzheimer's disease, unspecified" received less education. Multiple teaching methods were associated with discharge location. Conclusion: Multiple characteristics were related to PLWD care partner identification and education differences during hospital stays. Innovation: Novel analyses highlight need for a protocol to systematically prepare dementia care partners.

Acute care nurses' decisions to recognise and respond to patient improvement: A qualitative study.

AIM: To explore and describe acute care nurses' decisions to recognise and respond to improvement in patients' clinical states as they occurred in the real-world clinical environment. DESIGN: A descriptive study. METHODS: Nine medical and eleven surgical nurses in a large Australian metropolitan hospital were individually observed during nurse-patient interactions and followed up in interview to describe their reasoning and clinical judgements behind observed decisions. Verbal description of observations and interviews were recorded and transcribed. Reflexive thematic analysis was used to analyse the data. RESULTS: The three themes constructed from the data were as follows: nurses checking in; nurses reaching judgements about improvements; and nurses deciding on the best person to respond. Acute care nurses made targeted assessment decisions based on predicted safety risks related to improvement in clinical states. Subjective and objective cues were used to assess for and make judgements about patient improvement. Acute care nurses' judgment of patient safety and a desire to promote patient centred care guided their decisions to select the appropriate person to manage improvement. CONCLUSIONS: The outcomes of this research have demonstrated that the proven safety benefits of acute care nurses' decision making in response to deterioration extend to improvement in patients' clinical states. In response to improvement, acute care nurses' decisions protect patients from harm and promote recovery. IMPLICATIONS FOR PATIENT CARE: Early recognition and response to improvement enable acute care nurses to protect patients from risks of unnecessary treatment and promote recovery. IMPACT: This study makes explicit nurses' essential safety role in recognising and responding to improvement in patients' clinical states. Healthcare policy and education must reflect the equal importance of assessment for and management of deterioration and improvement to ensure patients are protected and provided with safe care.

Tempo de espera no atendimento e internação: satisfação dos usuários e a perspectiva do planejamento e avaliação em saúde / Waiting time for service and hospitalization: user satisfaction and the perspective of planning and health evaluation / Tiempo de espera de servicio y hospitalización: satisfacción del usuario y la perspectiva de la planificación y evaluación en salud

Introdução:A relevância da participação e controle social, promulgados pela Constituição Federal de 1988, garante o exercício da cidadania ao permitir que a população participe ativamente na formulação das políticas públicas de saúde. Neste contexto, surgiram as ouvidorias públicas, com o objetivo de permitir a escuta direta da população, dando protagonismo à sociedade civil.Objetivo:Elaborar um planejamento estratégico e avaliação sobre o tempo de espera por atendimento e internação em um hospital universitário. Metodologia:Trata-se de um estudo ecológico, realizado em junho de 2023 num hospital de ensino no Nordeste do Brasil. Os dados foram obtidos de relatórios da avaliação de usuários atendidos no ambulatório e internação, nos anos de 2016, 2017, 2019 e 2022.Resultados:A partir da análise dos dados foi identificado que há discrepâncias nos índices de satisfação entre os anos estudados. A ausência de detalhes nos relatórios, causa vieses nas pesquisas de satisfação, uma vez que a cada ano é variável o número de usuários pesquisados e o questionário utilizado sofre mudanças nas perguntas, sem justificativa para as alterações. O tempo de espera pelo atendimento e internação foi avaliado e considerado o que obteve piores índices de satisfação.Conclusão:Os resultados deste estudo mostraram que a pesquisa de satisfação com o usuário é uma importante ferramenta de avaliação para a gestão, contudo, há necessidade de um método mais seguro para a execução da avaliação de satisfação. Otempo de espera tem sido uma variávelquefrequentementenão tem atendido de forma satisfatória, sendo necessário identificar e corrigir as causas desse desconforto. Espera-se que este estudo possa contribuir para o fortalecimento da ouvidoria e da pesquisa de satisfação como ferramentas de gestão (AU).

Introduction:The relevance of participation and social control, promulgated by the Federal Constitution of 1988, ensures the exercise of citizenship by allowing the population to participate actively in the formulation of public health policies.In this context, public ombudsmen arise, in order to allow direct listening of the population, giving prominence to civil society.Objective:The study aims to Elaborate a strategic planning and evaluation of the waiting time for care and hospitalization in a university hospital. Methodology:This is an ecological study, carried out in June 2023 in a teaching hospital in Northeast Brazil. Data were obtained from evaluation reports of users treated at the outpatient clinic and hospitalization, in the years 2016, 2017, 2019 and 2022.Results:From the data analysis it was identified that there are discrepancies in the satisfaction rates between the years studied. The absence of methodology described in the reports causes bias in the satisfaction surveys, since each year the number of users surveyed is variable and the questionnaire used undergoes changes in the questions, without justification for the changes. The waiting time for care/hospitalization was considered the one that had the worst satisfaction rates.Conclusion:The results of this study showed that the user satisfaction survey is an important assessment tool for management, however, there is a need for a safer method for carrying out the satisfaction assessment. The waiting time has been a variable that has often not been attended satisfactorily, and it is necessary to identify and correct the causes of this discomfort. It is hoped that this study can contribute to strengthening the ombudsman and the satisfaction survey as management tools (AU).

Introducción:La relevancia de la participación y control social, promulgados por la Constitución Federal de 1988, garantiza el ejercicio de la ciudadanía al permitir que la población participe activamente en la formulación de las políticas públicas de salud.En este contexto, surgen las defensorías públicas, con el objetivo de permitir la escucha directa de la población, dando protagonismo a la sociedad civil.Objetivo:Elaborar una planificación estratégica y evaluación del tiempo de espera para atención y hospitalización en un hospital universitario.Metodología:Se trata de un estudio ecológico, realizado en junio de 2023 en un hospital universitario del Norestede Brasil. Los datos se obtuvieron de informes de evaluación de usuarios atendidos en el ambulatorio y hospitalización, en los años 2016, 2017, 2019 y 2022.Resultados:A partir del análisis de los datos fue identificado que hay discrepancias en los índices de satisfacción entre los años estudiados. La ausencia de metodología descrita en los informes, causa sesgos en las encuestas de satisfacción, una vez que cada año es variable el número de usuarios investigados yel cuestionario utilizado sufre cambios en las preguntas, sin justificación para las alteraciones. El tiempo de espera por la atención/internación fue considerado el que tuvo los peores índices de satisfacción.Conclusión:Los resultados de este estudio mostraron que la encuesta de satisfacción del usuario es una herramienta de evaluación importante para la gestión, sin embargo, existe la necesidad de un método más seguro para llevar a cabo la evaluación de la satisfacción. El tiempo de espera ha sido una variable que muchas veces no ha sido atendida satisfactoriamente, siendo necesario identificar y corregir las causas de este malestar. Se espera que este estudio pueda contribuir a fortalecer la Defensoría del Pueblo y la encuesta de satisfacción como herramientas de gestión (AU).

External validation of the preHEART score and comparison with current clinical risk scores for prehospital risk assessment in patients with suspected NSTE-ACS.

BACKGROUND: Emergency Medical Services (EMS) studies have shown that prehospital risk stratification and triage decisions in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) can be improved using clinical risk scores with point-of-care (POC) troponin. In current EMS studies, three different clinical risk scores are used in patients suspected of NSTE-ACS: the prehospital History, ECG, Age, Risk and Troponin (preHEART) score, History, ECG, Age, Risk and Troponin (HEART) score and Troponin-only Manchester Acute Coronary Syndromes (T-MACS). The preHEART score lacks external validation and there exists no prospective comparative analysis of the different risk scores within the prehospital setting. The aim of this analysis is to externally validate the preHEART score and compare the diagnostic performance of the these three clinical risk scores and POC-troponin. METHODS: Prespecified analysis from a prospective, multicentre, cohort study in patients with suspected NSTE-ACS who were transported to an ED between April 2021 and December 2022 in the Netherlands. Risk stratification is performed by EMS personnel using preHEART, HEART, T-MACS and POC-troponin. The primary end point was the hospital diagnosis of NSTE-ACS. The diagnostic performance was expressed as area under the receiver operating characteristic (AUROC), sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV). RESULTS: A total of 823 patients were included for external validation of the preHEART score, final hospital diagnosis of NSTE-ACS was made in 29% (n=235). The preHEART score classified 27% as low risk, with a sensitivity of 92.8% (95% CI 88.7 to 95.7) and NPV of 92.3% (95% CI 88.3 to 95.1). The preHEART classified 9% of the patients as high risk, with a specificity of 98.5% (95% CI 97.1 to 99.3) and PPV of 87.7% (95% CI 78.3 to 93.4). Data for comparing clinical risk scores and POC-troponin were available in 316 patients. No difference was found between the preHEART score and HEART score (AUROC 0.83 (95% CI 0.78 to 0.87) vs AUROC 0.80 (95% CI 0.74 to 0.85), p=0.19), and both were superior compared with T-MACS (AUROC 0.72 (95% CI 0.66 to 0.79), p≤0.001 and p=0.03, respectively) and POC-troponin measurement alone (AUROC 0.71 (95% CI 0.64 to 0.78), p<0.001 and p=0.01, respectively). CONCLUSION: On external validation, the preHEART demonstrates good overall diagnostic performance as a prehospital risk stratification tool. Both the preHEART and HEART scores have better overall diagnostic performance compared with T-MACS and sole POC-troponin measurement. These data support the implementation of clinical risk scores in prehospital clinical pathways. TRIAL REGISTRATION NUMBER: NCT05243485.

Key performance indicators in pre-hospital response to disasters and mass casualty incidents: a scoping review.

PURPOSE: The objective of this study was to offer a comprehensive synthesis of the existing Key performance indicators (KPIs) used in the evaluation of the pre-Hospital response to disasters and mass casualty incidents (MCIs). METHODS: At the end of December 2022 a scoping review has been performed on PubMed, Scopus, Embase, and Medline to identify articles describing the use of KPIs to assess the performance of first responders during the prehospital phase of an MCI (real or simulated). Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, fourteen articles were included in the analysis. RESULTS: Eleven articles applied indicators in exercises and/or simulations. Two articles proposed new KPIs, and one used KPIs for developing a model for benchmarking pre-Hospital response. All articles analyzed quantitative indicators of time, whereas two studied indicators of structure, of process, and of outcome as well. CONCLUSION: The findings from this review emphasize the need for employing common terminology and using uniformed data collection tools, if obtaining standardized evaluation method is the goal to be achieved.

[Personnel shortages in the healthcare sector-will de-economization solve or exacerbate the problem?] / Personalmangel im Gesundheitswesen ­ Löst oder verstärkt die Entökonomisierung das Problem?

The healthcare industry has long complained about an acute shortage of skilled workers. Vacancies can often only be filled by skilled workers from abroad. While rural areas are increasingly experiencing a shortage of personnel, many urban centers continue to have an oversupply and a sufficient number of young doctors. Hospitals do not expect the situation to improve in the future. Hospitals are trying to counteract the negative development of the job situation in nursing staff. Government intervention can limit the economically motivated adjustment of resource utilization. The demand for staff will not fall as a result of de-economization.

Stroke survivor views on ambulance redirection as a strategy to increase access to thrombectomy in England.

Introduction: Intravenous thrombolysis and mechanical thrombectomy are effective time-sensitive treatments for selected cases of acute ischaemic stroke. While thrombolysis is widely available, thrombectomy can only be provided at facilities with the necessary equipment and interventionists. Suitable patients admitted to other hospitals require secondary transfer, causing delays to treatment. Pre-hospital ambulance redirection to thrombectomy facilities may improve access but treatment eligibility cannot be confirmed pre-hospital. Some redirected patients would travel further and be displaced without receiving thrombectomy. This study aimed to elicit stroke survivor and carer/relative views about the possible consequences of introducing a conceptual, idealised ambulance redirection pathway. Methods: Focus groups were undertaken using a topic guide describing four hypothetical ambulance redirection scenarios and their possible consequences: earlier treatment with thrombectomy; delayed diagnosis of non-stroke 'mimic' conditions; delayed thrombolysis treatment; and delayed diagnosis of haemorrhagic stroke. Meetings were audio recorded, transcribed verbatim and data analysed thematically using emergent coding. Results: Fifteen stroke survivors and carers/relatives participated in three focus groups. There was wide acceptance of possible low-risk consequences of ambulance redirection, including extended travel time, being further from home and experiencing longer hospital stays. Participants were more uncertain about higher-risk consequences, including delays in diagnosis/treatment for patients unsuitable for thrombectomy, but remained positive about ambulance redirection overall. Participants rationalised acceptance of higher-risk consequences by recognising that redirected patients would still access appropriate treatment, even if delayed. In addition, acceptance of ambulance redirection would be increased if there were robust clinical evidence showing net benefit over secondary transfer pathways. Conclusions: Participant views were generally supportive of ambulance redirection to facilitate access to thrombectomy. Further research is needed to demonstrate overall benefit in an NHS context.

From identifying patient safety risks to reporting patient complaints: A grounded theory study on patients' hospital experiences.

AIM: To explore how patients with hospital experience construct patient safety, from the identification of a patient safety risk to the decision to file a complaint. BACKGROUND: Patients play an important role in the prevention of adverse events in hospitals, but the ability of patients to act and influence their own safety is still challenged by multiple factors. Understanding how patients perceive risk and act to prevent harm may shed light on how to enhance patients' opportunities to participate in patient safety. DESIGN: The research design of this study is qualitative and exploratory. METHODS: Twelve participants who had experienced Swedish hospital care were interviewed between June 2022 and July 2023. The method of analysis was constructivist grounded theory, focusing on social processes. The COREQ checklist for qualitative research was followed. RESULTS: Four categories were constructed: (1) defining the boundary between one's own capacity and that of the hospital, (2) acting to minimize the impact on one's safety, (3) finding oneself in the hands of healthcare professionals and (4) exploring the boundaries between normality and abnormality of the situation. This process was captured in the core category of navigating the path of least suffering. This illustrated how the participants constructed meaning about patient safety risks and showed that they prevented multiple adverse events. CONCLUSIONS: Provided that participants were able to act independently, they avoided a multitude of adverse events. When they were dependent on healthcare professionals, their safety became more vulnerable. Failure to respond to the participants' concerns could lead to long-term suffering. RELEVANCE TO CLINICAL PRACTICE: By responding immediately to patients' concerns about their safety, healthcare professionals can help prevent avoidable suffering and exhaustive searching for someone in the healthcare system who will take their needs seriously. PATIENT CONTRIBUTION: A member check was performed with the help of one of the participants who read the findings to confirm familiarity.

Comorbidities and use of health services in people with diabetes mellitus according to risk levels by adjusted morbidity groups.

BACKGROUND: People with diabetes mellitus frequently have other comorbidities and involve greater use of primary and hospital care services. The aim of this study was to describe the comorbidities and use of primary and hospital care services of people with diabetes according to their risk level by adjusted morbidity groups (AMG) and to analyse the factors associated with the utilisation of these services. METHODS: Cross-sectional study. People with diabetes were identified within the population of patients with chronic conditions of an urban health care centre by the AMG stratification tool integrated into the primary health care electronic clinical record of the Community of Madrid. Sociodemographic, functional, clinical characteristics and annual health care services utilisation variables were collected. Univariate, bivariate and Poisson regression analyses were performed. RESULTS: A total of 1,063 people with diabetes were identified, representing 10.8% of patients with chronic conditions within the health centre. A total of 51.4% were female, the mean age was 70 years, 94.4% had multimorbidity. According to their risk level, 17.8% were high-risk, 40.6% were medium-risk and 41.6% were low-risk. The most prevalent comorbidities were hypertension (70%), dyslipidaemia (67%) and obesity (32.4%). Almost 50% were polymedicated. Regarding health services utilisation, 94% were users of primary care, and 59.3% were users of hospital care. Among the main factors associated with the utilisation of both primary and hospital care services were AMG risk level and complexity index. In primary care, utilisation was also associated with the need for primary caregivers, palliative care and comorbidities such as chronic heart failure and polymedication, while in hospital care, utilisation was also associated with comorbidities such as cancer, chronic obstructive pulmonary disease or depression. CONCLUSIONS: People with diabetes were older, with important needs for care, many associated comorbidities and polypharmacy that increased in parallel with the patient's risk level and complexity. The utilisation of primary and hospital care services was very high, being more frequent in primary care. Health services utilization were principally associated with functional factors related to the need of care and with clinical factors such as AMG medium and high-risk level, more complexity index, some serious comorbidities and polymedication.

Trends in mortality after emergency department presentation for suicidal behaviour in California.

INTRODUCTION: Emergency department patients presenting with non-fatal suicidal behaviour face elevated risk of suicide and all-cause mortality, but the extent to which this has changed over time is unknown. This study tracked trends in mortality risks faced by emergency department patients presenting with deliberate self-harm and suicidal ideation in California. METHODS: Using statewide linked emergency department and death data, we estimated 2010-2016 trends in suicide and all-cause mortality among emergency department patients with either deliberate self-harm (n=111 658) or suicidal ideation (n=162 959). We also calculated average annual percent changes in age-adjusted mortality rates and compared these to the general California population. RESULTS: Deliberate self-harm and suicidal ideation patients' age-adjusted suicide rates decreased by approximately 5% per year during the study period; however, their all-cause mortality trends were flat. In the general California population, suicide rate trends were flat while all-cause mortality slightly declined. CONCLUSIONS: Suicide mortality unexpectedly declined among self-harming and suicidal patients presenting to California emergency departments. Additional research is needed to understand the reasons behind this decline and inform quality improvement efforts for suicide prevention in hospital settings.