CORONAcrisis-An Observational Study on the Experience of Healthcare Professionals in a University Hospital during a Pandemic Emergency.

The Coronavirus disease 2019 (COVID-19) pandemic continues to affect millions worldwide and has posed unique challenges to healthcare professionals. Caring for patients during a pandemic may have negative impacts on their mental health. We describe the first part of a study using a mixed-method sequential explanatory design (QUANT→QUAL). This quantitative part examines the experiences of healthcare professionals during the pandemic in a University Hospital in Italy. We performed a cross-sectional hospital-based survey involving all healthcare professionals between 19 May 2020 and 3 June 2020. Perceived Stress Scale, Patient Health Questionnaire, and General Anxiety Disorder scores were calculated, in order to assess how the pandemic emergency changed the occupational and social habits of the healthcare professionals. The mean age of the 275 respondents was 47 years and females accounted for 80.2%. A total of 29.8% had a Perceived Stress Scale (PSS) score ≥25, 22.9% scored ≥15 on the Patient Health Questionnaire (PHQ-9) scale, and 17.1% scored ≥15 on the General Anxiety Disorder (GAD) scale. Stress symptoms were mostly manifested for interviewees over 55, females, those who live far from their family, those who have only one child, and those who had a qualification lower than high school or who had a medical specialization. Our findings show a relevant level of psychological distress, anxiety, and depression in up to 30% of the sample, highlighting a significant psychological burden in all professionals.

Diagnostic anticipation to reduce emergency department length of stay: a retrospective cohort study in Ferrara University hospital, Italy.

BACKGROUND: Emergency Department (ED) crowding reduces staff satisfaction and healthcare quality and safety, which in turn increase costs. Despite a number of proposed solutions, ED length of stay (LOS) - a main cause of overcrowding - remains a major issue worldwide. This retrospective cohort study was aimed at evaluating the effectiveness on ED LOS of a procedure called "Diagnostic Anticipation" (DA), which consisted in anticipating the ordering of blood tests by nurses, at triage, following a diagnostic algorithm approved by physicians. METHODS: In the second half of 2019, the ED of the University Hospital of Ferrara, Italy, adopted the DA protocol on alternate weeks for all patients with chest pain, abdominal pain, and non-traumatic bleeding. A retrospective cohort study on DA impact was conducted. Using ED electronic data, LOS independent predictors (age, sex, NEDOCS and Priority Color Code, imaging tests, specialistic consultations, hospital admission) were evaluated through multiple regression. RESULTS: During the weeks when DA was adopted, as compared to control weeks, the mean LOS was shorter by 18.2 min for chest pain, but longer by 15.7 min for abdominal pain, and 33.3 for non-traumatic bleeding. At multivariate analysis, adjusting for age, gender, triage priority, specialist consultations, imaging test, hospitalization and ED crowding, the difference in visit time was significant for chest pain only (p < 0.001). CONCLUSIONS: The impact of DA varied by patients' condition, being significant for chest pain only. Further research is needed before the implementation, estimating the potential proportion of inappropriate blood tests and ED crowding status.

Predictors of severe or lethal COVID-19, including Angiotensin Converting Enzyme inhibitors and Angiotensin II Receptor Blockers, in a sample of infected Italian citizens.

AIMS: This retrospective case-control study was aimed at identifying potential independent predictors of severe/lethal COVID-19, including the treatment with Angiotensin-Converting Enzyme inhibitors (ACEi) and/or Angiotensin II Receptor Blockers (ARBs). METHODS AND RESULTS: All adults with SARS-CoV-2 infection in two Italian provinces were followed for a median of 24 days. ARBs and/or ACEi treatments, and hypertension, diabetes, cancer, COPD, renal and major cardiovascular diseases (CVD) were extracted from clinical charts and electronic health records, up to two years before infection. The sample consisted of 1603 subjects (mean age 58.0y; 47.3% males): 454 (28.3%) had severe symptoms, 192 (12.0%) very severe or lethal disease (154 deaths; mean age 79.3 years; 70.8% hypertensive, 42.2% with CVD). The youngest deceased person aged 44 years. Among hypertensive subjects (n = 543), the proportion of those treated with ARBs or ACEi were 88.4%, 78.7% and 80.6% among patients with mild, severe and very severe/lethal disease, respectively. At multivariate analysis, no association was observed between therapy and disease severity (Adjusted OR for very severe/lethal COVID-19: 0.87; 95% CI: 0.50-1.49). Significant predictors of severe disease were older age (with AORs largely increasing after 70 years of age), male gender (AOR: 1.76; 1.40-2.23), diabetes (AOR: 1.52; 1.05-2.18), CVD (AOR: 1.88; 1.32-2.70) and COPD (AOR: 1.88; 1.11-3.20). Only gender, age and diabetes also predicted very severe/lethal disease. CONCLUSION: No association was found between COVID-19 severity and treatment with ARBs and/or ACEi, supporting the recommendation to continue medication for all patients unless otherwise advised by their physicians.

Usuários frequentes dos serviços de emergência: um estudo observacional de métodos mistos na Emilia-Romanha (Itália) / Frequent users of the emergency department: a mixed-methods observational and retrospective study in Emilia-Romagna (Italy) / Usuarios frecuentes de los servicios de emergencia: un estudio de observación retrospectivo y de métodos mixtos en la región de Emilia-Romagna (Italia)

HISTÓRICO. A superlotação dos serviços de emergência (SE) representa uma grande preocupação na Itália. Os usuários frequentes (UF) contribuem para a superlotação, desperdiçando recursos de saúde. OBJETIVO. Descrever as características dos UF e avaliar a confiabilidade dos sistemas de informação do SE. Desenho. Estudo retrospectivo observacional unicêntrico. MÉTODOS. Análise quali-quantitativa de prontuários médicos de admissões de UF para SE em um período de 15 meses em um hospital de ensino na Itália. RESULTADOS. 1.766 UF acessaram o SE, realizando 11.842 admissões. Os códigos verde e branco foram mais frequentes (n = 9,065; 76,5%). As condições agudas prevaleceram entre os motivos da admissão. A análise qualitativa mostrou que os UF estiveram sobrecarregados principalmente com condições crônicas e destacou o papel do SE na sua administração. DISCUSSÃO. Os UF sofrem de condições múltiplas e crônicas, que não são capturadas pelo sistema de informação do SE. CONCLUSÕES. A adoção de uma abordagem centrada no paciente, orientada para condições crônicas, pode resultar em informações mais ricas e melhor gerenciamento dos UF.

BACKGROUND. The overcrowding of Emergency Departments (EDs) represents a major concern in Italy. Frequent users (FUs) contribute to overcrowding, wasting health care resources. OBJECTIVE. To describe the characteristics of FUs and to evaluate the reliability of the ED information systems. DESIGN. An observational single-centre retrospective study.METHODS. A quali-quantitative analysis of medical records from FU admissions to the ED in a 15-month period at a Teaching Hospital in Italy. RESULTS. 1,766 FUs accessed the ED, totalizing 11,842 admissions. The green and white codes were the most frequent ones (n=9,065; 76.5%). Acute conditions prevailed among the reasons for admission. The qualitative analysis showed that FUs were mainly burdened with chronic conditions and highlighted the role of the ED in managing them. DISCUSSION. FUs suffer from mltiple and chronic conditions, which are not captured by the ED's information system. CONCLUSIONS. The adoption of a patient-centred approach oriented towards chronic conditions could result in richer information and better management of FUs.

ANTECEDENTES. La saturación de los Servicios de Emergencia (SE) representa una gran preocupación en Italia. Los usuarios frecuentes (UF) contribuyen a dicha saturación, desperdiciando recursos sanitarios. OBJETIVO. Describir las características de los UF y evaluar la confiabilidad de los sistemas de información de los SE. DISEÑO. Estudio retrospectivo unicéntrico observacional. MÉTODOS. Análisis cuali-cuantitativo de las historias clínicas de los ingresos de los UF a los SE en un período de 15 meses en un Hospital Universitario de Italia. RESULTADOS. Un total de 1.766 UF accedieron a los SE, notificándose una cantidad de 11.842 ingresos. Los códigos verde y blanco fueron los más frecuentes (n=9.065, 76,5%). Entre los motivos de ingreso predominaron las afecciones agudas. El análisis cualitativo demostró que los UF padecían principalmente enfermedades crónicas y destacó el rol de los SE en el manejo de las mismas. DISCUSIÓN. Los UF padecen enfermedades múltiples y crónicas, que no son diagnosticadas por el sistema de información de los SE. CONCLUSIONES. Adoptar un enfoque centrado en el paciente y orientado a las condiciones crónicas podría dar lugar a información más detallada y a una mejor gestión de los UF.

Do health care professionals' perceptions help to measure the degree of overcrowding in the emergency department? A pilot study in an Italian University hospital.

BACKGROUND: Overcrowding in emergency departments (EDs) is internationally recognized as one of the greatest challenges to healthcare provision. Numerous studies have highlighted the ill-effects of overcrowding, including increased length of stay, mortality and cost per admission. This study measures overcrowding in EDs through health care professionals' perceptions of it, comparing the results with the NEDOCS score, an objectively validated measurement tool and describing meaningful tools and strategies used to manage ED overcrowding. METHODS: This single-centre prospective, observational, pilot study was conducted from February 19th to March 7th, 2018 at the ED in the University Hospital of Ferrara, Italy to measure the agreement of the NEDOCS, comparing objective scores with healthcare professionals' perception of overcrowding, using the kappa statistic assessing linear weights according to Cohen's method. The tools and strategies used to manage ED overcrowding are described. RESULTS: Seventy-two healthcare professionals (66.1% of 109 eligible subjects) were included in the analyses. The study obtained a total of 262 surveys from 23 ED physicians (31.9%), 31 nurses (43.1%) and 18 nursing assistants (25.0%) and a total of 262 NEDOCS scores. The agreement between the NEDOCS and the subjective scales was poor (k = 0.381, 95% CI 0.313-0.450). CONCLUSIONS: The subjective health care professionals' perceptions did not provide an adequate real-time measure of the current demands and capacity of the ED. A more objective measure is needed to make quality decisions about health care professional needs and the ability to manage patients to ensure the provision of proper care.

Daylight Saving Time and Acute Myocardial Infarction: A Meta-Analysis.

BACKGROUND: The available evidence on the effects of daylight saving time (DST) transitions on major cardiovascular diseases is limited and conflicting. We carried out the first meta-analysis aimed at evaluating the risk of acute myocardial infarction (AMI) following DST transitions. METHODS: We searched cohort or case-control studies evaluating the incidence of AMI, among adults (≥18 y), during the weeks following spring and/or autumn DST shifts, versus control periods. The search was made in MedLine and Scopus, up to 31 December 2018, with no language restriction. A summary odds ratio of AMI was computed after: (1) spring, (2) autumn or (3) both transitions considered together. Meta-analyses were also stratified by gender and age. Data were combined using a generic inverse-variance approach. RESULTS: Seven studies (>115,000 subjects) were included in the analyses. A significantly higher risk of AMI (Odds Ratio: 1.03; 95% CI: 1.01⁻1.06) was observed during the two weeks following spring or autumn DST transitions. However, although AMI risk increased significantly after the spring shift (OR: 1.05; 1.02⁻1.07), the incidence of AMI during the week after winter DST transition was comparable with control periods (OR 1.01; 0.98⁻1.04). No substantial differences were observed when the analyses were stratified by age or gender. CONCLUSION: The risk of AMI increases modestly but significantly after DST transitions, supporting the proposal of DST shifts discontinuation. Additional studies that fully adjust for potential confounders are required to confirm the present findings.

Patient and Health Care Professional Perspectives: A Case Study of the Lung Cancer Integrated Care Pathway.

INTRODUCTION: The purpose of this study was to evaluate the perception of the quality of care, considering both patient experience and health care professionals' perceptions as well as patient outcome measures of an integrated lung cancer pathway. METHODS: A cross-sectional study was conducted in 2016 at Ferrara University Hospital, Italy. OPportunity for Treatment In ONcology (OPTION) questionnaires were administered to 77 patients, and the Care Process Self-Evaluation Tool (CPSET) questionnaires were given to 38 health care professionals. The effectiveness of the pathway was evaluated by analysing the tool's positive impact on lung cancer surgery volume and 30-day mortality. RESULTS: Seventy-seven patients were enrolled, and 38 health care professionals assessed the CPSET questionnaire. The highest scores were related to "respect" (100%), "satisfaction" (98.7%), and "trust" (97.4%) on the OPTION and to "patient-focused vision" (97.2%) and "patient engagement" (94.4%) on the CPSET. The lowest scores were related to "information" (26%) and "cooperation with general practitioner" (17.6%) on the OPTION and "cooperation between the hospital and primary care" (23.5%) for the CPSET. The outcomes analysis shows an increase in the volume of activity and a decrease in 30-day mortality after pathway implementation. DISCUSSION: The lung cancer pathway is a patient-centred intervention that enables care to be shaped for patient needs in order to improve the quality and efficiency of service and clinical outcome.

Validation of the OPportunity for Treatment In ONcology (OPTION) questionnaire measuring continuity of care.

Increasing efforts are ongoing to deliver effective cancer care through integrated networks of services. Measuring patients' experience of care is essential to identify problematic areas that require organisational adjustments. The aim of the present study was to examine the validity of OPTION questionnaire, designed to measure patient's perceived continuity of care across different phases of their care pathway. The study was carried at the Institute for Cancer Treatment and Research, Meldola and the oncology departments of the Local Health Authority of Romagna, Italy. Principal component analysis (PCA) was performed to identify factors underlying patients' perception of continuity of care. Factor scores were compared between patients with or without a care coordinator using Mann-Whitney test. The study sample consisted of 214 patients with breast or colorectal cancer, with a mean age of 62.3 years. Most patients identified the oncologist as their care coordinator. Five factors were extracted using PCA: (1) "trustful relationship with health care staff," (2) "information on care pathway," (3) "information on changes related to the illness," (4) "feelings of abandonment" and (5) "collaboration among health care professionals." The scores of factors 2 and 3 were significantly higher among those with a care coordinator. The OPTION questionnaire is a reliable instrument that can help clinicians and administrative stakeholder target efforts and resources in the pursuit of quality of care.

[Continuity of care in oncology. Quantitative analysis of data from patients treated in two different settings in Emilia--Romagna.] / La continuità delle cure in oncologia. Un'analisi quantitativa dell'esperienza dei pazienti in due realtà emiliano-romagnole.

INTRODUCTION: In order to ensure high-quality treatment for patients with cancer it is vital to implement organisational models (pathways and networks) and that guarantee continuity of care. Appropriate assessment tools that promote the evaluation and analysis of care pathways from the patients' perspective are available. Hence the aim of this study was to verify whether or not the coordination between the various stages and care providers in a cancer treatment pathway is perceived by our patients. METHODS: Patients being treated for cancer of the lung, breast or colorectal tract by the Ferrara University Hospital (FUH) and the wider Romagna regional health service (RRHS), Italy, were administered the OPTION evaluation questionnaire. Univariate descriptive statistics of patients' sociodemographic features and care pathways were generated, and means and standard deviations were calculated for patient responses to OPTION items 1-19 on continuity of care throughout their treatment pathway. RESULTS: Responses from 341 patients (37.2 % treated by the FUH and 62.8% by the RRHS) were obtained. All mean scores provided for items 1-19 were above 4 on a Likert scale of 1-5, showing that the patients' perception of the continuity of their care was very positive on the whole. The highest mean scores were given for items regarding their emotional experience, while the lowest were given for those regarding information and integration with the GPs. DISCUSSION AND CONCLUSIONS: Organisational efforts to promote patient-centred continuity of oncological care improved the experience of patients in our sample. Our data suggest that integration with the GPs still remains a problem, both from an organisational standpoint and in the perception of the patient being treated for cancer at one of the facilities under investigation. Although our findings are non-controlled and not generalisable to other geographical areas, they do show how such tools can be used to monitor and analyse patient's experience with continuity of care with a view to continual improvement in care provision.

[Patient engagement in health care. New perspectives in oncology]. / La partecipazione della persona al percorso di cura.Nuove prospettive in oncologia.

During the last decade, an increasing number of studies has been focused on patient engagement programs through which patients can be effective and informed managers of their health and health care. Based on our recent review, studies examining the nature of patient participation in service planning have found that most activities are limited to various forms of consultation, rather than the interactive partnerships advocated for treatment decision-making. Despite this clear evidence, many people want to play an active role in their own healthcare. They want to know how to protect and improve their health when they are well; and when they are ill, they want information about treatment options and likely outcomes. Consistent with these considerations, this paper intends to underline the importance to engage patients, to describe some different interventions to make patient effective informed; and, finally, to show some pilot projects from around the world, with a special focus on cancer care service of Ontario.

Is a clear benefit in survival enough to modify patient access to the surgery service? A retrospective analysis in a cohort of gastric cancer patients.

BACKGROUND: Surgery has become an important tool for cancer treatment, requiring many available resources and a good organization of the surgery service. The aim of this study was to provide robust data for policymakers on the impact of hospital volume on survival, taking into account different sources of information. METHODS: We performed a retrospective study in a cohort of patients with gastric cancer submitted to partial or total gastrectomy. Data for the analysis were retrieved from regional administrative databases, the regional death registry, and histological reports. The main outcome measures were operative mortality and long-term survival. The associations between hospital volume and risk of mortality were calculated using a Cox multiple regression analysis. RESULTS: The estimated relationship between operative mortality and volume was not statistically significant. Conversely, high-volume hospitals had an increased likelihood of long-term survival compared to low-volume institutions: hazard ratio 0.79 (95% confidence interval, 0.66-0.94, p = 0.01). The percentage variation between crude and adjusted HRs using only administrative data or administrative and histological data was very small. However, the combined use of administrative and clinical data provided a more accurate model for estimating risk-adjusted mortality. CONCLUSIONS: A positive association between hospital volume and survival was evident for long-term outcome after adjusting for patient and tumor confounding. Moreover, the patient's choice of hospital was not guided by specific care pathways or screening programs, and prognosis was not poorer for patients in high-volume hospitals. These findings suggest that there is leeway for improving access to surgery for gastric cancer patients.

Sociodemographic, clinical and organisational factors associated with delayed hospital discharges: a cross-sectional study.

BACKGROUND: Evidence from studies conducted in Western countries indicates that a significant proportion of hospital beds are occupied by patients who experience a delayed hospital discharge (DHD). However, evidence about this topic is lacking in Italy, and little is known on the patients' and organisational characteristics that influence DHDs. Therefore, we carried out a survey in all the hospitals of a Northern Italian region to analyse the prevalence and the determinants of DHD. METHODS: A cross-sectional study was carried out during an index period of 15 days in 256 operative units in Emilia-Romagna, a Northern Italian region with 4.4 million inhabitants, to identify patients medically fit for discharge but still hospitalised. The characteristics of these patients (n = 510) were compared with all the other patients (n = 5,815) hospitalised in the same operative units during the index period using multilevel logistic regression models. RESULTS: The one-day prevalence of DHD was 8.1%. More than half of DHD patients (52.7%) waited to access long-term/rehabilitation units or residential care homes, 16.7% experienced a delay for family-related reasons, and 14.5% were waiting to be admitted to other rehabilitation services. Among DHD patients hospitalised in long-term/rehabilitation units, 45.3% were waiting to be transferred to residential care homes. Patients' characteristics associated with a higher likelihood of DHD in multilevel logistic regression were older age, provision of intensive care, a diagnosis of dementia, tumours or femoral/shoulder fractures, and a number of comorbidities. Patients hospitalised in long-term/rehabilitation units, as well as in orthopaedics/traumatology units, were significantly more likely to have a DHD compared with patients hospitalised in general surgery units. Moreover, compared with Local Health Authority Hospitals, being hospitalised in Hospital Trusts was associated with a higher likelihood of DHD. CONCLUSIONS: Although the prevalence of DHD in the present study is markedly lower than that reported in the literature, we submit that the DHD problem should be addressed with major organisational innovations, with a special focus on the ageing of the population and epidemiological trends. Organisational changes imply new ways of managing emerging clusters of patients whose needs are not efficiently or effectively met by traditional organisation models and services.