Pre-pandemic geographic access to hospital-based telehealth for cancer care in the United States.

IMPORTANCE: Little is known about US hospitals' capacity to ensure equitable provision of cancer care through telehealth. OBJECTIVE: To conduct a national analysis of hospitals' provision of telehealth and oncologic services prior to the SARS-CoV-2 pandemic, along with geographic and sociodemographic correlates of access. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional analysis with Geographic Information Systems mapping of 1) 2019 American Hospital Association (AHA) Annual Hospital Survey and IT Supplement, 2) 2013 Urban Influence Codes (UIC) from the United States Department of Agriculture, 3) 2018 Area Health Resources Files from the Health Services and Resources Administration (HRSA). INTERVENTIONS: Hospitals were categorized by telehealth and oncology services availability. Counties were classified as low-, moderate-, or high-access based on availability of hospital-based oncology and telehealth within their boundaries. MAIN OUTCOMES AND MEASURES: Geospatial mapping of access to hospital-based telehealth for cancer care. Generalized logistic mixed effects models identified associations between sociodemographic factors and county- and hospital-level access to telehealth and oncology care. RESULTS: 2,054 out of 4,540 hospitals (45.2%) reported both telehealth and oncology services. 272 hospitals (6.0%) offered oncology without telehealth, 1,369 (30.2%) offered telehealth without oncology, and 845 (18.6%) hospitals offered neither. 1,288 out of 3,152 counties with 26.6 million residents across 41 states had no hospital-based access to either oncology or telehealth. After adjustment, rural hospitals were less likely than urban hospitals to offer telehealth alongside existing oncology care (OR 0.27; 95% CI 0.14-0.55; p < .001). No county-level factors were significantly associated with telehealth availability among hospitals with oncology. CONCLUSIONS AND RELEVANCE: Hospital-based cancer care and telehealth are widely available across the US; however, 8.4% of patients are at risk for geographic barriers to cancer care. Advocacy for adoption of telehealth is critical to ensuring equitable access to high-quality cancer care, ultimately reducing place-based outcomes disparities. Detailed, prospective, data collection on telehealth utilization for cancer care is also needed to ensure improvement in geographic access inequities.

Suicide and Self-Harm in Youth Presenting to a US Rural Hospital During COVID-19.

OBJECTIVE: Rural-residing children in the United States experience higher suicide mortality than urban-residing children but are underrepresented in research. We examined changes in emergency department (ED) utilization and subsequent hospitalization for suicide or self-harm in a rural hospital after the coronavirus disease 2019 pandemic onset. METHODS: This retrospective cohort study involved children aged 5 to 17 years visiting a rural, Northeastern hospital from January 1, 2017 to May 31, 2021. We used autoregressive integrated moving average modeling, an interrupted time series analysis, to examine monthly changes after the pandemic onset (March 2020) in ED visits with a primary mental health diagnosis, number of mental health visits with a suicide or self-harm diagnosis, proportion of patients with suicide or self-harm admitted to hospital, and length of stay for suicide or self-harm. RESULTS: Prepandemic, there was an average of 20.6 visits per month for mental health conditions, with 23.3 visits per month postpandemic (P = .16). Monthly visits for suicide or self-harm were greater in the postpandemic (15.6 visits per month) versus prepandemic months (11.4 visits per month, P < .01). In autoregressive integrated moving average modeling, pandemic onset related to an additional 0.83 (95% confidence interval: 0.31 to 1.36) primary mental health visits with suicide or self-harm diagnoses per month. Of these visits, there was an immediate, absolute increase of 39.6% (95% confidence interval: 26.0% to 53.1%) in the proportion resulting in admission; admission rates declined in subsequent months. Pandemic onset was not associated with significant changes in the number of visits for mental health conditions or length of stay. CONCLUSIONS: Pediatric ED visits for suicide or self-harm increased at a significant rate during the coronavirus disease 2019 pandemic and a greater proportion resulted in hospitalization, highlighting the acute mental health needs of rural-residing children.

[Limitations of the Xpert-MTB/RIF® assay in the initial diagnosis of tuberculosis in the context of a rural hospital in Ethiopia]. / Limitaciones del ensayo Xpert-MTB/RIF® en el diagnóstico inicial de tuberculosis en el contexto de un hospital rural en Etiopia.

OBJECTIVE: To evaluate the implementation of Xpert-MTB/RIF®, as an early diagnosis technique, in a rural area of Ethiopia. METHODS: Data were retrospectively collected from those patients over 13 years of age who were requested to take the Xpert MTB/RIF® test in a rural hospital located 45 km from the reference laboratory, during the first 3 years of its implementation (2015, April -2018, April). RESULTS: A total of 306 patients older than 13 years were evaluated, in 85 (27.8%) there was an error in the processing of the test and the result was not obtained. Of the 221 samples with results, the median time between obtaining the sample and receiving the result was 21 days and 42 of them were positive (19%, 95% CI: 14.2-24.9%). The sample with the highest diagnostic yield was adenopathy (88.8%; [8/9]; p<0.001). CONCLUSIONS: There are more bacteriological diagnoses with Xpert-MTB/RIF®, but with a delay in obtaining the result and its main objective, which is early diagnosis, is not achieved.

What Operations Should a Modern Rural Surgeon Do?

Rural patients have fewer complications and deaths, shorter hospital stay, and less resource utilization than their urban counterparts. They also tend to have fewer chronic illnesses; this reflects a system working as intended, with high-risk patients transferred to better-resourced institutions, while others receive surgical care closer to home. Deciding which operations a modern rural surgeon should-and shouldn't-perform starts with the question "Who decides?" Government, insurers, hospitals, surgeons, and patients are all stakeholders, with a vested interest in the answer.Rural hospitals depend on surgeons for their financial existence, and rural surgeons need hospitals to function. The closure of rural hospitals throughout the country threatens the future of rural surgery. Without surgeons, rural patients will die unnecessarily. During the first COVID surge, patients died from such basic surgical emergencies as small bowel obstruction, when tertiary referral hospitals were full. Rural surgeons are essential in providing timely care of the injured patient; even today, patients die in isolated facilities from treatable injuries from lack of a surgeon who can do a splenectomy, or tube thoracostomy for traumatic pneumothorax, for example.Recruitment of rural surgeons requires identifying interested trainees, often from rural backgrounds, and a defined residency curriculum with emphasis on endoscopy and vascular surgery plus basic gynecology, obstetrics, urology, and orthopedics. Financial incentives & credentials support are also essential for the new rural surgeon. We need to develop many more focused rural surgery programs, and quickly, before the possibility of a broadly skilled rural surgeon in the USA evaporates.

The bystander effect: Impact of rural hospital closures on the operations and financial well-being of surrounding healthcare institutions.

INTRODUCTION: There is presently a rural hospital shortage in the United States with 180 closures since 2005 and hundreds of institutions in financial peril. Although the hospital closure phenomenon is well-established, less is known about the spillover impact on the operations and financial wellbeing of surrounding hospitals. This preliminary study quantified how discrete rural hospital closures impact institutions in their regional proximity, finding a significant increase in inpatient admissions and emergency department visits for these "bystander hospitals". METHODS: Using a repository of rural hospital closures collected by the UNC Sheps Center for Health Services Research, we identified closures over the past 15 years. Criteria for inclusion were hospitals that had been fully closed between 2005-2016 and with >25-bed capacity. We then designated surrounding hospitals within a 30-mile radius of each closed hospital as "bystander hospitals." We examined the average rate-of-change for inpatient admissions and emergency department visits in surrounding hospitals both two years before and after relevant hospital closures. RESULTS: We identified 53 hospital closures and 93 bystander hospitals meeting our criteria during the study period. With respect to geographic distribution, 66% of closures were in the Southern US, including 21% in Appalachia. Average emergency department visits increased by 3.59% two years prior to a hospital's closure; however, at two years post-closure the average rate of increase rose to 10.22% (F (4,47) = 2.77, p = 0.0375). Average bystander hospital admissions fell by 5.73% in the two years preceding the hospital closure but increased 1.17% in the two years after (F (4,46) = 3.05, p = 0.0259). CONCLUSION: These findings predict a daunting future for rural healthcare. While previous literature has described the acute effects hospital closures have on communities, this study suggests a significant spillover effect on hospitals within the geographic region and a cyclical process at play in the rural healthcare sector. In the absence of significant public health assistance in regions affected by closures, poor health outcomes, including "diseases of despair," are likely to continue proliferating, disproportionately affecting the most vulnerable. In the COVID-19 era, it will be especially necessary to focus on hospital closures given increased risk of maintaining solvency due to delayed and deferred care atop already tight margins.

Telestewardship programs support clinical care and improve fiscal outcomes across the continuum through partnership between hospitals and health systems: A systematic review.

PURPOSE: A systematic review was performed to determine if remote stewardship (telestewardship) provides clinical and fiscal benefit and is a feasible alternative to local stewardship programs. SUMMARY: Antibiotic resistance is an increasingly important national and global threat. US regulators have made antimicrobial stewardship programs a condition of participation in federally funded healthcare programs, and stewardship programs are surveyed during accreditation visits. Small and rural hospitals are at risk for stewardship noncompliance because lack of resources limits comprehensive stewardship program implementation. Remote stewardship programs are established to remedy this area of partial compliance. To characterize the impact of remote stewardship on selected clinical and fiscal outcomes, PubMed was searched for studies involving telestewardship that reported data on antimicrobial utilization, patient length of stay, mortality, bacterial susceptibility, hospital-acquired Clostridioides difficile infection (HA-CDI), and/or antimicrobial costs. A systematic approach was used to screen study titles, abstracts, and content and data extracted. Study quality was analyzed using Cochrane risk-of-bias assessment tools. Fourteen studies were included in the final review. Collectively, the antimicrobial utilization data was positive, with utilization of targeted antimicrobials decreasing after telestewardship implementation. Mixed (both positive and neutral) results were found for patient length of stay, mortality, and HA-CDI rates. Fiscal outcomes were consistently positive. CONCLUSION: Based on the reviewed evidence, remote antimicrobial stewardship programs may aid in the more judicious use of antimicrobials by decreasing utilization rates. More studies are needed to clarify patient-oriented outcomes. Telestewardship has positive effects in terms of cost savings, although savings may be offset by the structure of the program.

Rural hospital bed management practices during influenza season.

INTRODUCTION: Rural health services face greater challenges in managing infectious patients due to lack of specialty beds and longer lengths of stay. The pressures of seasonal influxes of influenza patients with a heavy burden of chronic disease and an ageing population result in an increased demand for hospital beds. During these peak periods it is common for rural hospitals to experience bed block. The result is that patients may be placed into any available bed or ward at the time, increasing the need for transfer and the risk of spreading hospital-acquired respiratory illnesses to other patients and staff across the hospital. This further exacerbates bed block, with patients then requiring more specialised treatment and longer lengths of stay. This places additional strain on already existing workforce shortages and limited resources that must accommodate higher-than-normal patient loads. The objective of this study was to examine rural hospital bed management practices with a focus on the transfer of patients who are actively diagnosed with influenza (either on admission or during their stay in hospital) and to investigate the association of increased bed movement with the rate of nosocomial transmission and staff workload. METHODS: The rates of patients admitted to a rural hospital in New South Wales, Australia, during the yearly peak influenza season (July to September) during 2016-2019 with either community-acquired or hospital-acquired influenza were examined using an infection control surveillance program. Bed management practices related to these inpatients were audited to examine their contribution towards nosocomial transmissions and staff workload during these periods. RESULTS: A total of 229 patients presented to this hospital with an influenza diagnosis over the study period and generated 175 bed transfers. Forty percent of community-acquired and 70% of hospital-acquired influenza inpatients experienced one or more intrahospital bed transfers during their active infection period. Half of all bed transfers involved patients being transferred to another ward (interward) and the other half consisted of those transferred within the same ward (intraward). These transfers impacted staff workload, requiring a total of 245 extra hours from nursing and cleaning staff to facilitate - time not included when allocating staff at the start of each shift. CONCLUSION: Findings from this study indicate that there is no active strategy for influenza containment during high-occupancy periods for this rural facility. This resulted in multiple bed transfers occurring during the active phase of influenza infection. This then led to an exacerbation of bed block and thus further inappropriate placement of newly admitted patients. The development of an optimal bed management plan for future surges of influenza and other highly infectious respiratory illnesses is essential to reduce nosocomial infection and staff workload, especially given the limited resources available in rural areas compared to metropolitan centres.

Impact of COVID-19 on the Level of Work Engagement of Nurses at a Small, Rural Hospital.

Background There is a severe nursing shortage. Nurses are experiencing pressure, stress, and negative effects on their mental health from the ongoing pandemic. Understanding how their work engagement has been affected is essential. Method A descriptive, cross-sectional design was used. A survey plus the Fear of COVID-19 scale, the Utrecht Work Engagement Scale, and three open-ended questions were used. Results Participants (n = 107) were mostly female, had a bachelor degree or higher, worked full-time, had access to personal protective equipment, and followed Centers for Disease Control and Prevention guidelines. Receiving education about COVID-19 and feeling that the hospital provided adequate education were correlated with engagement scores. The type of education significantly correlated with engagement scores, with in-service education having the highest scores. Conclusion Understanding the needs of nurses during a pandemic is critical to engaging and retaining them. This study provides information that may be beneficial in future health crises. [J Contin Educ Nurs. 2022;53(4):157-164.].

Legislation Increased Medicare Telestroke Billing, But Underbilling And Erroneous Billing Remain Common.

In the Furthering Access to Stroke Telemedicine (FAST) Act, passed as part of a budget omnibus in 2018, Congress permanently expanded Medicare payment for telemedicine consultations for acute stroke ("telestroke") from delivery only in rural areas to delivery in both urban and rural areas, effective January 1, 2019. Using a controlled time-series analysis, we found that one year after FAST Act implementation, billing for Medicare telestroke increased substantially in emergency departments at both directly affected urban hospitals and indirectly affected rural hospitals. However, at that time only a minority of hospitals with known telestroke capacity had ever billed Medicare for that service, and there was substantial billing inconsistent with Medicare requirements. As Congress considers options for Medicare telemedicine payment after the COVID-19 pandemic, our findings, which are consistent with confusion among providers regarding telemedicine billing requirements, suggest that simplified payment rules would help ensure that expanded reimbursement achieves its intended impact.

Staff perceptions of the management of mental health presentations to the emergency department of a rural Australian hospital: qualitative study.

INTRODUCTION: Current research demonstrates higher prevalence of mental health related emergency department (ED) presentations in rural areas, despite similar overall prevalence of these conditions in rural and metropolitan contexts. This stems from shortages in availability of specialised mental health professionals, greater stigma against mental illness, greater socioeconomic disadvantages, and access to means of self-harm in rural regions. Little is known, however, about the specific characteristics of mental health presentations to rural emergency departments (EDs) in Australia. Additionally, studies have shown that ED staff feel uncomfortable managing mental health presentations to ED due to factors such as lack of confidence and stigma against mental illnesses. AIM: This qualitative study sought to examine ED staff perceptions regarding the management of mental health presentations in a rural Australian ED. METHODS: A qualitative study design was used, incorporating semi-structured interviews of current ED staff. Ten interviews were conducted in person or over the phone by two researchers and thematically analysed to draw out key themes from the data. RESULTS: Staff perceived deficiencies in availability of mental health expertise, de-escalation, and referral pathways as major barriers to effective patient management. These factors contributed to increased retention of mental health patients in ED due to uncertainties regarding their definitive care. Despite acknowledging the value of practical experience with mental health presentations as the best way of increasing clinician confidence, staff expressed a desire for more face-to-face training to better equip them to respond to mental health presentations. CONCLUSION: A combination of departmental and hospital-wide issues in conjunction with individual staff attitudes regarding mental health conditions contributes to issues in mental health patient care in this ED. In particular, limited training in mental health and resources available to ED staff affects confidence in managing mental health presentations and contributes to prolonged time to definitive treatment.

Impact of the early COVID-19 pandemic on outcomes in a rural Ugandan neonatal unit: A retrospective cohort study.

BACKGROUND: During the early COVID-19 pandemic travel in Uganda was tightly restricted which affected demand for and access to care for pregnant women and small and sick newborns. In this study we describe changes to neonatal outcomes in one rural central Ugandan newborn unit before and during the early phase of the COVID-19 pandemic. METHODS: We report outcomes from admissions captured in an electronic dataset of a well-established newborn unit before (September 2019 to March 2020) and during the early COVID-19 period (April-September 2020) as well as two seasonally matched periods one year prior. We report excess mortality as the percent change in mortality over what was expected based on seasonal trends. FINDINGS: The study included 2,494 patients, 567 of whom were admitted during the early COVID-19 period. During the pandemic admissions decreased by 14%. Patients born outside the facility were older on admission than previously (median 1 day of age vs. admission on the day of birth). There was an increase in admissions with birth asphyxia (22% vs. 15% of patients). Mortality was higher during COVID-19 than previously [16% vs. 11%, p = 0.017]. Patients born outside the facility had a relative increase of 55% above seasonal expected mortality (21% vs. 14%, p = 0.028). During this period patients had decreased antenatal care, restricted transport and difficulty with expenses and support. The hospital had difficulty with maternity staffing and supplies. There was significant community and staff fear of COVID-19. INTERPRETATION: Increased newborn mortality during the early COVID-19 pandemic at this facility was likely attributed to disruptions affecting maternal and newborn demand for, access to and quality of perinatal healthcare. Lockdown conditions and restrictions to public transit were significant barriers to maternal and newborn wellbeing, and require further focus by national and regional health officials.

Barriers and Opportunities for Sustainable Hand Hygiene Interventions in Rural Liberian Hospitals.

Hand hygiene is central to hospital infection control. During the 2014-2016 West Africa Ebola virus disease epidemic in Liberia, gaps in hand hygiene infrastructure and health worker training contributed to hospital-based Ebola transmission. Hand hygiene interventions were undertaken post-Ebola, but many improvements were not sustainable. This study characterizes barriers to, and facilitators of, hand hygiene in rural Liberian hospitals and evaluates readiness for sustainable, locally derived interventions to improve hand hygiene. Research enumerators collected data at all hospitals in Bong and Lofa counties, Liberia, in the period March-May 2020. Enumerators performed standardized spot checks of hand hygiene infrastructure and supplies, structured observations of hand hygiene behavior, and semi-structured key informant interviews for thematic analysis. During spot checks, hospital staff reported that handwashing container water was always available in 89% (n = 42) of hospital wards, piped running water in 23% (n = 11), and soap in 62% (n = 29). Enumerators observed 5% of wall-mounted hand sanitizer dispensers (n = 8) and 95% of pocket-size dispensers (n = 53) to be working. In interviews, hospital staff described willingness to purchase personal hand sanitizer dispensers when hospital-provided supplies were unavailable. Low-cost, sustainable interventions should address supply and infrastructure-related obstacles to hospital hand hygiene improvement.

Assessment of laparoscopic instrument reprocessing in rural India: a mixed methods study.

BACKGROUND: Laparoscopy is a minimally-invasive surgical procedure that uses long slender instruments that require much smaller incisions than conventional surgery. This leads to faster recovery times, fewer post-surgical wound infections and shorter hospital stays. For these reasons, laparoscopy could be particularly advantageous to patients in low to middle income countries (LMICs). Unfortunately, sterile processing departments in LMIC hospitals are faced with limited access to equipment and trained staff which poses an obstacle to safe surgical care. The reprocessing of laparoscopic devices requires specialised equipment and training. Therefore, when LMIC hospitals invest in laparoscopy, an update of the standard operating procedure in sterile processing is required. Currently, it is unclear whether LMIC hospitals, that already perform laparoscopy, have managed to introduce updated reprocessing methods that minimally invasive equipment requires. The aim of this study was to identify the laparoscopic sterile reprocessing procedures in rural India and to test the effectiveness of the sterilisation equipment. METHODS: We assessed laparoscopic instrument sterilisation capacity in four rural hospitals in different states in India using a mixed-methods approach. As the main form of data collection, we developed a standardised observational checklist based on reprocessing guidelines from several sources. Steam autoclave performance was measured by monitoring the autoclave cycles in two hospitals. Finally, the findings from the checklist data was supported by an interview survey with surgeons and nurses. RESULTS: The checklist data revealed the reprocessing methods the hospitals used in the reprocessing of laparoscopic instruments. It showed that the standard operating procedures had not been updated since the introduction of laparoscopy and the same reprocessing methods for regular surgical instruments were still applied. The interviews confirmed that staff had not received additional training and that they were unaware of the hazardous effects of reprocessing detergents and disinfectants. CONCLUSION: As laparoscopy is becoming more prevalent in LMICs, updated policy is needed to incorporate minimally invasive instrument reprocessing in medical practitioner and staff training programmes. While reprocessing standards improve, it is essential to develop instruments and reprocessing equipment that is more suitable for resource-constrained rural surgical environments.

Self-reported maternal handwashing knowledge and behaviours observed in a rural hospital in Pakistan.

BACKGROUND: Under-5 mortality remains high in developing nations despite decades of multilateral cooperation to reduce it. Diarrhoea contributes up to 15% of all mortality in this age group. Frequently reported barriers include poor hygiene, lack of sanitation facilities, and negligible public health education on the issue. Interventions such as Water, Sanitation, and Hygiene (WASH) could complement modern public health approaches with renewed vigour in wake of SARS-CoV-II (COVID-19). AIMS: We sought to assess maternal hand hygiene and ability to prepare oral rehydration solution at home. METHODS: In addition to the ability to prepare oral rehydration solution at home, this cross-sectional study, carried out at the Sughra Shafi Medical Complex, Narowal during 2017, compared knowledge, attitudes and behaviours of mothers of children with diarrhoea to those shoes children did not have diarrhoea. RESULTS: 511 (48%) children < 5 years were diagnosed with diarrhoea irrespective of household location. Among 1065 accompanying mothers recruited for this study, only 130 (12%) were able to prepare ORS at home and 288 (27%) qualified as regular hand-washers according to the criteria. Just over half of the respondents consumed untreated water supplied via a nearby canal. Almost 80% of neighbourhoods lacked waste collection. CONCLUSION: These findings informed management of frequent child diarrhoea cases presented at the hospital with locally relevant preventive knowledge. They are also expected to be useful in educating mothers on regular handwashing and the preparation of ORS as home-based interventions.

COVID-19 in a rural health system in New York - case series and an approach to management.

INTRODUCTION: Many rural hospitals and health systems in the USA lack sufficient resources to treat COVID-19. St Lawrence Health (SLH) developed a system for managing inpatient COVID-19 hospital admissions in St Lawrence County, an underserved rural county that is the largest county in New York State. METHODS: SLH used a hub-and-spoke system to route COVID-19 patients to its flagship hospital. It further assembled a small clinical team to manage admitted COVID-19 patients and to stay abreast of a quickly changing body of literature and standard of care. A review of clinical data was completed for patients who were treated by SLH's inpatient COVID-19 treatment team between 20 March and 22 May 2020. RESULTS: Twenty COVID-19 patients were identified. Sixteen patients (80%) met National Institutes of Health criteria for severe or critical disease. One patient died. No patients were transferred to other hospitals. CONCLUSION: During the first 2 months of the pandemic, the authors were able to manage hospitalized COVID-19 patients in their rural community. Development of similar treatment models in other rural areas should be considered.