The Psychosocial Impact of Treating Patients with COVID-19 on Psychiatry Residents in a Community Hospital: a Qualitative Study.

OBJECTIVE: The authors explored the experiences of psychiatry residents caring for patients during the COVID-19 pandemic on a medical unit. METHODS: From June 2020 through December 2020, structured, individual interviews were conducted with psychiatry residents deployed to internal medicine wards in a community hospital to provide medical care to COVID-19 patients for greater than or equal to 1 week. Interviews were recorded, transcribed verbatim, and analyzed using thematic analytical methods. RESULTS: Psychiatry residents (n = 16) were interviewed individually for approximately 45 min each. During the interviews, many residents described emotions of fear, anxiety, uncertainty, lack of preparedness, and difficulty coping with high patient mortality rates. Many of the residents expressed concerns regarding insufficient personal protective equipment, with the subsequent worries of their own viral exposure and transmission to loved ones. Multiple residents expressed feeling ill-equipped to care for COVID-19 patients, in some cases stating that utilizing their expertise in mental health would have better addressed the mental health needs of colleagues and patients' families. Participants also described the benefits of processing emotions during supportive group sessions with their program director. CONCLUSIONS: The COVID-19 pandemic represents a public health crisis with potential negative impacts on patient care, professionalism, and physicians' well-being and safety. The psychiatry residents and fellows described the overwhelmingly negative impact on their training. The knowledge gained from this study will help establish the role of the psychiatrist not only in future crises but in healthcare as a whole.

Kotter's 8 stages of change: implementation of clinical screening protocols for assessing patients for COVID-19 - a review of an academic medical centre's preparedness.

BACKGROUND: COVID-19 screening protocols rapidly evolved as a result of changing Centers for Disease Control and Prevention (CDC) and California Department of Public Health (CDPH) recommendations. These protocols led to operational improvements at one large academic medical centre using change management methods explained in Kotter's 8-stage change model. METHODS: We reviewed all iterations of clinical process maps for identifying, isolating and assessing COVID-19 infections in paediatric and adult populations within one emergency department (ED) from 28 February 2020 to 5 April 2020. We incorporated CDC and CDPH criteria for the various roles of healthcare workers in ED patient assessment. RESULTS: Using Kotter's 8-stage change model, we outlined the chronological evolution of basic screening criteria, as well as how these were reviewed, modified and implemented during the onset and through the time of greatest uncertainty of COVID-19 in the USA. Our results demonstrate a successful creation, and subsequent execution, of rapidly changing protocols across a large workforce. CONCLUSION: We effectively applied a business change management framework to the hospital management response during a pandemic; we share these experiences and challenges to inform and guide future operational decision making during times of rapid change.

Key Indicators Affecting Hospital Efficiency: A Systematic Review.

Background: Measuring hospital efficiency is a systematic process to optimizing performance and resource allocation. The current review study has investigated the key input, process, and output indicators that are commonly used in measuring the technical efficiency of the hospital to promote the accuracy of the results. Methods: To conduct this systematic review, the electronic resources and databases MEDLINE (via PubMed), Scopus, Ovid, Proquest, Google Scholar, and reference lists of the selected articles were used for searching articles between 2010 and 2019. After in-depth reviews based on the inclusion and exclusion criteria, among 1,537 studies, 144 articles were selected for the final assessment. Critical Appraisal Skills Programme (CASP) Checklist was used for evaluating the quality of the articles. The main findings of studies have been extracted using content analysis. Results: After the final analysis, the Context/Input indicators that were commonly considered by studies in analyzing hospital technical efficiency include different variables related to Hospital Capacity, Structure, Characteristics, Market concentration, and Costs. The Process/Throughput indicators include different variables related to Hospital Activity or services-oriented process Indicators, Hospital Quality-oriented process indicators, and Hospital Educational processes. Finally, the Output/Outcome indicators include different variables related to Hospital Activity-related output variables and Quality-related output/outcomes variables. Conclusion: This study has identified that it is necessary to mix and assess a set of input, process, and output indicators of the hospital with both quantitative and qualitative indicators for measuring the technical efficiency of hospitals comprehensively.

Intraorganization conflicts of interest in hospitals adapting to a changing ecosystem.

PURPOSE: Health systems function in an ecosystem that is turbulent and competitive because of demographic, economic, political, technological and lifestyle changes and sociopolitical influences, requiring hospitals to adopt comprehensive business strategies. Failure to do so may result in duplication, waste and deficits. This original article uses the prism of agency theory to examine differences in approach at two levels of hospital management and the consequent problems in the incorporation of necessary changes. Agency theory posits an inherent conflict of interest in organizations, including health organizations: the managers (agents) always aim to maximize their profit or personal interest instead of that of the owner or organization (principal), potentially causing difficulty in managing the organization. The aim is to generate recommendations for policymakers. DESIGN/METHODOLOGY/APPROACH: The study is based on 30 semi-structured, in-depth interviews with key figures in the health system and on two levels of hospital management: senior managers and heads of selected departments. The analysis used a categorical qualitative methodology. FINDINGS: The main findings are five key themes: views of business behavior, asymmetry of interests, asymmetry of information, transparency and cooperation between various levels of management and ambivalence toward business in hospitals. The two levels of management are clearly divided in terms of interests, information and activity, leading to difficulty in cooperation, efficiency and achievement of organizational goals. ORIGINALITY/VALUE: Using agency theory, this study provides a systemic and organizational view of hospitals' management and environmental adaptation. Understanding the processes and increasing cooperation at various managerial levels can help make the system more efficient and ensure its survival in a dynamic market.

Pre-Hospital Administration of Remdesivir During a Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Outbreak in a Skilled Nursing Facility.

Completion of a 5-day course of remdesivir was associated with approximately 17-fold increased odds of survival among a sample of 54 nursing home residents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the course of an outbreak from October to December 2020. Remdesivir was well tolerated; administration was logistically feasible in a pre-hospital environment.

Improving patient flow during infectious disease outbreaks using machine learning for real-time prediction of patient readiness for discharge.

BACKGROUND: Delays in patient flow and a shortage of hospital beds are commonplace in hospitals during periods of increased infection incidence, such as seasonal influenza and the COVID-19 pandemic. The objective of this study was to develop and evaluate the efficacy of machine learning methods at identifying and ranking the real-time readiness of individual patients for discharge, with the goal of improving patient flow within hospitals during periods of crisis. METHODS AND PERFORMANCE: Electronic Health Record data from Oxford University Hospitals was used to train independent models to classify and rank patients' real-time readiness for discharge within 24 hours, for patient subsets according to the nature of their admission (planned or emergency) and the number of days elapsed since their admission. A strategy for the use of the models' inference is proposed, by which the model makes predictions for all patients in hospital and ranks them in order of likelihood of discharge within the following 24 hours. The 20% of patients with the highest ranking are considered as candidates for discharge and would therefore expect to have a further screening by a clinician to confirm whether they are ready for discharge or not. Performance was evaluated in terms of positive predictive value (PPV), i.e., the proportion of these patients who would have been correctly deemed as 'ready for discharge' after having the second screening by a clinician. Performance was high for patients on their first day of admission (PPV = 0.96/0.94 for planned/emergency patients respectively) but dropped for patients further into a longer admission (PPV = 0.66/0.71 for planned/emergency patients still in hospital after 7 days). CONCLUSION: We demonstrate the efficacy of machine learning methods at making operationally focused, next-day discharge readiness predictions for all individual patients in hospital at any given moment and propose a strategy for their use within a decision-support tool during crisis periods.

Effect of after action review on safety culture and second victim experience and its implementation in an Irish hospital: A mixed methods study protocol.

BACKGROUND: After Action Review is a form of facilitated team learning and review of events. The methodology originated in the United States Army and forms part of the Incident Management Framework in the Irish Health Services. After Action Review has been hypothesized to improve safety culture and the effect of patient safety events on staff (second victim experience) in health care settings. Yet little direct evidence exists to support this and its implementation has not been studied. AIM: To investigate the effect of After Action Review on safety culture and second victim experience and to examine After Action Review implementation in a hospital setting. METHODS: A mixed methods study will be conducted at an Irish hospital. To assess the effect on safety culture and second victim experience, hospital staff will complete surveys before and twelve months after the introduction of After Action Review to the hospital (Hospital Survey on Safety Culture 2.0 and Second Victim Experience and Support Tool). Approximately one in twelve staff will be trained as After Action Review Facilitators using a simulation based training programme. Six months after the After Action Review training, focus groups will be conducted with a stratified random sample of the trained facilitators. These will explore enablers and barriers to implementation using the Theoretical Domains Framework. At twelve months, information will be collected from the trained facilitators and the hospital to establish the quality and resource implications of implementing After Action Review. DISCUSSION: The results of the study will directly inform local hospital decision-making and national and international approaches to incorporating After Action Review in hospitals and other healthcare settings.

Critical Access Hospital Leaders Beat Challenges to Support Their Communities and Staffs.

SUMMARY: Critical access hospitals (CAHs) serve their rural communities as the main access points and communication centers for healthcare, typically with very limited financial, staffing, and support resources. Local residents rely on their CAHs as the only providers for many miles around. When the COVID-19 pandemic hit in early 2020, CAH leaders had to rethink operations and priorities, both internally with staffs and externally with community leaders and organizations. Few critical care beds were available when the need was greatest. Testing was problematic, and cultural barriers complicated care. Now, as virus variants strike where vaccination numbers are low, CAH leaders remain wary of financial hits to elective procedure income, limited resources, and added stress for their staffs. Working with community service organizations and larger regional healthcare centers is a crucial strategy for CAHs as they address care delivery issues and ensure that their caregivers can do their jobs now and in the future.

Local COVID-19 Epicenter in Detroit Metropolitan Area Causing Profound and Pervasive Reorganization of Clinical, Educational, Research, and Financial Programs of a Large Academic Gastroenterology Division with a GI Fellowship and Primary Medical School Affiliation.

AIM: To report revolutionary reorganization of academic gastroenterology division from COVID-19 pandemic surge at metropolitan Detroit epicenter from 0 infected patients on March 9, 2020, to > 300 infected patients in hospital census in April 2020 and > 200 infected patients in April 2021. SETTING: GI Division, William Beaumont Hospital, Royal Oak, has 36 GI clinical faculty; performs > 23,000 endoscopies annually; fully accredited GI fellowship since 1973; employs > 400 house staff annually since 1995; tertiary academic hospital; predominantly voluntary attendings; and primary teaching hospital, Oakland-University-Medical-School. METHODS: This was a prospective study. Expert opinion. Personal experience includes Hospital GI chief > 14 years until 2020; GI fellowship program director, several hospitals > 20 years; author of > 300 publications in peer-reviewed GI journals; committee-member, Food-and-Drug-Administration-GI-Advisory Committee > 5 years; and key hospital/medical school committee memberships. Computerized PubMed literature review was performed on hospital changes and pandemic. Study was exempted/approved by Hospital IRB, April 14, 2020. RESULTS: Division reorganized patient care to add clinical capacity and minimize risks to staff of contracting COVID-19 infection. Affiliated medical school changes included: changing "live" to virtual lectures; canceling medical student GI electives; exempting medical students from treating COVID-19-infected patients; and graduating medical students on time despite partly missing clinical electives. Division was reorganized by changing "live" GI lectures to virtual lectures; four GI fellows temporarily reassigned as medical attendings supervising COVID-19-infected patients; temporarily mandated intubation of COVID-19-infected patients for esophagogastroduodenoscopy; postponing elective GI endoscopies; and reducing average number of endoscopies from 100 to 4 per weekday during pandemic peak! GI clinic visits reduced by half (postponing non-urgent visits), and physical visits replaced by virtual visits. Economic pandemic impact included temporary, hospital deficit subsequently relieved by federal grants; hospital employee terminations/furloughs; and severe temporary decline in GI practitioner's income during surge. Hospital temporarily enhanced security and gradually ameliorated facemask shortage. GI program director contacted GI fellows twice weekly to ameliorate pandemic-induced stress. Divisional parties held virtually. GI fellowship applicants interviewed virtually. Graduate medical education changes included weekly committee meetings to monitor pandemic-induced changes; program managers working from home; canceling ACGME annual fellowship survey, changing ACGME physical to virtual site visits; and changing national conventions from physical to virtual. CONCLUSION: Reports profound and pervasive GI divisional changes to maximize clinical resources devoted to COVID-19-infected patients and minimize risks of transmitting infection.

One year with the COVID-19 pandemic - Lessons learnt? Intersectoral collaboration measures established during the crisis could benefit capacity and patient flow management in daily clinical practice.

PURPOSE: The COVID-19 pandemic has changed the way hospitals work. Strategies that were detached from the boundaries of departments and responsibilities in the COVID-19 pandemic have proven themselves under extreme conditions and show a beneficial influence on patient flow and resource management as well as on the communication culture. The continuation of closer interdisciplinary and cross-sectoral co-operation in a "new clinical routine" could have a positive impact on personnel concepts, communication strategies, and the management of acute care capacities and patient pathways. DESIGN/METHODOLOGY/APPROACH: The aim of the paper is to critically discuss the knowledge gained in the context of the COVID-19 pandemic from the various approaches in patient flow and capacity management as well as interdisciplinary co-operation. More recent research has evaluated patient pathway management, personnel planning and communication measures with regard to their effect and practicability for continuation in everyday clinical practice. FINDINGS: Patient flows and acute care capacities can be more efficiently managed by continuing a culture change towards closer interdisciplinary and intersectoral co-operation and technologies that support this with telemedicine functionalities and regional healthcare data interoperability. Together with a bi-directional, more frequent and open communication and feedback culture, it could form a "new clinical routine". ORIGINALITY/VALUE: This paper discusses a holistic approach on the way away from silo thinking towards cross-departmental collaboration.

Using Dominance Analysis to Identify the Most Important Dimensions of Safety Culture for Predicting Patient Safety.

Studies have demonstrated associations between safety culture and patient safety based on the perceptions of healthcare professionals, but limited attention has been given to the perceptions of nurses. Moreover, most studies have used regression modeling, an approach that limits researchers' ability to identify the most important predictors of patient safety due to intercorrelations among predictors in the model. Therefore, the purpose of this study was to examine the effects of seven dimensions of safety culture on nurse-rated patient safety and identify the relative importance of these dimensions for predicting patient safety. This correlational study used data from the Agency for Healthcare Research and Quality's 2018 Hospital Survey on Patient Safety Culture. Data from 13,031 nurses working in surgical areas of 443 hospitals in the United States were examined using logistic regression and dominance analysis. Staffing adequacy was the strongest predictor of patient safety, followed by hospital management support for patient safety and organizational learning/continuous improvement. However, dominance analysis showed that hospital management support for patient safety was the most important predictor rather than staffing adequacy. Nurse managers and hospital administrators should role model a culture of safety and demonstrate their valuing of patient safety by providing sufficient resources, listening to and valuing staff suggestions regarding patient safety, and providing feedback about organizational changes to improve patient safety.

Kanban system applications in healthcare services: A literature review.

Lean Management method has been applied in several fields before its implementation in healthcare area. Among the different techniques associated with Lean, in this paper, we are focused on Kanban system, which is a method that presents several benefits such as inventory holding reduction or improvement of the employees' satisfaction. Our main objective is to carry out a literature review focused on Kanban methodology applied to health care. In this sense, this study can serve as a script to improve hospital management in pandemic periods, such as the one currently lived on COVID-19. We carry out a literature review searching in four different databases. We combine several terms to achieve our objective. We identify several articles which describe Kanban methodology applied to health field. More specifically, we present in what areas (nursing or pharmacy, among others) this method has been applied. In addition, we show all the barriers as well as benefits caused by the implementation of this system. There are a few studies focused on analysing how Kanban is applied to health care. Therefore, we can affirm that this topic is still recent.