Barriers to the Implementation of Infant- and Family-Centered Developmental Care From Focus Groups With Neonatal Care Providers.

AIM: Although infant- and family-centered developmental care (IFCDC) is scientifically grounded and offered in many hospitals to some extent, it has not yet been universally implemented as the standard of care. In this article, we aim to identify barriers to the implementation of IFCDC in Belgian neonatal care from the perspective of neonatal care providers. METHODS: We conducted 8 online focus groups with 40 healthcare providers working in neonatal care services. An inductive thematic analysis was carried out by means of Nvivo. RESULTS: The focus groups revealed barriers related to contextual, hospital, and neonatal unit characteristics. Barriers found in the hospital and neonatal unit were related to financing, staffing, infrastructure, access to knowledge/information and learning climate, leadership engagement, and relative priority of IFCDC. Contextual barriers were related to peer pressure and partnerships, newborn/parent needs and resources, external policy, and budgetary incentives. CONCLUSION: Three main barriers to IFCDC implementation have been identified. Resources (staffing, financing, and infrastructure) must be available and aligned with IFCDC standards, knowledge and information have to be accessible and continuously updated, and hospital management should support IFCDC implementation to create an enabling climate, including compatibility with the existing workflow, learning opportunities, and priority setting.

Systematic literature review on the effectiveness and safety of paediatric hospital-at-home care as a substitute for hospital care.

The hospital landscape is shifting to new care models to meet current challenges in demand, technology, available budgets and staffing. These challenges also apply to the paediatric population, leading to a reduction in paediatric hospital beds and occupancy rates. Paediatric hospital-at-home (HAH) care is used to substitute hospital care in an attempt to bring hospital services closer to children's homes. In addition, these models attempt to avoid fragmentation of care between hospitals and the community. An important prerequisite for this paediatric HAH care is that it is safe and at least as effective as standard hospital care. The aim of this systematic review is to analyse the evidence on the impact of paediatric HAH care on hospital utilisation, patient outcomes and costs. Four bibliographic databases (Medline, Embase, Cinahl and Cochrane Library) were systematically searched for RCTs and pseudo-RCTs that studied the effectiveness and safety of short-term paediatric HAH care with a focus on models as an alternative to acute hospital admissions. Pseudo-RCTs are defined as observational studies that mimic the design of an RCT, but without randomisation. Outcomes of interest were the length of stay, acute (re)admissions, adverse health outcomes, therapy adherence, parental satisfaction or experience and costs. Only articles written in English, Dutch and French conducted in upper-middle and high-income countries and published between 2000 and 2021 were included. Quality assessment was carried out by two assessors using the Cochrane Collaboration's tool for assessing the risk of bias. Reporting is done in accordance with the PRISMA guidelines. We identified 18 (pseudo) RCTs and 25 publications of low to very low quality. Most of the included RCTs focused on the neonatal population: phototherapy for neonatal jaundice, early discharge after birth combined with outpatient neonatal care. Other RCTs focused on chemotherapy for acute lymphoblastic leukaemia, diabetes type 1 education, oxygen therapy for acute bronchiolitis, an outpatient service for children with infectious diseases and antibiotic treatment for low-risk febrile neutropenia, cellulitis and perforated appendicitis. The identified study results show that paediatric HAH care is not associated with more adverse events or hospital readmissions. The impact of paediatric HAH care on costs is less clear.  Conclusions: This review suggests that paediatric HAH care is not associated with more adverse events or hospital readmissions for various clinical indications compared to a standard hospital. Because of the low to very low level of evidence, it is worthwhile to further investigate safety, efficacy and cost effects under strict and well-controlled conditions. This systematic review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention. What is Known: • The hospital landscape is shifting new models of care to meet current challenges in demand, technology, staffing and models of care. Paediatric HAH care is one of these models. Previous literature reviews are inconclusive whether this is a safe and effective way of providing care. What is New: • New evidence suggests that paediatric HAH care for various clinical indications is not associated with adverse events or hospital readmissions compared to a standard hospital. Current evidence is characterised by a low level of quality.  • The current review provides guidance on the essential elements that should be included in HAH care programmes for each type of indication and/or intervention.

Difficulties encountered by long COVID patients in the Belgian health system / Difficultés rencontrées par les patients COVID long dans le système de santé belge

INTRODUCTION: After contracting COVID-19, many people have continued to experience various symptoms for several weeks and months, even after a mild acute phase. These people with ‘long COVID’ faced difficulties when confronted with the healthcare system. PURPOSE OF RESEARCH: In order to better understand their experience, we supplemented the information obtained in an online survey with a mixed qualitative approach based on 33 individual interviews and discussions with 101 participants in a forum in March 2021. RESULTS: Several shortcomings were identified in the contacts of ‘long’ COVID patients with the health care system, such as the lack of listening or empathy of some health care professionals, the lack of a systematic or proactive approach during the diagnostic assessment, or the lack of interdisciplinary coordination. Patients feel misunderstood and are forced to develop their own strategies, whether for diagnosis or treatment. Patients’ discomfort has led them to question the value of medicine and to resort to unconventional therapies to alleviate their symptoms, sometimes at great cost. CONCLUSIONS: Better informing the medical profession about the manifestation of the disease and the possible treatments, including the possibilities of reimbursement, would raise awareness and give them the tools to respond to the needs of ‘ long’ COVID patients. A comprehensive assessment of the patient through an “interdisciplinary assessment” seems necessary.

Introduction: Suite à une infection COVID-19, bon nombre de personnes ont ressenti divers symptômes pendant plusieurs semaines et mois, et ce, même après une phase aiguë légère. Ces personnes atteintes de « COVID long ¼ se sont trouvées confrontées au système de soins de santé, non sans difficultés. But de l'étude: Afin de mieux comprendre leurs expériences, nous avons complété les informations obtenues via une enquête en ligne par une approche qualitative mixte, comprenant 33 entretiens individuels et les discussions de 101 participants à un forum durant le mois de mars 2021. Résultats: Plusieurs lacunes ont été mises en évidence lors des contacts des patients « COVID long ¼ avec le système de santé, comme l'absence d'écoute ou d'empathie de certains professionnels de la santé, d'approche systématique ou proactive lors du bilan diagnostique, ou encore l'absence de coordination interdisciplinaire. Les patients se sentent incompris et se voient obligés de développer leurs propres stratégies afin d'établir un diagnostic ou un traitement. Le malaise des patients les ont amenés à remettre en question la valeur de la médecine et à recourir à des thérapies non conventionnelles afin de soulager leurs symptômes, parfois à un prix élevé. Conclusions: Mieux informer le corps médical quant à la manifestation de la maladie et aux prises en charge possibles, y compris les possibilités de remboursement, permettrait de le sensibiliser et de lui donner les outils pour répondre aux besoins des patients « COVID long ¼. Évaluer de manière globale le patient via un « bilan interdisciplinaire ¼ est nécessaire.

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.

Varying viewpoints of Belgian stakeholders on models of interhospital collaboration.

BACKGROUND: Hospitals are increasingly parts of larger care collaborations, rather than individual entities. Organizing and operating these collaborations is challenging; a significant number do not succeed, as it is difficult to align the goals of the partners. However, little research has focused on stakeholders' views regarding hospital collaboration models or on whether these views are aligned with those of hospital management. This study explores Belgian hospital stakeholders' views on the factors affecting hospital collaborations and their perspectives on different models for Belgian interhospital collaboration. METHODS: Qualitative focus group study on the viewpoints, barriers, and facilitators associated with hospital collaboration models (health system, network, joint venture). RESULTS: A total of 55 hospital stakeholders (hospital managers, chairs of medical councils, chair of hospital boards and special interest groups) participated in seven focus group sessions. Collaboration in health care is challenging, as the goals of the different stakeholder groups are partly parallel but also sometimes conflicting. Hospital managers and special interest groups favored health systems as the most integrated form. Hospital board members also opted for this model, but believed a coordinated network to be the most pragmatic and feasible model at the moment. Members of physicians' organizations preferred the joint venture, as it creates more flexibility for physicians. Successful collaboration requires trust and commitment. Legislation must provide a supporting framework and governance models. CONCLUSIONS: Involvement of all stakeholder groups in the process of decision-making within the collaboration is perceived as a necessity, which confirms the importance of the stakeholders' theory. The health system is the collaboration structure best suited to enhancing task distribution and improving patient quality. However, the existence of networks and joint ventures is considered necessary in the process of transformation towards more solid hospital collaborations such as health systems.

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.

BACKGROUND: Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures. METHODS: For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics. FINDINGS: An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients. INTERPRETATION: Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths. FUNDING: European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.

The view of severely burned patients and healthcare professionals on the blind spots in the aftercare process: a qualitative study.

BACKGROUND: In most Western countries burn centres have been developed to provide acute and critical care for patients with severe burn injuries. Nowadays, those patients have a realistic chance of survival. However severe burn injuries do have a devastating effect on all aspects of a person's life. Therefore a well-organized and specialized aftercare system is needed to enable burn patients to live with a major bodily change. The aim of this study is to identify the problems and unmet care needs of patients with severe burn injuries throughout the aftercare process, both from patient and health care professional perspectives in Belgium. METHODS: By means of face-to-face interviews (n = 40) with individual patients, responsible physicians and patient organizations, current experiences with the aftercare process were explored. Additionally, allied healthcare professionals (n = 17) were interviewed in focus groups. RESULTS: Belgian burn patients indicate they would benefit from a more integrated aftercare process. Quality of care is often not structurally embedded, but depends on the good intentions of local health professionals. Most burn centres do not have a written discharge protocol including an individual patient-centred care plan, accessible to all caregivers involved. Patients reported discontinuity of care: nurses working at general wards or rehabilitation units are not specifically trained for burn injuries, which sometimes leads to mistakes or contradictory information transmission. Also professionals providing home care are often not trained for the care of burn injuries. Some have to be instructed by the patient, others go to the burn centre to learn the right skills. Finally, patients themselves underestimate the chronic character of burn injuries, especially at the beginning of the care process. CONCLUSIONS: The variability in aftercare processes and structures, as well as the failure to implement locally developed best-practices on a wider scale emphasize the need for a comprehensive network, which can initiate transversal activities such as the development of discharge protocols, common guidelines, and quality criteria.

Stakeholders' perception on the organization of chronic care: a SWOT analysis to draft avenues for health care reforms.

BACKGROUND: Adequate care for individuals living with chronic illnesses calls for a healthcare system redesign, moving from acute, disease-centered to patient-centered models. The aim of this study was to identify Belgian stakeholders' perceptions on the strengths, weaknesses, opportunities and threats of the healthcare system for people with chronic diseases in Belgium. METHODS: Four focus groups were held with stakeholders from the micro and meso level, in addition to two interviews with stakeholders who could not attend the focus group sessions. Data collection and the discussion were based on the Chronic Care model. Thematic analysis of the transcripts allowed for the identification of the strengths, weaknesses, opportunities and threats of the current health care system with focus on chronic care. RESULTS: Informants stressed the overall good quality of the acute health care system and the level of reimbursement of care as an important strength of the current system. In contrast, the lack of integration of care was identified as one of the biggest weaknesses of today's health care system, along with the unclear definitions of the roles and functions of health professionals involved in care processes. Patient education to support self-management exists for patients with diabetes and/or terminal kidney failure but not for those living with other or multiple chronic conditions. The current overall fee-for-service system is a barrier to integrated care, as are the lack of incentives for integrated care. Attending multidisciplinary meetings, for example, is underfinanced to date. Finally, clinical information systems lack interoperability, which further impedes the information flow across settings and disciplines. CONCLUSION: Our study's methods allowed for the identification of problematic domains in the health system for people living with chronic conditions. These findings provided useful insights surrounding perceived priorities. This methodology may inspire other countries faced with the challenge of drafting reforms to tackle the issue of chronic care.

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.

The effect of consultations performed by specialised nurses or advanced nurse practitioners on patient and organisational outcomes in patients with complex health conditions: An umbrella review.

BACKGROUND: Policymakers and researchers often suggest that nurses may play a crucial role in addressing the evolving needs of patients with complex conditions, by taking on advanced roles and providing nursing consultations. Nursing consultations vary widely across settings and countries, and their activities range from complementing to substituting traditional physician-led consultations or usual care. OBJECTIVE: This study was aimed at describing the effects of nursing consultations with patients with complex conditions in any setting on patient outcomes (quality of life, physical status, psychosocial health, health behaviour, medication adherence, mortality, anthropometric and physiological outcomes, and patient satisfaction) and organisational outcomes (health resource use and costs). DESIGN: Umbrella review. METHODS: We followed the Joanna Briggs Institute method for umbrella reviews. We searched PubMed, Embase, Cochrane Database of Systematic Reviews and CINAHL to identify relevant articles published in English, Dutch, French, Spanish or German between January 2013 and February 2023. We included systematic literature reviews, with or without meta-analyses, that included randomised controlled trials conducted in high-income countries. Reviews were eligible if they pertained to consultations led by specialised nurses or advanced nurse practitioners. Article selection, data extraction and quality appraisal were performed independently by at least two reviewers. RESULTS: We included 50 systematic reviews based on 473 unique trials. For all patient outcomes, nursing consultations achieved effects at least equivalent to those of physician-led consultations or usual care (i.e., non-inferiority). For quality of life, health behaviour, medication adherence, mortality and patient satisfaction, more than half the meta-analyses found statistically significant effects in favour of nursing consultations (i.e., superiority). Cost results must be interpreted with caution, because very few and heterogeneous cost-related data were extracted, and the methodological quality of the cost analyses was questionable. Narrative syntheses confirmed the overall conclusions of the meta-analyses. CONCLUSIONS: The effects of nursing consultations on patients with complex health conditions across healthcare settings appear to be at least similar to physician-led consultations or usual care. Nursing consultations appear to be more effective than physician-led consultations or usual care in terms of quality of life, health behaviour, mortality, patient satisfaction and medication adherence. Further analysis of the primary data is necessary to determine the patient populations and settings in which nursing consultations are most effective. Moderate study quality, diversity amongst and within systematic reviews, and quality of reporting hamper the strength of the findings.

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.

Cross-cultural evaluation of the relevance of the HCAHPS survey in five European countries.

OBJECTIVE: To describe the systematic language translation and cross-cultural evaluation process that assessed the relevance of the Hospital Consumer Assessment of Healthcare Providers and Systems survey in five European countries prior to national data collection efforts. DESIGN: An approach involving a systematic translation process, expert review by experienced researchers and a review by 'patient' experts involving the use of content validity indexing techniques with chance correction. SETTING: Five European countries where Dutch, Finnish, French, German, Greek, Italian and Polish are spoken. PARTICIPANTS: 'Patient' experts who had recently experienced a hospitalization in the participating country. Main OutcomeMeasure(s) Content validity indexing with chance correction adjustment providing a quantifiable measure that evaluates the conceptual, contextual, content, semantic and technical equivalence of the instrument in relationship to the patient care experience. RESULTS: All translations except two received 'excellent' ratings and no significant differences existed between scores for languages spoken in more than one country. Patient raters across all countries expressed different concerns about some of the demographic questions and their relevance for evaluating patient satisfaction. Removing demographic questions from the evaluation produced a significant improvement in the scale-level scores (P= .018). The cross-cultural evaluation process suggested that translations and content of the patient satisfaction survey were relevant across countries and languages. CONCLUSIONS: The Hospital Consumer Assessment of Healthcare Providers and Systems survey is relevant to some European hospital systems and has the potential to produce internationally comparable patient satisfaction scores.

The relationship between in-hospital mortality, readmission into the intensive care nursing unit and/or operating theatre and nurse staffing levels.

AIM: The aim of this article was to assess the relationship between (1) in-hospital mortality and/or (2) unplanned readmission to intensive care units or operating theatre and nurse staffing variables. BACKGROUND: Adverse events are used as surrogates for patient safety in nurse staffing and patient safety research. A single adverse event cannot adequately capture the multi-dimensional attributes of patient safety; hence, there is a need to consider composite measures. Unplanned readmission into the postoperative Intensive Care nursing unit and/or operating Theatre and in-hospital mortality can be viewed as measures that incorporate the effects of several adverse events. METHODS: We conducted a Bayesian multilevel analysis on a subset of the 2003 Belgian Hospital Discharge and Nursing Minimum Data sets. The sample included 9054 patients who underwent coronary artery bypass surgery or heart valve procedures from 28 Belgian acute hospitals. Two proxies of patient safety were considered, namely postoperative in-hospital mortality in the first postoperative intensive care unit and unplanned readmission into the intensive care and/or operating theatre (including mortality beyond the first postoperative intensive care unit) after the first-operative intensive care nursing unit. RESULTS: There is an association between in-hospital mortality and/or unplanned readmissions and nurse staffing levels, but the relationship is moderated by volume and severity of illness respectively. In addition, the relationship differs between the two endpoints. CONCLUSION: Higher nurse staffing levels on postoperative general nursing cardiac surgery units protected patients from unplanned readmission to intensive care units or operating theatre and in-hospital mortality.

Retrospective medical record evaluation: reliability in assessing causation, preventability, and disability of adverse events.

PURPOSE: The purpose of this article is to assess the reliability of an in-depth analysis on causation, preventability, and disability by two separate review teams on five selected adverse events in acute hospitals: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator-associated pneumonia and postoperative wound infection. DESIGN/METHODOLOGY/APPROACH: The analysis uses a retrospective medical record review of 1,515 patient records by two independent teams in eight acute Belgian hospitals for the year 2005. The Mann-Whitney U-test is used to identify significant differences between the two review teams regarding occurrence of adverse events as well as regarding the degree of causation, preventability, and disability of found adverse events. FINDINGS: Team 1 stated a high probability for health care management causation in 95.5 per cent of adverse events in contrast to 38.9 per cent by Team 2. Likewise, high preventability was considered in 83.1 per cent of cases by Team 1 versus 51.7 per cent by Team 2. Significant differences in degree of disability between the two teams were also found for pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis and postoperative wound infection, but not for postoperative sepsis and ventilator-associated pneumonia. ORIGINALITY/VALUE: New insight on the degree of and reasons for the huge differences in adverse event evaluation is provided.

Organisational models at the emergency department to reduce hospital admissions among paediatric patients: a systematic literature review.

Paediatric attendances at the emergency department (ED) are often admitted to the hospital less than 24 h to allow time for more extended evaluation. Innovative organisational models could prevent these hospital admissions without compromising safety or quality of delivered care. Therefore, this systematic review identifies evidence on organisational models at the ED with the primary aim to reduce hospital admissions among paediatric patients. Following the PRISMA guidelines, three bibliographic databases (Ovid Medline, Embase, and Cochrane Library) were searched. Studies on organisational models in Western countries, published between January 2009 and January 2021, which applied a comparative design or review and studied at least hospital admission rates, were included. Analyses were mainly descriptive because of the high heterogeneity among included publications. The primary outcome is hospital admission rates. Secondary outcomes are ED length of stay (LOS), waiting time, and patient satisfaction. Sixteen publications described several innovative organisational models ranging from the creation of dedicated units for paediatric patients, innovative staffing models to bringing paediatric critical care physicians to patients at rural EDs. However, the effect on hospital admission rates and other outcomes are inconclusive, and some organisational models may improve certain outcomes in certain settings or vice versa. It appears that a paediatric consultation liaison team has the most consistent effect on hospital admission rates and LOS of paediatric patients presenting with mental problems at the ED. Implementing new innovative organisational models at the ED for paediatric patients could be worthwhile to decrease hospital admissions. However, the existing evidence is of rather weak quality. Future service developments should, therefore, be conducted in a way that allows objective evaluation.

The use of "lives saved" measures in nurse staffing and patient safety research: statistical considerations.

BACKGROUND: Lives saved predictions are used to quantify the impact of certain remedial measures in nurse staffing and patient safety research, giving an indication of the potential gain in patient safety. Data collected in nurse staffing and patient safety are often multilevel in structure, requiring statistical techniques to account for clustering in the data. OBJECTIVE: The purpose of this study was to assess the impact of model specifications on lives saved estimates and inferences in a multilevel context. METHODS: A simulation study was carried out to assess the impact of model assumptions on lives saved predictions. Scenarios considered were omitting an important covariate, taking different link functions, neglecting the correlations coming from the multilevel data structure, and neglecting a level in a multilevel model. Finally, using a cardiac surgery data set, predicted lives saved from the random intercept logistic model and the clustered discrete time logistic model were compared. RESULTS: Omitting an important covariate, neglecting the association between patients within the same hospital, and the complexity of the model affect the prediction of lives saved estimates and the inferences thereafter. On the other hand, a change in the link function led to the same predicted lives saved estimates and standard deviations. Finally, the lives saved estimates from the two-level random intercept model were similar to those of the clustered discrete time logistic model, but the standard deviations differed greatly. CONCLUSIONS: The results stress the importance of verifying model assumptions. It is recommended that researchers use sensitivity analyses to investigate the stability of lives saved results using different statistical models or different data sets.

Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology.

BACKGROUND: Current human resources planning models in nursing are unreliable and ineffective as they consider volumes, but ignore effects on quality in patient care. The project RN4CAST aims innovative forecasting methods by addressing not only volumes, but quality of nursing staff as well as quality of patient care. METHODS/DESIGN: A multi-country, multilevel cross-sectional design is used to obtain important unmeasured factors in forecasting models including how features of hospital work environments impact on nurse recruitment, retention and patient outcomes. In each of the 12 participating European countries, at least 30 general acute hospitals were sampled. Data are gathered via four data sources (nurse, patient and organizational surveys and via routinely collected hospital discharge data). All staff nurses of a random selection of medical and surgical units (at least 2 per hospital) were surveyed. The nurse survey has the purpose to measure the experiences of nurses on their job (e.g. job satisfaction, burnout) as well as to allow the creation of aggregated hospital level measures of staffing and working conditions. The patient survey is organized in a sub-sample of countries and hospitals using a one-day census approach to measure the patient experiences with medical and nursing care. In addition to conducting a patient survey, hospital discharge abstract datasets will be used to calculate additional patient outcomes like in-hospital mortality and failure-to-rescue. Via the organizational survey, information about the organizational profile (e.g. bed size, types of technology available, teaching status) is collected to control the analyses for institutional differences.This information will be linked via common identifiers and the relationships between different aspects of the nursing work environment and patient and nurse outcomes will be studied by using multilevel regression type analyses. These results will be used to simulate the impact of changing different aspects of the nursing work environment on quality of care and satisfaction of the nursing workforce. DISCUSSION: RN4CAST is one of the largest nurse workforce studies ever conducted in Europe, will add to accuracy of forecasting models and generate new approaches to more effective management of nursing resources in Europe.