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1.
J Orthop Surg Res ; 16(1): 237, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-33794939

RESUMO

BACKGROUND: Concerns of contracting the highly contagious disease COVID-19 have led to a reluctance in seeking medical attention, which may contribute to delayed hospital arrival among traumatic patients. The study objective was to describe differences in time from injury to arrival for patients with traumatic hip fractures admitted during the pandemic to pre-pandemic patients. MATERIALS AND METHODS: This retrospective cohort study at six level I trauma centers included patients with traumatic hip fractures. Patients with a non-fall mechanism and those who were transferred in were excluded. Patients admitted 16 March 2019-30 June 2019 were in the "pre-pandemic" group, patients were admitted 16 March 2020-30 June 2020 were in the "pandemic" group. The primary outcome was time from injury to arrival. Secondary outcomes were time from arrival to surgical intervention, hospital length of stay (HLOS), and mortality. RESULTS: There were 703 patients, 352 (50.1%) pre-pandemic and 351 (49.9%) during the pandemic. Overall, 66.5% were female and the median age was 82 years old. Patients were similar in age, race, gender, and injury severity score. The median time from injury to hospital arrival was statistically shorter for pre-pandemic patients when compared to pandemic patients, 79.5 (56, 194.5) min vs. 91 (59, 420), p = 0.04. The time from arrival to surgical intervention (p = 0.64) was statistically similar between groups. For both groups, the median HLOS was 5 days, p = 0.45. In-hospital mortality was significantly higher during the pandemic, 1.1% vs 3.4%, p = 0.04. CONCLUSIONS: While time from injury to hospital arrival was statistically longer during the pandemic, the difference may not be clinically important. Time from arrival to surgical intervention remained similar, despite changes made to prevent COVID-19 transmission.


Assuntos
/epidemiologia , Fraturas do Quadril/epidemiologia , Admissão do Paciente , Tempo para o Tratamento , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Fraturas do Quadril/cirurgia , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Assistência de Longa Duração , Masculino , Pandemias , Alta do Paciente , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem , Centros de Traumatologia , Estados Unidos/epidemiologia
2.
MMWR Morb Mortal Wkly Rep ; 70(11): 396-401, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33735160

RESUMO

Residents of long-term care facilities (LTCFs), particularly those in skilled nursing facilities (SNFs), have experienced disproportionately high levels of COVID-19-associated morbidity and mortality and were prioritized for early COVID-19 vaccination (1,2). However, this group was not included in COVID-19 vaccine clinical trials, and limited postauthorization vaccine effectiveness (VE) data are available for this critical population (3). It is not known how well COVID-19 vaccines protect SNF residents, who typically are more medically frail, are older, and have more underlying medical conditions than the general population (1). In addition, immunogenicity of the Pfizer-BioNTech vaccine was found to be lower in adults aged 65-85 years than in younger adults (4). Through the CDC Pharmacy Partnership for Long-Term Care Program, SNF residents and staff members in Connecticut began receiving the Pfizer-BioNTech COVID-19 vaccine on December 18, 2020 (5). Administration of the vaccine was conducted during several on-site pharmacy clinics. In late January 2021, the Connecticut Department of Public Health (CT DPH) identified two SNFs experiencing COVID-19 outbreaks among residents and staff members that occurred after each facility's first vaccination clinic. CT DPH, in partnership with CDC, performed electronic chart review in these facilities to obtain information on resident vaccination status and infection with SARS-CoV-2, the virus that causes COVID-19. Partial vaccination, defined as the period from >14 days after the first dose through 7 days after the second dose, had an estimated effectiveness of 63% (95% confidence interval [CI] = 33%-79%) against SARS-CoV-2 infection (regardless of symptoms) among residents within these SNFs. This is similar to estimated effectiveness for a single dose of the Pfizer-BioNTech COVID-19 vaccine in adults across a range of age groups in noncongregate settings (6) and suggests that to optimize vaccine impact among this population, high coverage with the complete 2-dose series should be recommended for SNF residents and staff members.


Assuntos
/administração & dosagem , Surtos de Doenças/prevenção & controle , Instituições de Cuidados Especializados de Enfermagem , Idoso , Idoso de 80 Anos ou mais , Connecticut/epidemiologia , Feminino , Humanos , Esquemas de Imunização , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
3.
BMC Infect Dis ; 21(1): 263, 2021 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-33722204

RESUMO

BACKGROUND: The Pandemic of coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has critically impacted the spread of infection within nursing facilities. We evaluated the usefulness of genetic and serological tests conducted during a COVID-19 outbreak in a nursing facility in Japan. METHODS: After the first identification of SARS-CoV-2 infection, a comprehensive, facility- and/or unit-wide PCR testing from nasopharyngeal swabs was repeatedly performed in a three-unit facility including 99 residents with dementia and 53 healthcare personnel. Additionally, PCR testing was conducted separately for residents and staff with fever of ≥37.5 °C. Facility-wide serological testing, including rapid kit testing and quantitative assay, was conducted twice over 1 month apart. RESULTS: A total of 322 PCR and 257 antibody tests were performed. 37 (24.3%) of the 152 individuals (25/99 residents, 25.3%; 12/53 staff, 22.6%) were identified as PCR-positive. Seven residents died with a mortality of 7.1% (7/99). Among the 37 individuals, 10 (27.0%) were asymptomatic at the time of testing. PCR positivity was concentrated on one unit (Unit 1) (20/30 residents, 66.7%; 9/14 staff, 64.3%). The other units showed a limited spread of infection. In unit-wide and separate tests, PCR positivity detection was highly prevalent (22.9 and 44.4%, respectively) in Unit 1, compared with that in the other units. Serological testing identified two additional infected residents with a negative PCR result and showed that no staff was newly identified as infected. CONCLUSIONS: Thorough PCR testing, in combination with comprehensive and separate tests, is critical for managing COVID-19 outbreaks in nursing facilities, particularly, in units considered an epicenter. Serological testing is also beneficial for tracing contacts, confirming the number of infected individuals, and authorizing the termination of the outbreak.


Assuntos
/diagnóstico , Surtos de Doenças , Instituições de Cuidados Especializados de Enfermagem , Idoso , Idoso de 80 Anos ou mais , Busca de Comunicante , Feminino , Febre/virologia , Pessoal de Saúde , Humanos , Japão , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Pandemias
5.
Stroke ; 52(3): 905-912, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33535779

RESUMO

BACKGROUND AND PURPOSE: Acute ischemic stroke may occur in patients with coronavirus disease 2019 (COVID-19), but risk factors, in-hospital events, and outcomes are not well studied in large cohorts. We identified risk factors, comorbidities, and outcomes in patients with COVID-19 with or without acute ischemic stroke and compared with patients without COVID-19 and acute ischemic stroke. METHODS: We analyzed the data from 54 health care facilities using the Cerner deidentified COVID-19 dataset. The dataset included patients with an emergency department or inpatient encounter with discharge diagnoses codes that could be associated to suspicion of or exposure to COVID-19 or confirmed COVID-19. RESULTS: A total of 103 (1.3%) patients developed acute ischemic stroke among 8163 patients with COVID-19. Among all patients with COVID-19, the proportion of patients with hypertension, diabetes, hyperlipidemia, atrial fibrillation, and congestive heart failure was significantly higher among those with acute ischemic stroke. Acute ischemic stroke was associated with discharge to destination other than home or death (relative risk, 2.1 [95% CI, 1.6-2.4]; P<0.0001) after adjusting for potential confounders. A total of 199 (1.0%) patients developed acute ischemic stroke among 19 513 patients without COVID-19. Among all ischemic stroke patients, COVID-19 was associated with discharge to destination other than home or death (relative risk, 1.2 [95% CI, 1.0-1.3]; P=0.03) after adjusting for potential confounders. CONCLUSIONS: Acute ischemic stroke was infrequent in patients with COVID-19 and usually occurs in the presence of other cardiovascular risk factors. The risk of discharge to destination other than home or death increased 2-fold with occurrence of acute ischemic stroke in patients with COVID-19.


Assuntos
Fibrilação Atrial/epidemiologia , Diabetes Mellitus/epidemiologia , Insuficiência Cardíaca/epidemiologia , Mortalidade Hospitalar , Hiperlipidemias/epidemiologia , Hipertensão/epidemiologia , /epidemiologia , Lesão Renal Aguda/epidemiologia , Adulto , Afro-Americanos , Idoso , Idoso de 80 Anos ou mais , Edema Encefálico/epidemiologia , Hemorragia Cerebral/epidemiologia , Estudos de Coortes , Comorbidade , Grupo com Ancestrais do Continente Europeu , Feminino , Hispano-Americanos , Hospitais de Reabilitação/estatística & dados numéricos , Humanos , Falência Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Casas de Saúde/estatística & dados numéricos , Alta do Paciente , Insuficiência Respiratória/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Estados Unidos/epidemiologia
6.
MMWR Morb Mortal Wkly Rep ; 70(8): 273-277, 2021 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-33630817

RESUMO

Reinfection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is believed to be rare (1). Some level of immunity after SARS-CoV-2 infection is expected; however, the evidence regarding duration and level of protection is still emerging (2). The Kentucky Department for Public Health (KDPH) and a local health department conducted an investigation at a skilled nursing facility (SNF) that experienced a second COVID-19 outbreak in October 2020, 3 months after a first outbreak in July. Five residents received positive SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test results during both outbreaks. During the first outbreak, three of the five patients were asymptomatic and two had mild symptoms that resolved before the second outbreak. Disease severity in the five residents during the second outbreak was worse than that during the first outbreak and included one death. Because test samples were not retained, phylogenetic strain comparison was not possible. However, interim period symptom resolution in the two symptomatic patients, at least four consecutive negative RT-PCR tests for all five patients before receiving a positive test result during the second outbreak, and the 3-month interval between the first and the second outbreaks, suggest the possibility that reinfection occurred. Maintaining physical distance, wearing face coverings or masks, and frequent hand hygiene are critical mitigation strategies necessary to prevent transmission of SARS-CoV-2 to SNF residents, a particularly vulnerable population at risk for poor COVID-19-associated outcomes.* Testing, containment strategies (isolation and quarantine), and vaccination of residents and health care personnel (HCP) are also essential components to protecting vulnerable residents. The findings of this study highlight the importance of maintaining public health mitigation and protection strategies that reduce transmission risk, even among persons with a history of COVID-19 infection.


Assuntos
/diagnóstico , Surtos de Doenças , Instituições de Cuidados Especializados de Enfermagem , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Kentucky/epidemiologia , Masculino , Pessoa de Meia-Idade
7.
MMWR Morb Mortal Wkly Rep ; 70(5): 178-182, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33539332

RESUMO

Residents and staff members of long-term care facilities (LTCFs), because they live and work in congregate settings, are at increased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). In particular, skilled nursing facilities (SNFs), LTCFs that provide skilled nursing care and rehabilitation services for persons with complex medical needs, have been documented settings of COVID-19 outbreaks (3). In addition, residents of LTCFs might be at increased risk for severe outcomes because of their advanced age or the presence of underlying chronic medical conditions (4). As a result, the Advisory Committee on Immunization Practices has recommended that residents and staff members of LTCFs be offered vaccination in the initial COVID-19 vaccine allocation phase (Phase 1a) in the United States (5). In December 2020, CDC launched the Pharmacy Partnership for Long-Term Care Program* to facilitate on-site vaccination of residents and staff members at enrolled LTCFs. To evaluate early receipt of vaccine during the first month of the program, the number of eligible residents and staff members in enrolled SNFs was estimated using resident census data from the National Healthcare Safety Network (NHSN†) and staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal.§ Among 11,460 SNFs with at least one vaccination clinic during the first month of the program (December 18, 2020-January 17, 2021), an estimated median of 77.8% of residents (interquartile range [IQR] = 61.3%- 93.1%) and a median of 37.5% (IQR = 23.2%- 56.8%) of staff members per facility received ≥1 dose of COVID-19 vaccine through the Pharmacy Partnership for Long-Term Care Program. The program achieved moderately high coverage among residents; however, continued development and implementation of focused communication and outreach strategies are needed to improve vaccination coverage among staff members in SNFs and other long-term care settings.


Assuntos
/administração & dosagem , Farmácia/organização & administração , Parcerias Público-Privadas , Instituições de Cuidados Especializados de Enfermagem/organização & administração , Cobertura Vacinal/estatística & dados numéricos , Idoso , /prevenção & controle , Centers for Disease Control and Prevention, U.S. , Humanos , Assistência de Longa Duração , Avaliação de Programas e Projetos de Saúde , Estados Unidos/epidemiologia
8.
Trials ; 22(1): 120, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33546737

RESUMO

BACKGROUND: Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home. METHODS: The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients' home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient's illness at home; and (b) a Connect-Home Activation RN visits the patient's home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient's preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients' quality of life, functional status, and days of acute care use and (b) caregivers' burden and distress. DISCUSSION: Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. TRIAL REGISTRATION: ClinicalTrials.gov NCT03810534 . Registered on January 18, 2019.


Assuntos
/epidemiologia , Pandemias , Qualidade da Assistência à Saúde , Instituições de Cuidados Especializados de Enfermagem , Cuidado Transicional , Idoso , Cuidadores , Análise por Conglomerados , Cuidados Críticos/métodos , Feminino , Seguimentos , Idoso Fragilizado , Humanos , Masculino , North Carolina/epidemiologia , Alta do Paciente , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto
9.
J Am Med Dir Assoc ; 22(3): 498-503, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33549565

RESUMO

BACKGROUND: Effective halting of outbreaks in skilled nursing facilities (SNFs) depends on the earliest recognition of cases. We assessed confirmed COVID-19 cases at an SNF impacted by COVID-19 in the United States to identify early indications of COVID-19 infection. METHODS: We performed retrospective reviews of electronic health records for residents with laboratory-confirmed SARS-CoV-2 during February 28-March 16, 2020. Records were abstracted for comorbidities, signs and symptoms, and illness outcomes during the 2 weeks before and after the date of positive specimen collection. Relative risks (RRs) of hospitalization and death were calculated. RESULTS: Of the 118 residents tested among approximately 130 residents from Facility A during February 28-March 16, 2020, 101 (86%) were found to test positive for SARS-CoV-2. At initial presentation, about two-thirds of SARS-CoV-2-positive residents had an abnormal vital sign or change in oxygen status. Most (90.2%) symptomatic residents had elevated temperature, change in mental status, lethargy, change in oxygen status, or cough; 9 (11.0%) did not have fever, cough, or shortness of breath during their clinical course. Those with change in oxygen status had an increased relative risk (RR) of 30-day mortality [51.1% vs 29.7%, RR 1.7, 95% confidence interval (CI) 1.0-3.0]. RR of hospitalization was higher for residents with underlying hepatic disease (1.6, 95% CI 1.1-2.2) or obesity (1.5, 95% CI 1.1-2.1); RR of death was not statistically significant. CONCLUSIONS AND IMPLICATIONS: Our findings reinforce the critical role that monitoring of signs and symptoms can have in identifying COVID-19 cases early. SNFs should ensure they have a systematic approach for responding to abnormal vital signs and oxygen saturation and consider ensuring common signs and symptoms identified in Facility A are among those they monitor.


Assuntos
/diagnóstico , Instituições de Cuidados Especializados de Enfermagem , Idoso , Idoso de 80 Anos ou mais , /métodos , Comorbidade , Feminino , Humanos , Masculino , Registros Médicos , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Estados Unidos
10.
Am J Nurs ; 121(3): 72, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33625020
11.
Nurs Adm Q ; 45(2): 109-113, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33570877

RESUMO

Postacute care is a term used to describe a group of health care providers, caring for patients outside of traditional acute care. The populations served and measures of outcomes are similar, but the services provided may vary by type of setting and individual provider. Managing through the coronavirus disease-2019 (COVID-19) pandemic has been both a challenge and an opportunity to demonstrate the vital role of postacute providers in the health care continuum. National media outlets have highlighted emergency departments, critical care areas, and start-up COVID units in acute care hospitals treating critically ill patients battling COVID-19. Stories of nursing homes in crisis over the rapid spread of COVID-19 have saddened readers of newspapers and social media alike. Postacute providers have experienced the pandemic alongside the acute care hospitals in ways that have highlighted the flexibility of postacute care, challenged leaders to lead with intensity, and demonstrated their importance in the continuum of care. Through a series of interviews with postacute care leaders, this article explores the response to the pandemic from the perspective of providers in postacute care settings.


Assuntos
/reabilitação , Assistência de Longa Duração/organização & administração , Instituições de Cuidados Especializados de Enfermagem/organização & administração , Cuidados Semi-Intensivos/organização & administração , /enfermagem , Feminino , Humanos , Liderança , Masculino , Pandemias , Estados Unidos
12.
Mayo Clin Proc ; 96(1): 242-256, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33413822

RESUMO

Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.


Assuntos
Polimedicação , Idoso , Analgésicos Opioides/efeitos adversos , Antipsicóticos/efeitos adversos , Desprescrições , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/etiologia , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Humanos , Reconciliação de Medicamentos , Instituições de Cuidados Especializados de Enfermagem
13.
BMJ Open ; 11(1): e044278, 2021 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-33478966

RESUMO

OBJECTIVES: To evaluate the predictive utility of the Activity Measure for Post-Acute Care '6-Clicks' daily activity and basic mobility functional assessment short forms on inpatient discharge to home compared with skilled nursing facilities, including by diagnostic group (trauma injury, major lower joint replacement/reattachment, spinal fusion excluding cervical), as well as assess the effect of the short forms on 30-day inpatient readmissions. DESIGN: Retrospective, observational cohort study of electronic health record data. SETTING: Five hospitals in a multistate, integrated healthcare system serving a large, rural US population. PARTICIPANTS: The population-based adult (age ≥18) sample of acute care hospitalised patients receiving rehabilitation services included 10 316 patients with 12 314 hospital admissions from the year prior to 6-Clicks implementation (1 June 2015-31 May 2016) (pre-6-Clicks cohort) and 10 931 patients with 13 241 admissions from the year after 6-Clicks implementation (1 January 2017-31 December 2017) (post-6-Clicks cohort). Patients were admitted for major lower joint replacement/reattachment, spinal fusion excluding cervical, trauma injury or another reason. INTERVENTION: Occupational and physical therapist use of 6-Clicks daily activity and basic mobility short forms in the post-6-Clicks cohort. PRIMARY AND SECONDARY OUTCOMES: Discharge disposition (home, including to assisted living, or skilled nursing facility, including swing beds) and 30-day inpatient readmissions. RESULTS: Areas under the receiver operating characteristic curve were 0.82-0.92 (daily activity) and 0.87-0.94 (basic mobility) for discharge to home or skilled nursing facilities, with trauma and spinal fusion patients having the highest values. Daily activity and basic mobility standardised positive and negative predictive values were highest for the three diagnostic groups compared with the full study sample. Few significant differences in 30-day readmissions were seen between pre- and post-6-Clicks cohorts. CONCLUSIONS: 6-Clicks performed well when distinguishing between discharge home or skilled nursing facilities, especially by diagnostic group, supporting use by occupational and physical therapists in discharge planning. Future research could assess where additional intervention or training may reduce 30-day readmissions.


Assuntos
Registros Eletrônicos de Saúde , Alta do Paciente , Readmissão do Paciente , Reabilitação/normas , Cuidados Semi-Intensivos , Adulto , Estudos de Coortes , Feminino , Humanos , Avaliação de Resultados em Cuidados de Saúde/métodos , Valor Preditivo dos Testes , Melhoria de Qualidade , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem
16.
Health Aff (Millwood) ; 40(1): 146-155, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33400571

RESUMO

Medicare's Skilled Nursing Facility Value-Based Purchasing Program, which awards value-based incentive payments based on hospital readmissions, distributed its first two rounds of incentives during fiscal years 2019 and 2020. Incentive payments were based on achievement or improvement scores-whichever was better. Incentive payments were as low as -2.0 percent in both program years and as high as +1.6 percent in FY 2019 and +3.1 percent in FY 2020. In FY 2019, 26 percent of facilities earned positive incentives and 72 percent earned negative incentives, compared with 19 percent positive and 65 percent negative incentives in FY 2020. Larger, rural, and not-for-profit facilities were more likely to earn positive incentives, as were those with the highest registered nurse staffing levels. Although these findings indicate the potential to reward high-quality care at skilled nursing facilities, intended and unintended outcomes of this new value-based purchasing program should be monitored closely for possible program refinements, particularly in light of the disproportionate impacts of coronavirus disease 2019 (COVID-19) on nursing facilities.


Assuntos
Medicare , Motivação , Readmissão do Paciente/estatística & dados numéricos , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Aquisição Baseada em Valor/estatística & dados numéricos , Humanos , Medicare/economia , Medicare/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Instituições de Cuidados Especializados de Enfermagem/economia , Estados Unidos
17.
JAMA Netw Open ; 4(1): e2033980, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33443582

RESUMO

Importance: Patient transitions from hospitals to skilled nursing facilities (SNFs) require robust information sharing. After a decade of investment in health information technology infrastructure and new incentives to promote hospital-SNF coordination in the US, the current state of information sharing at this critical transition is unknown. Objective: To measure the completeness, timeliness, and usability of information shared by hospitals when discharging patients to SNFs, and to identify relational and structural characteristics associated with better hospital-SNF information sharing. Design, Setting, and Participants: Survey of 500 SNFs from a US nationally representative sample (265 respondents representing 471 hospital-SNF pairs; response rate of 53.0%) that collected detailed data on information sharing that supports care transitions from each of the 2 hospitals from which they receive the largest volume of patient referrals. Survey administration occurred between January 2019 and March 2020. Main Outcomes and Measures: Overall assessment of information completeness, timeliness, and usability using 5-point Likert scales. Detailed measures, including (1) completeness-routine sharing of 23 specific information types; (2) timeliness-how often information arrived after the patient; and (3) usability-whether information was duplicative, extraneous, or not tailored to SNF needs. In addition, 8 relational characteristics (eg, shared staffing, collaborative meetings, and referral volume) and 10 structural characteristics (eg, size, ownership, and staffing) were assessed as potential factors associated with better information sharing. Results: Of 471 hospital-SNF pairs, 64 (13.5%) reported excellent performance on all 3 dimensions of information sharing, whereas 141 (30.0%) were at or below the mean performance on all dimensions. Social status (missing in 309 pairs [65.7%]) and behavioral status (missing in 319 pairs [67.7%]) were the most common types of missing information. Receipt of hospital information was delayed, sometimes (159 pairs [33.8%]) or often (77 pairs [16.4%]) arriving after the patient. In total, 358 pairs [76.0%] reported at least 1 usability shortcoming. Having a hospital clinician on site at the SNF was associated in multivariate analysis with more complete (odds ratio, 1.72; 95% CI, 1.07-2.78; P = .03), timely (odds ratio, 1.76; 95% CI, 1.08-2.88; P = .02), and usable (odds ratio, 1.64; 95% CI, 1.02-2.63; P = .04) information sharing. Hospital accountable care organization participation was associated with more timely information sharing (odds ratio, 1.88; 95% CI, 1.13-3.14; P = .02). Conclusions and Relevance: In this study, US SNFs reported significant shortcomings in the completeness, timeliness, and usability of information provided by hospitals to support patient transitions. These shortcomings are likely associated with a suboptimal transition experience. Shared clinicians represent a potential strategy to improve information sharing but are costly. New payment models such as accountable care organizations may offer a more scalable approach but were only associated with more timely sharing.


Assuntos
Hospitais , Disseminação de Informação , Transferência de Pacientes , Instituições de Cuidados Especializados de Enfermagem , Cuidado Transicional/normas , Humanos , Inquéritos e Questionários , Estados Unidos
19.
Am J Cardiol ; 144: 83-90, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33383014

RESUMO

Kidney transplant recipients (KTRs) are considered high-risk patients for surgical interventions. Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) at high operative risk. However, the outcomes of TAVI compared with SAVR KTRs have not been well-studied in nationally representative data. Patients with prior history of functioning kidney transplant who were hospitalized for TAVI and SAVR between January 2012 and December 2017 were identified retrospectively in the Nationwide Readmissions Database. Our study included 762 TAVI and 1,278 SAVR KTRs. Compared with SAVR, TAVI patients generally had higher rates of co-morbidities with lower risk of in-hospital mortality (3.1% vs 6.3, p = 0.002), blood transfusion (11.5% vs 38.6%, p <0.001), acute myocardial infarction (3.9% vs 6.5%, p = 0.16), acute kidney injury (24.5% vs 42.1%, p <0.001), sepsis (3.9% vs 9.5%, p <0.001) and discharge with disability (42.6% vs 68.4%, p <0.001). However, the rate of permanent pacemaker implantation was significantly higher in TAVI group (11.4% vs 3.9%, p <0.001). Of note, in-hospital stroke and 30-day readmission were comparable between both groups. These findings were confirmed after adjusting for other co-morbidities. TAVI is growing as a valid and safe alternative for KTRs with severe AS.


Assuntos
Estenose da Valva Aórtica/cirurgia , Mortalidade Hospitalar , Transplante de Rim , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter/métodos , Lesão Renal Aguda/epidemiologia , Idoso , Transfusão de Sangue/estatística & dados numéricos , Comorbidade , Endocardite/epidemiologia , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Instituições para Cuidados Intermediários/estatística & dados numéricos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/terapia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Marca-Passo Artificial/estatística & dados numéricos , Alta do Paciente , Diálise Renal , Insuficiência Renal Crônica/epidemiologia , Estudos Retrospectivos , Sepse/epidemiologia , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Acidente Vascular Cerebral/epidemiologia , Resultado do Tratamento , Estados Unidos/epidemiologia
20.
Proc Natl Acad Sci U S A ; 118(1)2021 01 07.
Artigo em Inglês | MEDLINE | ID: mdl-33323526

RESUMO

Nursing homes and other long-term care facilities account for a disproportionate share of COVID-19 cases and fatalities worldwide. Outbreaks in US nursing homes have persisted despite nationwide visitor restrictions beginning in mid-March. An early report issued by the Centers for Disease Control and Prevention identified staff members working in multiple nursing homes as a likely source of spread from the Life Care Center in Kirkland, WA, to other skilled nursing facilities. The full extent of staff connections between nursing homes-and the role these connections serve in spreading a highly contagious respiratory infection-is currently unknown given the lack of centralized data on cross-facility employment. We perform a large-scale analysis of nursing home connections via shared staff and contractors using device-level geolocation data from 50 million smartphones, and find that 5.1% of smartphone users who visited a nursing home for at least 1 h also visited another facility during our 11-wk study period-even after visitor restrictions were imposed. We construct network measures of connectedness and estimate that nursing homes, on average, share connections with 7.1 other facilities. Traditional federal regulatory metrics of nursing home quality are unimportant in predicting outbreaks, consistent with recent research. Controlling for demographic and other factors, a home's staff network connections and its centrality within the greater network strongly predict COVID-19 cases.


Assuntos
/epidemiologia , Casas de Saúde , Pandemias , /patogenicidade , /prevenção & controle , Surtos de Doenças , Feminino , Humanos , Masculino , Instituições de Cuidados Especializados de Enfermagem , Smartphone , Rede Social
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