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Background and Aims Since 2015, the medical intensive care unit (ICU) with a focus on hepatology of the Department of Internal Medicine 1 at the University Hospital Regensburg, Germany, has a particular emphasis on interprofessional collaboration with staf nurses and hospital pharmacists. Furthermore, there is a joint training and teaching of medical, nursing and pharmacy students within the intensive care training ward Regensburg (I'M A-STAR project). The study aims to investigate to what extent the newly introduced structural changes afect clinical and economic outcomes. Method We examined clinical performance data and consumption fgures for antibiotics and other drugs over a 10-year period from 2011 to 2021. An electronic platform was developed specifically to improve documentation. The years 2020 and 2021 were considered separately due to the COVID-19 pandemic and the care of numerous COVID-19 patients in the ICU. Results It could be shown that the pharmacist's recommendations regarding drug administration were mainly related to indication (43.6 %), dosage (27.6 %), interactions (9.4 %), and side effects (4.1 %). Antibiotic consumption was reduced by 12.2 % from 2015 to 2019. Encouragingly, this included a 23.4 % reduction in carbapenem use. Antibiotic spending was reduced by 24.9 % overall. In another analysis, antibiotic spending per case-mix point was calculated. While spending was EUR 60.22 per case-mix point in 2015, this could be reduced by 42.9 % to EUR 34.37 per case-mix point by 2019. Conclusion Through close interprofessional collaboration between physicians, staf nurses, and pharmacists, the consumption of antibiotics and other drugs was signifcantly reduced, thus improving patient care.
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Background. The percentage of all respiratory diagnoses prescribed an antibiotic is an outpatient stewardship metric and was introduced as a HEDIS measure in 2022. Given a stable case mix, this metric is not affected by differences in coding practices between clinicians or health systems since all respiratory diagnoses are considered together. The onset of the COVID-19 pandemic introduced a high number of viral illness episodes where antibiotics are not recommended. The impact of this shift in case mix on respiratory diagnosis coding and prescribing metrics has not been explored. Methods. We examined antibiotic prescribing rates for respiratory diagnoses in a network of urgent care clinics affiliated with the University of Utah during two periods. Pre-Pandemic was Mar 2019-Feb 2020 and Pandemic was Mar 2020-Mar 2022. Respiratory diagnoses were identified using ICD10 codes and further stratified into 3 Tiers (Tier 1: antibiotics indicated;Tier 2: antibiotics sometimes indicated;Tier 3: antibiotics not indicated). We examined trends in antibiotic prescribing across these periods including the percentage of all respiratory visits prescribed antibiotics and by Tier and the distribution of diagnoses by Tier. No formalized stewardship interventions were introduced during these periods. Results. There were 146,897 urgent care visits during the study period (47,423 Pre Pandemic and 99,474 Pandemic). The respiratory prescribing rate declined from 42.3% Pre Pandemic to 26.2% during the Pandemic (Figure). The distribution of respiratory diagnoses by Tier and prescribing within Tier are shown in the Table. Tier 3 diagnoses increased from 48% to 67%, while Tier 2 diagnoses declined from 47% to 31%. Antibiotic prescribing declined for both Tier 2 and Tier 3 diagnoses. 15,429 (23%) of Tier 3 diagnoses during the Pandemic were coded as COVID-19. 50% of the reduction in prescribing is attributable to changes in Tiers alone. Figure Table Conclusion. The COVID 19 pandemic was associated with a reduction in the percentage of respiratory diagnoses prescribed antibiotics. Half was due to an increase in Tier 3 encounters although declines in prescribing occurred with Tiers in addition. Using this metric for benchmarking requires accounting for the impact of case mix differences over time or between systems and clinicians.
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Background. COVID-19 shifted antibiotic stewardship program resources and changed antibiotic use (AU). Shifts in patient populations with COVID surges, including pauses to surgical procedures, and dynamic practice changes makes temporal associations difficult to interpret. Our analysis aimed to address the impact of COVID on AU after adjusting for other practice shifts. Methods. We performed a longitudinal analysis of AU data from 30 Southeast US hospitals. Three pandemic phases (1: 3/20-6/20;2: 7/20-10/20;3: 11/20-2/21) were compared to baseline (1/2018-1/2020). AU (days of therapy (DOT)/1000 patient days (PD)) was collected for all antimicrobial agents and specific subgroups: broad spectrum (NHSN group for hospital-onset infections), CAP (ceftriaxone, azithromycin, levofloxacin, moxifloxacin, and doxycycline), and antifungal. Monthly COVID burden was defined as all PD attributed to a COVID admission. We fit negative binomial GEE models to AU including phase and interaction terms between COVID burden and phase to test the hypothesis that AU changes during the phases were related to COVID burden. Models included adjustment for Charlson comorbidity, surgical volume, time since 12/2017 and seasonality. Results. Observed AU rates by subgroup varied over time;peaks were observed for different subgroups during distinct pandemic phases (Figure). Compared to baseline, we observed a significant increase in overall, broad spectrum, and CAP groups during phase 1 (Table). In phase 2, overall and CAP AU was significantly higher than baseline, but in phase 3, AU was similar to baseline. These phase changes were separate from effects of COVID burden, except in phase 1 where we observed significant effects on antifungal (increased) and CAP (decreased) AU (Table). Conclusion. Changes in hospital AU observed during early phases of the COVID pandemic appeared unrelated to COVID burden and may have been due to indirect pandemic effects (e.g., case mix, healthcare resource shifts). By pandemic phase 3, these disruptive effects were not as apparent, potentially related to shifts in non-COVID patient populations or ASP resources, availability of COVID treatments, or increased learning, diagnostic certainty, and provider comfort with avoiding antibacterials in patients with suspected COVID over time. (Figure Presented).
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Objectives: Care coordination is a key component of the population health management. However, the mechanism for identifying patients who may benefit the most from this model of care is unclear. The objective of study is to evaluate the performance of a risk-stratification instrument using a model of AI - Rule-based expert system (RBES) - in predicting healthcare utilization and costs. Method(s): Retrospective cohort study from beneficiaries of a health plan using administrative databases (prior authorizations claims systems): 27,539 individuals were assigned a predicted illness burden score using a case-mix adjustment system from diagnoses and health utilization data (2019 to 2021). Population was stratified according to the score into three main groups: G1) case management;G2) health support;G3) health promotion. Analysis was also performed in subgroups: prolonged hospitalization, readmission, complex medical conditions (CC), continued therapy (CT) (G1);chronic unstable (CU), post-COVID 19, high cost, high user (G2);healthy elderly, risk factor, low risk (G3). Data Science team analyzed population using algorithms which uses a set of logical rules derivatives of human specialists. Result(s): According to score 1,053 individuals stratified in G1, average age 68 years, annual cost U$11,318, 10 times more than average;G2, n=5,429;67 years;U$2,863;G3, n=21,037;53 years;U$246. The sickest population: 3.8%, 19.7% and 76.5% uses about 37%, 48% and 15% of healthcare expenses respectively. Most representative subgroups: CC, CT, and CU with average annual cost five or more times than average. Conclusion(s): Dashboard developed using RBES tools can supports healthcare management. Stratifying risk helps to address specific health care challenges, to align levels of care, to implement a value-based care approach. Also demonstrates to be the most logical and practical initial step to create a data set with labeled variables to start a machine learning using supervised training - the next phase in this project. Copyright © 2022
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COVID-19 led to a break in the standard of medical practice. During the first outbreak, many Ambulatory Surgical Units (ASU) were adapted to the management of COVID-19 patients, as happened at Hospital de Braga.This article presents a descriptive analysis of ambulatory surgical activity at our ASU in 2019 and 2020.Although the total number of procedures decreased, we achieved an increase in both ambulatory (72,6%) and day-case achievable procedures (51,8%) rates and Case-Mix Index (0,79), without compromising ambulatory surgery outcomes and quality indicators.At our ASU, the pandemic created the opportunity to improve the standard practice. Copyright © 2021 International Association for Ambulatory Surgery. All rights reserved.
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Aim This study examines the impact of the COVID-19 pandemic on hospitalized patients with cancer and/or COVID-19 disease at a university-based maximum care provider. Do the patient collectives differ in terms of health economics and do the results yield administrative implications for proactive management of regional cancer care. Method A retrospective, descriptive data analysis of clinical and health economic parameters of all oncological and COVID-19-postive patients admitted as in-patients at Marburg University Hospital and the combination of oncological patients with COVID-19 disease within the observation period from 2017 to 2021 was performed. Results A decrease in oncology-treated patients was observed throughout the COVID-19 pandemic period. Oncology patients with COVID-19 disease represent the patient population with the highest severity of disease, followed by COVID-19 and oncology-only patients. This is reflected in the economic performance measures. The chronological progression of DRG revenue and Case Mix Index per COVID-19 patient shows differences for time periods of the pandemic in Germany. Conclusion The comparison of the patient collectives confirms the particularly high-risk potential of oncological patients, which is reflected in a health economic costly treatment. National measures, contact restrictions or pandemic events can be traced by the chronological progression of clinical and economic parameters. Despite the international decline in out-patient and in-patient oncological patients, "state-of-the-art" cancer care is feasible in pandemic times. Because of this, there is a need for action for an inpatient maximum care provider to manage oncology care more proactively through communication and care modeling. Copyright © 2022 Georg Thieme Verlag. All rights reserved.
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Background: Access to nephrology care including dialysis in rural Alabama (AL) hospitals is lacking. The University of Alabama at Birmingham (UAB) with Sanderling Inc. started inpatient tele-nephrology (TN) services in 2019 and currently serves 3 rural AL hospitals. Since the COVID-19 pandemic, transfer to TN-equipped hospitals in AL played a pivotal role for patients needing nephrology services when primary referral centers were at capacity. Method(s): TN services were 100% virtual and video-based. Consults were completed by UAB nephrology faculty. Home hemodialysis machine (HHD) was used to provide kidney replacement therapy (KRT) in the hospital, with aid of inpatient dialysis technicians supervised remotely by TN dialysis nurses. TN consults were evaluated from Jun 2019 to Dec 2021. Retrospective chart review for pre-defined outcomes was performed and analyzed. Result(s): There were 694 inpatient TN encounters. Mean age was 64 (18-96) yr. 74% of consultations involved black patients. Mean stay was 6 d. 44% were ICU patients;18% were COVID-19 positive. AKI and known ESKD patients contributed to 48% and 44% consults, respectively. 11% had AKI necessitating KRT. 20% and 13% of consults involved hyperkalemia and dysnatremias, respectively. 792 dialysis treatments were performed with 11% complicated by intradialytic hypotension (IDH). Patients were discharged 64% and transferred to higher level of care 18% of the time. 90 patients expired. 66% of deaths were attributable to COVID-19. Preliminary economics analysis at the hospital with the most consults showed increase in case-mix index and higher census since implementation of TN services. Conclusion(s): Inpatient TN in community hospitals in rural AL provided essential nephrology care to underserved populations amidst a pandemic limiting transfer to nephrology-staffed medical centers at capacity. Most patient encounters resulted in discharge without need for transfer to bigger centers thus saving vital time and resources. Dialysis safety was favorable with low IDH prevalence likely given HHD use. TN services can be beneficial for nephrology care in remote community hospitals with further studies warranted.
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Introduction: Since 2015, the medical intensive care unit (ICU) with a focus on gastroenterology of the Department of Internal Medicine 1 at the University Hospital Regensburg, Germany, has a particular emphasis on interprofessional collaboration with staff nurses and hospital pharmacists. The hospital pharmacists have access to the hospital information system and the electronic charting program. Consultations take place on daily basis. Furthermore, weekly joint rounds within the antibiotic stewardship program are performed. Furthermore, there is a joint training and teaching of medical, nursing and pharmacy students within the intensive care training ward Regensburg (I'M A-STAR project). Aims & Methods: The study aims to investigate to what extent the newly introduced structural changes affect clinical and economic outcomes. We examined clinical performance data and consumption figures for antibiotics and other drugs over a 10-year period from 2011 to 2021. Data from the hospital pharmacy, hospital administration, electronic charting, and hospital information systems were included in the analyses. An electronic platform was developed specifically to improve documentation. The years 2020 and 2021 were considered separately due to the COVID-19 pandemic and the care of numerous COVID-19 patients in the ICU. Result(s): It could be shown that the pharmacist's recommendations regarding drug administration were mainly related to indication (43.6%), dosage (27.6%), interactions (9.4%), and side effects (4.1%). Antibiotic consumption was reduced by 12.2% from 2015 to 2019. Encouragingly, this included a 23.4% reduction in carbapenem use. Antibiotic spending was reduced by 24.9% overall. An analysis of the intensive care G-DRGs showed that the case-mix points increased significantly by 31.6% during the period under review. Similarly, patient severity of illness as measured by the SAPS II score increased by 21.4%. The proportion of mechanically ventilated patients exceeded 50%. In another analysis, antibiotic spending per case-mix point was calculated. While spending was EUR 60.22 per case-mix point in 2015, this could be reduced by 42.9% to EUR 34.37 per case-mix point by 2019. Conclusion(s): Through close interprofessional collaboration between physicians, staff nurses, and pharmacists, the consumption of antibiotics and other drugs (e.g., albumin) was significantly reduced, thus improving patient care. There was also a positive economic effect - with a simultaneous increase in case-mix points, expenditure on antibiotics was significantly reduced. Responsible use of resources and high-performance medicine are not contradictory. In our view, a close interprofessional collaboration between physicians, staff nurses, and pharmacists will be of outstanding importance in the future, particularly in intensive care medicine.
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Background: Hospital readmissions are associated with increased health care utilization and unfavorable patient outcomes. Oncology patients have an increased risk of hospital readmission compared to the general patient population. The 30-day readmission rate for cancer patients at our institution is 27.7% which is higher than the reported national average of 20.2%. We sought to reduce 30-day hospital readmission rates by 25% for solid tumor oncology patients through a prospective integrated multidisciplinary discharge approach. Methods: Hospital readmissions for adult patients with a known solid tumor cancer diagnosis admitted to the oncology service at UVA from Jan 2019 - Apr 2019 were identified. Baseline information on tumor type, reason for readmission, interventions, length of stay (LOS), and inpatient morbidity and mortality (including ICU admission and transition to hospice) were collected via retrospective review. Qualitative and quantitative tools including process maps, causeand- effect diagrams, Pareto charts, and priority matrix were used to identify potential areas for intervention. Two PDSA cycles were implemented: daily multidisciplinary discharge rounds with physicians, nursing, social work, case management, and PT/OT (PDSA1), and a templated discharge email to patients' primary oncology team including attending oncologist, mid-level providers, nurse coordinator, pharmacist, and urgent care team (PDSA2). An SPC chart with 3-ℙ limits and t-test of unequal variance with 2-sided p-value was used to evaluate impact on readmission rates from baseline to PDSA2. Results: Following PDSA1 (May 2019 - Oct 2019), the 30-day readmission was 25.7%;PDSA2 was postponed due to COVID-19, however the 30-day readmission rate remained stable during the pandemic. Following PDSA2 (Sept 2021 - Dec 2021), the 30-day readmission rate was 18.2% corresponding to an absolute decrease of 34.3% which was statistically significant (p≤0.05). This was associated with a trend towards increased LOS, rate of ICU admission, and case-mix severity index although not statistically significant. There was no significant difference in inpatient mortality or transition to hospice (Table). Conclusions: Implementation of multidisciplinary discharge rounds and templated discharge communication resulted in a significant decrease in rate of 30-day readmissions for solid tumor oncology patients. There was a trend towards increased LOS and ICU admissions without increased inpatient mortality. Improvement in discharge email compliance and implementation of an urgent symptom clinic may further reduce the 30-day readmission rate.
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Peter Ng Raleigh NC1, Afton Carducci Raleigh NC1, Lindsey Sharp Raleigh NC1, Dustin Bermudez Raleigh NC1, Linda Youngwirth Durham NC1, Tricia Burns Raleigh NC1, Erica McKearney Raleigh NC1, Lauren Massey Raleigh NC2 UNC Rex Bariatric Specialist1 UNC REX Hospital2 Introduction: The COVID-19 pandemic stressed inpatient hospital capacity and restricted elective surgery, limiting bariatric access. A novel outpatient home health program was introduced to support early discharge after bariatric surgery and preserve inpatient healthcare resources for COVID. This retrospective study evaluates the clinical/financial impact of enhanced home health in early post-operative bariatric recovery. Methods: Our program offered enhanced home health (EHH) to all bariatric patients with insurance inclusion. Patients were separated into 3 care tiers based on BMI and comorbidity with each tier adding complementary services. Tier 1 provided home intravenous hydration, anti-emetics x 3 days, and home nursing care. Tier 2 (BMI>50 kg/m2) added physical therapy. Tier 3 (plus comorbidity) added virtual primary care medical consultation. Patients were planned for scheduled discharge on post-operative day one by 10 am, if deemed medically appropriate. Results: From December to June 2021, 355 bariatric cases were performed, 158 non-EHH patients and 197 EHH patients with the following combined case mix: duodenal switch (54.6%), revision (17.2%), sleeve gastrectomy (16.6%), SADI-S (7.7%), and Roux-en-Y gastric bypass (3.9%). The prior year average hospital length of stay (LOS) was 2.0 days, non-EHH LOS of 2.0 days, versus EHH LOS of 1.5 days. A 6% reduction in direct variable costs per case was demonstrated, $9607 non-EHH versus $9036 EHH. Comparative readmission rates for nausea/vomiting/dehydration (NVD) equaled 3.8% for non-EHH and 1.5% for EHH patients. Conclusion: Enhanced home health preserved access to bariatric care while decreasing length of stay, variable costs, and reduced readmission for NVD.
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Background: The COVID-19 pandemic has presented many challenges to healthcare systems and providers. The impacts upon healthcare service utilization have been examined, however, research which explores the potential impacts upon the experiences of parents of hospitalized children is scant. We sought to a) report on the experiences of parents of children who were hospitalized during the COVID-19 pandemic, and b) compare these with historical results, in a large Canadian province. Methods: A random sample of parents were surveyed within six weeks of their child's discharge from 14 hospitals (2 stand-alone pediatric, 12 adult). Surveys were administered using a modified version of the Child Hospital Consumer Assessment of Healthcare Providers and Systems (Child HCAHPS) instrument and linked with administrative records. Discharges from April 2020 to February 2021 comprised the “during COVID-19” patient cohort, while those from April 2019 to February 2020 were the comparison (historical) cohort. These time periods were selected as they coincide with the introduction of COVID-related public health restrictions across our province. We examined 47 survey questions and reported unadjusted results as the percentage of “top box” responses to each question, determined by the most positive answer choice. Odds ratios and 95 percent confidence intervals for reporting a “top box” response among the “during COVID-19” cohort were calculated, while controlling for demographic and clinical features. Results: In total, 3,069 completed surveys (1,337 during COVID-19, 1,732 historical) were obtained. For the overall hospital rating, 70.3% of COVID-19 responses and 68.1% of historical responses were classified as “top box” (a rating of 9 or 10 out of 10). Taking the survey margin of error into account, the “during COVID-19” cohort had higher “top box” percentages on 12 of the questions examined, and lower ones on three. The remaining 32 questions showed no differences between the two time periods. In the adjusted regression analyses, the “during COVID-19” cohort had higher odds of “top box” ratings on two questions (confirming child's identity before giving medicine [aOR=1.38, 95%CI: 1.17-1.64], overall rating of nurses [aOR=1.25, 95%CI: 1.05-1.50]), and lower odds on two questions (staff reviewed vitamins, herbal medicines, and over the counter medicines on first day of hospital stay [aOR=0.75, 95%CI: 0.64- 0.89], hospital had age-appropriate toys, books, mobiles and games [aOR=0.64, 95%CI: 0.55-0.76]). Conclusion: Our study demonstrates that the experiences of parents of children who were hospitalized during the COVID-19 pandemic were comparable to historical results in our province. This highlights that despite the challenges imposed by the pandemic, the quality of hospital-based pediatric care remained intact. From a methodological perspective, the results also highlight the need for appropriate case-mix adjustments when comparing Child HCAHPS results from multiple cohorts.
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Introduction: The COVID-19 pandemic has affected the health services globally. The impact on the provision of vascular access services for patients with chronic kidney disease is not known. One can speculate that reduced hospital bed capacity, limited elective theatre lists, and the shielding requirement for vulnerable patients in this particular group will have an adverse effect. This study was conducted to evaluate the effect of the COVID-19 pandemic on dialysis access procedures performed at a tertiary care centre. Methods: This was a single centre, retrospective, observational study of all dialysis access procedures performed between January 2019 and December 2020. Patient data were collected from electronic patient records, operation theatre databases, and clinical case records. Vascular access procedures were categorised according to the site and type of dialysis access (autogenous/non-autogenous fistulas) and secondary access procedures. Secondary access procedures were those that dealt with complications of vascular access. Peritoneal access procedures were also included in the data. Placement of acute and long term dialysis catheter lines were excluded. Pre-COVID data from 2019 were compared with the 2020 data. Statistical methods for data analysis were performed using SPSS version 23.0 by applying Pearson’s chi square test for variables to measure the significance of outcome. Results: A total of 271 dialysis access related procedures were performed in 2019 versus 212 in 2020. There was a significant drop of 21.7% in the total number of dialysis access procedures during the COVID-19 pandemic in the year 2020 (p <.05). In the pre-COVID era, 162 (59.8%) procedures were the formation of autogenous arteriovenous fistulas. The case mix consisted of 69 (25.5%) radiocephalic fistulas, 70 (25.8%) brachiocephalic fistulas, 13 (4.8%) first stage basilic vein transpositions, and 10 (3.7%) second stage basilic vein transpositions. In comparison, during the year 2020, 118 (55.7%) procedures were autogenous arteriovenous fistulas. The case mix included 54 (25.5%) radiocephalic fistulas and a similar proportion of brachiocephalic fistulas (n = 54 [25.5%]), six (2.8%) first stage basilic vein transpositions, and four (1.9%) second stage basilic vein transpositions. There were 14 (5.2%) non-autogenous arteriovenous graft formations in 2019 versus 21 (9.9%) in 2020 (p <.05). There were 53 (19.5%) secondary vascular access procedures in 2019 versus 30 (14.1%) in 2020 (p <.05). The proportion of peritoneal dialysis catheter placements, repositioning, and catheter exchanges increased slightly. Forty-two (15.5%) procedures were done in 2019 versus 43 (20.3%) in 2020. The proportion of new peritoneal catheters was significantly higher in the year 2020 (p <.05). There were 35 (12.9%) new peritoneal dialysis catheter placements (nine laparoscopic/26 open insertions) in 2019, whereas in 2020 there were 38 (17.9%) n (one laparoscopic, 31 open and five percutaneous). There were no laparoscopic peritoneal dialysis catheter placements after the start of the pandemic. Conclusion: During the COVID-19 pandemic, there was a significant reduction in the total number of vascular access procedures performed and also secondary surgical interventions, but an increase in the use of arteriovenous grafts. The number of new peritoneal dialysis access increased despite overall reduction in the total number of procedures. Percutaneous peritoneal tube insertion technique was introduced during the pandemic to reduce hospital admissions while laparoscopic techniques were abandoned.
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Background and aims: Since 2015, the medical intensive care unit (ICU) with a focus on hepatology of the Department of Internal Medicine 1 at the University Hospital Regensburg, Germany, has a particular emphasis on interprofessional collaboration with staff nurses and hospital pharmacists. The hospital pharmacists have access to the hospital information system and the electronic charting program. Consultations take place on daily basis. Furthermore, weekly joint rounds within the antibiotic stewardship program are performed. Furthermore, there is a joint training and teaching of medical, nursing and pharmacy students within the intensive care training ward Regensburg (I’M A-STAR project). The study aims to investigate to what extent the newly introduced structural changes affect clinical and economic outcomes. Method: We examined clinical performance data and consumption figures for antibiotics and other drugs over a 10-year period from 2011 to 2021. Data from the hospital pharmacy, hospital administration, electronic charting, and hospital information systems were included in the analyses. An electronic platform was developed specifically to improve documentation. The years 2020 and 2021 were considered separately due to the COVID-19 pandemic and the care of numerous COVID-19 patients in the ICU. Results: It could be shown that the pharmacist’s recommendations regarding drug administration were mainly related to indication (43.6%), dosage (27.6%), interactions (9.4%), and side effects (4.1%). Antibiotic consumption was reduced by 12.2% from 2015 to 2019. Encouragingly, this included a 23.4% reduction in carbapenem use. Antibiotic spending was reduced by 24.9% overall. An analysis of the intensive care G-DRGs showed that the case-mix points increased significantly by 31.6% during the period under review. Similarly, patient severity of illness as measured by the SAPS II score increased by 21.4%. The proportion of mechanically ventilated patients exceeded 50%. In another analysis, antibiotic spending per case-mix point was calculated. While spending was EUR 60.22 per case-mix point in 2015, this could be reduced by 42.9% to EUR 34.37 per case-mix point by 2019. Conclusion: Through close interprofessional collaboration between physicians, staff nurses, and pharmacists, the consumption of antibiotics and other drugs (e.g., albumin) was significantly reduced, thus improving patient care. There was also a positive economic effect-with a simultaneous increase in case-mix points, expenditure on antibiotics was significantly reduced. Responsible use of resources and high-performance medicine are not contradictory. In our view, a close interprofessional collaboration between physicians, staff nurses, and pharmacists will be of outstanding importance in the future, particularly in intensive care medicine.
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Objective: Pancreatectomies are technically challenging procedures frequently associated with morbidity and mortality. Nonetheless, pancreatectomies are the only potentially curative treatment for pancreatic cancer. The aim of this study is to compare the clinical and cost outcomes of patients undergoing pancreatectomy for treatment of pancreatic cancer at our institution against national benchmarks of large, specialized complex care medical centers (LSCMCs) and safety-net hospitals (America's Essential Hospitals, AEHs). Methods: The Vizient Clinical Data Base was queried for all participating institutions performing any type of pancreatectomy for pancreatic cancer for adults over the age of 18 from 2018-2020. Institution-level clinical and cost outcomes were compared across our institution, LSCMCs, and AEHs. Clinical outcomes included hospital length of stay (LOS) index, 30-day mortality index, case mix index (CMI), and percentage of 30-day readmissions. Cost outcomes comprised the direct cost index. LOS, mortality, and direct cost indices were defined as the ratio of observed values to expected values, derived from the Vizient comparison hospitals. Indices with a value greater than one indicated the observed value was greater than the expected comparison value for that measure. Continuous variables were summarized as weighted means and standard deviation. Continuous measures were analyzed by the twosample t-test or Mann-Whitney U test, as appropriate. P-values with α<0.05 defined statistical significance. Results: A total of 78 LSCMCs and 52 AEHs performed 6,795 pancreatectomies from 2018-2020. Our institution performed a total of 90 pancreatectomies during this period. LOS index was below national benchmarks at our institution (1.08-0.82), LSCMCs (0.91-0.85), and AEHs (0.94-0.93), with an increasing CMI at our institution (3.33-4.20) from 2018-2020. The mortality index declined at our institution (5.07-0.00) below national benchmarks compared to LSCMCs (1.23-1.29) and AEHs (1.19-1.45). 30-day readmissions were lower at our institution (6.25-10.26%) compared to LSCMCs (17.62-16.83%) and AEHs (18.93-15.51%). Direct cost index at our institution declined (1.00 to 0.67) below the benchmark compared to LSCMCs (0.90-0.93) and AEHs (1.02-1.04). Conclusion: From 2018-2020, clinical and cost outcomes after pancreatectomies for pancreatic cancer at our safety-net hospital are comparable to peer LSCMCs and AEHs. These outcomes have improved, exceeding national benchmarks despite an increasing CMI over this 3-year period. These findings are of particular importance given the growing reimbursement constraints coupled with the strain of the COVID-19 pandemic on the health care system. This study highlights the role of LSCMCs and safety-net hospitals in providing high-quality care to a medically underserved population requiring complex surgery. (Figure Presented)
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Rationale. Prone positioning (PP) of patients with moderate-severe acute respiratory distress syndrome (ARDS) is an evidence-based and guideline-recommended practice, but our 2019 survey found that fewer than half of Massachusetts ICUs could routinely offer PP. As studies have described rapid adoption of evidence- and nonevidence- based practices alike during COVID-19, we re-surveyed Massachusetts ICUs in 2021 to determine if institutional-level adoption of PP among intubated patients had changed during the COVID-19 pandemic;we additionally ascertained adoption of awake PP. Methods. In follow-up to our 2019 survey, we surveyed intensive care units (ICUs) at all acute-care hospitals in Massachusetts, June-October 2021. The survey asked: “Does your ICU have the ability to prone intubated patients?” (“Yes, routinely,” “Case-by-case,” or “No”). Follow-up questions inquired if ICUs had protocols/guidelines on intubated PP, trained nurses in intubated PP, and whether awake PP had been adopted. We collected descriptive hospital data (number of ICU and hospital beds, nonprofit status, teaching status, case-mix index) and tested for associations with chi-square tests. Results. Of the 57 acute care hospitals in Massachusetts with ICUs, 47 responded to the survey (82% response;compared to 54/60 [90%] in 2019;three hospitals surveyed in 2019 had closed ICUs in 2021). The number of hospitals able to routinely perform PP in intubated patients increased from 24 (44%) to 39 (83%);hospitals able to perform PP among intubated patients on a case-by-case basis or not at all decreased from 15 (28%) to 5 (11%) and 15 (28%) to 3 (6%), respectively (p<0.001) (Figure 1). ICUs with a protocol/guideline for intubated PP increased from 27 (50%) to 43 (92%) (p< 0.001);ICUs that had trained some or all nurses in intubated PP increased from 34 (63%) to 45 (96%) (p<0.001). In contrast to 2019, in 2021 there were no associations between availability of intubated PP and hospital/ICU bed number, teaching status, nonprofit status, or case-mix index. In 2021, 43 (92%) of Massachusetts ICUs had adopted awake PP, 19 of whom had not adopted routine PP of intubated patients in 2019, and 4 of whom had not adopted intubated PP in 2021. Conclusions. There was a significant increase in the proportion of Massachusetts ICUs that had adopted evidence-based, guideline-recommended PP in intubated patients by 2021. At the same time, almost all ICUs also adopted non-evidence-based PP in awake patients. Our results illustrate that factors other than available evidence play a large role in practice adoption.
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The urban population is increasing worldwide. This demographic shift generates great pressure over public services, especially those related to health-care. One of the most expensive health-care services is surgery, and in order to contain this growing cost of providing better services, the efficiency of surgical centers must be improved. This work proposes an integer linear programming model (ILP) considering the case-mix planning (CMP) and the master surgical scheduling (MSS) problems. The case-mix planning problem deals with the planning of the number of operating rooms to be assigned to surgical specialties. The master surgical scheduling is related to when to assign the rooms to the different specialties. The developed model uses a data set from a hospital of the city of Turin, Italy. The results are very promising, showing a reduction from 240 weeks to 144 weeks to empty the surgical waiting list (WL). Moreover, if changes to the hospital situation are implemented, including the introduction of two new surgical teams into one of the hospital’s specialties, the time to empty the surgical WL could decrease to 79 weeks.
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Background/Aims The COVID-19 pandemic forced rheumatology clinics to utilise telephone consultations as a means to limit footfall at hospitals and to protect our vulnerable patients. This was a new mode of service delivery for most rheumatology departments as previously all appointments used to be face-to-face. Although remote consultations were previously being considered as a mode of service delivery, the COVID-19 pandemic has expedited the uptake remote consultations within a very short span of time. There are no systematic studies to compare the effectiveness of remote consultations versus face-to-face consultations although remote consultations are now being widely adopted. Our aim was to assess the effectiveness of telephone consultations compared to face-to-face consultations in the routine review of rheumatology patients. Methods 101 face-to-face consultations and 98 telephone consultations were randomly selected from the months of June and August in 2019 and 2020 respectively. The clinic letters were then accessed and the clinic outcomes were noted. The parameters chosen to aid comparison included start of new medication, medication dose changes, referral for investigations, referral to another specialty, referral to MDT, referral for a steroid injection, timescale of subsequent follow up and discharge from services. Results The main results broadly showed similarities in case-mix and several outcomes, including time scale of follow up and intra-articular and intramuscular steroid injections. Fewer patients were started on a new medication following a telephone consultation (14.9% vs 10.2%), more patients had their current medication dose changed (14.9% vs 17.3%) and slightly more patients were referred for investigations (25.7% vs 30.6%). Furthermore, telephone consultations resulted in a lower rate of referrals to MDT (13.9% vs 5.1%) and marginally fewer discharges. Conclusion The evaluation showed there were clear similarities between the two groups which showed telephone consultations were comparable to face-to-face consultations. Out of the 98 telephone consultations, only 10 were converted to a face-to-face appointment which was lower than many had predicted. However, the drop in referral rates to other specialties may represent that consultants do not feel confident to refer to another team without a comprehensive face-to-face assessment. Telephone consultations, with the back up of face-to-face slots made available for appropriate patients, appear to be an effective means of service delivery and is likely to continue in a scaled down form.
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Background/Aims The National Early Inflammatory Arthritis Audit (NEIAA) has provided the opportunity for rheumatology services to benchmark the care they provide against NICE quality standards (QS)33. It has proven to be a powerful lever for improving quality and our department is testimony to this. Recruitment to all national audits was paused for several months due to the COVID-19 pandemic. Once pressures had eased we recognised that NEIAA would help to understand the impact of the pandemic on the diagnosis and initial management of patients with rheumatoid arthritis. Our department continued to see all new urgent referrals face-to-face and were fortunate that the team were not redeployed. Methods Data submitted to the NEIAA online tool during year 3 (September 2020-March 2021) were downloaded for analysis. Data from year 2 were downloaded for comparison. Results In year 3, 154 patients were recruited to the audit compared to 268 in year 2. 36 (23%) had rheumatoid arthritis and were included in the follow-up cohort compared to 73 (27%) in year 2. All patients had a baseline and a 3-month follow up form completed, however 17 patients in year 3 had a telephone appointment at 3 months and there was no available DAS28. Patient demographics were similar. The case mix of patients recruited was also;in year 3, 41% were diagnosed with autoimmune inflammatory arthritis compared to 47% in year 2 and 42% with a non-inflammatory condition compared to 39% in year 2. In year 3, 41% of all patients were seen within 3 weeks of being referred and 58% of patients with RA started DMARD therapy within 6 weeks of referral. This compared to 54% and 56%, respectively, in year 2. In year 3, symptom duration prior to referral appeared longer: 31% had symptoms for less than 3 months, 31% for 3-6 months, 22% for 6-12 months and 16% for more than 12 months compared to 67%, 18%, 12% and 3%, respectively, in year 2. DAS28 at baseline was higher in year 3 with 47% high, 47% moderate and 6% low disease activity or in remission compared to 27%, 61% and 12%, respectively, in year 2. DAS28 at 3-months was also higher in year 3 with 16% high, 37% moderate and 27% low disease activity or remission compared to 6%, 25% and 69% respectively in year 2. Conclusion Despite the impact of the pandemic we have maintained our performance against QS2 and 3. However, patients seemed to have longer duration of symptoms prior to referral, higher disease activity at baseline and at 3 months. We await the 12-month data to determine 1- year outcomes, including escalation to high cost drug therapies.
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Introduction: In March 2020 the UK reported its first coronavirus related death. The weeks following saw rapid and frequent changes to the delivery of healthcare;face-to-face appointments were limited, elective procedures cancelled, and concerns about the availability of PPE began to surface. The potential impact of changing personal and professional circumstances on junior doctor well-being has been alluded to in statements from all UK Royal Colleges. We present results from the first part of a planned longitudinal prospective cohort study tracking trainee experiences during the pandemic. Methods: In May 2020, two months after than start of the pandemic, all UK paediatric cardiology trainees were invited to participate in an electronic survey. Questions addressed the work environment, training experiences and personal circumstances. Individual interviews were also conducted with 4 trainees. Results: 30/45 (67%) paediatric cardiology trainees from 7/10 U.K training regions (Liverpool, Cardiff and Belfast were not represented) completed the survey. Respondents were mostly aged 30-40 (77%), 48% female and 6 (20%) from ethnic minority backgrounds. The majority were working full time 27 (90%) and in higher/sub-speciality training 23 (77%). Most felt safe at work (89%) with access to appropriate PPE. Perceptions of workload intensity varied by region. 79% received formal teaching at 50%-100% of pre-pandemic levels. However, 93% reported reduced opportunities for sub-speciality training;61% characterised this as very significant. Well-being was almost unanimously negatively affected. Conclusions: Even during the first wave of the pandemic, the majority of U.K paediatric cardiology trainees felt safe at work. Workload intensity varied, reflecting changes in the configuration of cardiac services;in 1 London Centre and the East-Midlands, surgical/ interventional activity was paused. Higher/sub-speciality training was most impacted;where elective activity provides most experience. Well-being was virtually unanimously negatively impacted. COVID-19 has been the defining global healthcare crisis of the modern era. There has been a measurable impact on paediatric cardiology trainees;fewer cardiac catheterisations', restricted fetal screening, and a more emergency-driven case mix. Consideration of adjustment to training duration may be required pre-certification and our follow-up survey will aim to evaluate the longer-term implications of the pandemic on training.
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OBJECTIVES AND RATIONALE Estimating the impact of COVID-19 on cancer screening programs and related outcomes can help health services prepare for potential delays in diagnoses and different demands on treatment services and plan for best approaches to recovery. Simulation modelling enables estimation of outcomes for a range of scenarios. In this study, we estimate the impact of various disruptions and recovery strategies for the Australian biennial mammographic breast screening program (BreastScreen). METHOD Policy1-Breast is a continuous-time, multiple-cohort micro-simulation model that simulates the whole Australian female population, incorporating breast cancer risk and natural history, breast density, menopause, hormone therapy use and breast cancer screening. Firstly, in the early stages of the COVID pandemic we used Policy1-Breast to evaluate how 3, 6, 9 and 12-month pauses to BreastScreen would impact on population-level breast cancer diagnoses, tumour staging, and breast cancer survival, compared to business-as-usual (BAU) outcomes. Secondly, to explore options for recovery after an actual one-month screening pause in April 2020, we evaluated a range of assumed throughput levels following screening resumption (50% or 80% up to December, then 100% to 120% from Jan 2021), comparing various protocols where specific sub-groups of clients were prioritised for screening during the recovery Speriod. Outcomes are reported for the target age range for the BreastScreen program (50-74 years). RESULTS For 3-to 12-month pauses, we estimated a slight reduction in 5-year survival following diagnosis for women directly affected by a pause, but no discernible changes to population-level breast cancer mortality rates up to 2023. We estimated marked fluctuations in population rates of invasive breast cancer diagnoses with a 10% increase in cancer diagnoses between 2020-2021 and 2022-2023. For a 12-month pause to screening we estimate that population-level breast cancers would increase in size (with an additional 4% >15mm at diagnosis) and be more likely to involve the nodes (increasing from 26% to 30% of all cancers). We estimate that median screening intervals during 2020-2021 would increase from 104 weeks under BAU up to 130 weeks with a 12-month pause, and BreastScreen recall rates and false positive recall rates would fluctuate markedly over time. For the second evaluation of a one-month pause followed by various throughput and prioritisation scenarios, we estimated that screen-detected cancer rates would vary markedly with throughput but interval cancer rates would not, leading to fluctuations in program sensitivity of up to 6%. Reflecting the periodic nature of screening participation, we estimated the extent to which longer-term future screening participation rates are expected echo the peaks and troughs in participation due to the impacts of the COVID pandemic in 2020. We estimate that for a given throughput assumption, client prioritisation could lead to different rescreening rates, screening intervals, and time required for prioritisation protocols, with little change to cancer outcomes. CONCLUSION These modelled evaluations estimate short and longer-term effects of COVID-19 on the impact of population breast cancer screening in Australia. The estimated changes in breast cancer rates and characteristics would be expected to have a flow-on effect on the demand for treatment services in terms of throughput and case-mix. Preparing for such outcomes is critical given that treatment services are also directly impacted by the pandemic. The modelled outcomes are likely to be relevant to other high-income settings with established population breast cancer screening programs.