Examining Violaceous Skin Discoloration during the COVID-19 Pandemic: Conducting Research in Resource Scarcity.

OBJECTIVE: To describe the observed patterns and presentations of violaceous discoloration that appeared to be related to the COVID-19 disease process. METHODS: This retrospective observational cohort study included adults who were COVID-19 positive with purpuric/violaceous lesions in pressure-adjacent areas of the gluteus without preexisting pressure injury. Patients were admitted to an ICU at a single quaternary academic medical center between April 1 and May 15, 2020. Data were compiled by review of the electronic health record. The wounds were described by location, tissue type (violaceous, granulation, slough, eschar), wound margin (irregular, diffuse, nonlocalized), and periwound condition (intact). RESULTS: A total of 26 patients were included in the study. Purpuric/violaceous wounds were found predominantly on White (92.3%) men (88.0%) aged 60 to 89 years (76.9%) with a body mass index 30 kg/m2 or higher (46.1%). The majority of wounds were located on the sacrococcygeal (42.3%) and fleshy gluteal regions (46.1%). CONCLUSIONS: Wounds were heterogeneous in appearance (poorly defined violaceous skin discoloration of acute onset), and the patient population had clinical characteristics similar to acute skin failure (eg, concomitant organ failures and hemodynamic instability). Additional larger population-based studies with biopsies may assist in finding patterns related to these dermatologic changes.

Capturing Essentials in Wound Photography Past, Present, and Future: A Proposed Algorithm for Standardization.

GENERAL PURPOSE: To discuss a standardized methodology for wound photography with a focus on aiding clinicians in capturing high-fidelity images. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will be able to:1. Discriminate the components of high-quality wound photography.2. Identify the technological innovations that can augment clinical decision-making capacity.3. Choose strategies that can help clinicians avoid adverse medicolegal outcomes.

According to a 2018 study, chronic wounds affect more than 8 million Americans and impose a substantial economic burden, with costs of care reaching upward of US $30 billion. As demographics in the US shift toward an aging population, these numbers are likely to progressively increase annually. Care of these patients relies heavily on photographic documentation, which catalogs disease progression and informs management decisions. This article elaborates a standardized methodology for wound photography and aims to aid clinicians in capturing high-fidelity images. Technological advancements, notably digital cameras and smart phones, have exponentially improved both the rate and quality of wound photography, but their potential has yet to be fully realized. Despite the indispensable nature of wound photography, literature detailing the photography process remains sparse. The absence of a standardized methodology for wound photography leads to subpar documentation, which ultimately hinders patient care. Further, information regarding medicolegal implications of wound photography remains fragmented and opaque to many clinicians. The authors provide a comprehensive overview of best practices in wound photography, medicolegal considerations, and an overview of emerging technologies. Photographic documentation is indispensable in the management of chronic wounds. Capturing consistent, high-fidelity images requires the adoption of standardized protocols. Emerging technologies, such as three-dimensional imagery, biosensors, and artificial intelligence, are poised to profoundly alter wound photography in the future. However, standardized protocols informed by sound clinical judgment will remain of paramount importance.

Increasing Rates of Prone Positioning in Acute Care Patients with COVID-19.

BACKGROUND: Prone positioning improves mortality in patients intubated with acute respiratory distress syndrome and has been proposed as a treatment for nonintubated patients with COVID-19 outside the ICU. However, there are substantial patient and operational barriers to prone positioning on acute floors. The objective of this project was to increase the frequency of prone positioning among acute care patients with COVID-19. METHODS: The researchers conducted a retrospective analysis of all adult patients admitted to the acute care floors with COVID-19 respiratory failure. A run chart was used to quantify the frequency of prone positioning over time. For the subset of patients assisted by a dedicated physical therapy team, oxygen before and after positioning was compared. The initiative consisted of four separate interventions: (1) nursing, physical therapy, physician, and patient education; (2) optimization of supply management and operations; (3) an acute care prone positioning team; and (4) electronic health record optimization. RESULTS: From March 9, 2020, to August 26, 2020, 176/875 (20.1%) patients were placed in prone position. Among these, 43 (24.4%) were placed in the prone position by the physical therapy team. Only 2/94 (2.1%) eligible patients admitted in the first two weeks of the pandemic were ever documented in prone position. After launching the initiative, weekly frequency peaked at 13/28 (46.4%). Mean oxygen saturation was 91% prior to prone positioning vs. 95.2% after (p < 0.001) in those positioned by physical therapy. CONCLUSION: A multidisciplinary quality improvement initiative increased frequency of prone positioning by proactively addressing barriers in knowledge, equipment, training, and information technology.

An Interprofessional Approach to Preventing Tracheostomy-Related Pressure Injuries.

OBJECTIVE: An interprofessional team known as the Tracheostomy Steering Committee (TSC) was established to prevent tracheotomy-related pressure injuries (TRPIs) and standardize practice for tracheostomy insertion and care of patients with tracheostomies. In addition to reducing the number TRPIs, the TSC sought establish an escalation process for all clinicians to raise concerns about the care and management of patients with tracheostomies. METHODS: This quality improvement initiative used the Define, Measure, Analyze, Improve, and Control framework with a pre- and postintervention design. The TSC created a TRPI-prevention bundle that included recommendations for protective foam dressing and skin barrier film use, suture tension, timing of suture removal, stoma care, offloading and positioning, escalation, documentation, and dual skin assessment. An electronic tracheostomy report was developed to track patients with a tracheostomy across the enterprise. RESULTS: A total of 289 patients had a tracheostomy during their inpatient hospital stay from January 2018 through December 2019. There was an observed a reduction in the daily rate of TRPIs by 50% with the use of the standardized TRPI-prevention bundle. CONCLUSIONS: Use of the bundle resulted in a significant reduction in the incidence of TRPI. Timely escalation of possible tracheostomy injuries or tracheostomies at risk enabled rapid intervention, likely preventing many injuries, and real-time feedback to clinicians reinforced best practices. Interprofessional collaboration is necessary to provide optimal tracheostomy care and ensure the best outcomes.

Validating Intelligent Automation Systems in Pharmacovigilance: Insights from Good Manufacturing Practices.

Pharmacovigilance is the science of monitoring the effects of medicinal products to identify and evaluate potential adverse reactions and provide necessary and timely risk mitigation measures. Intelligent automation technologies have a strong potential to automate routine work and to balance resource use across safety risk management and other pharmacovigilance activities. While emerging technologies such as artificial intelligence (AI) show great promise for improving pharmacovigilance with their capability to learn based on data inputs, existing validation guidelines should be augmented to verify intelligent automation systems. While the underlying validation requirements largely remain the same, additional activities tailored to intelligent automation are needed to document evidence that the system is fit for purpose. We propose three categories of intelligent automation systems, ranging from rule-based systems to dynamic AI-based systems, and each category needs a unique validation approach. We expand on the existing good automated manufacturing practices, which outline a risk-based approach to artificially intelligent static systems. Our framework provides pharmacovigilance professionals with the knowledge to lead technology implementations within their organizations with considerations given to the building, implementation, validation, and maintenance of assistive technology systems. Successful pharmacovigilance professionals will play an increasingly active role in bridging the gap between business operations and technical advancements to ensure inspection readiness and compliance with global regulatory authorities.

Telemedicine and the COVID-19 Pandemic: Are We Ready to Go Live?

Telemedicine use in the field of wound care had been increasing in popularity when the novel coronavirus 2019 paralyzed the globe in early 2020. To combat the constraints of healthcare delivery during this time, the use of telemedicine has been further expanded. Although many limitations of telemedicine are still being untangled, the benefits of virtual care are being realized in both inpatient and outpatient settings. In this article, the advantages and disadvantages of telemedicine are discussed through two case examples that highlight the promise of implementation during and beyond the pandemic.

Evaluating the Impact of an Innovative Educational Program for Skin Care Champions Using the Pieper-Zulkowski Pressure Ulcer Knowledge Test.

OBJECTIVE: To assess pressure injury knowledge of Skin Care Council nursing members using the Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT), to design an educational intervention informed by the results of the baseline assessment, and to evaluate the effect of the intervention. METHODS: This was a single-group pretest-posttest project conducted in an urban, academic, tertiary medical center from January to August 2017. Participants were measured on the pretest, received the intervention, and then were reevaluated on the posttest 3 months later. Pretest results informed the design of the intervention, which was a 1-day interactive, targeted educational program referred to as the "Skin Care Council Boot Camp." Paired-samples t tests were conducted to examine differences between pretest and posttest scores on the PZ-PUKT overall and in each test section. RESULTS: Seventy-seven participants enrolled in the project and completed the pretest. Of those, 58 (75.3%) were retained through the intervention and the posttest evaluation. Participants had a mean pretest score of 78.9 and a mean posttest score of 85.3. There were significant mean differences among pretest and posttest PZ-PUKT scores: 6.4 (t = 9.419, P < .001) overall; 4.6 (t = 5.356, P < .001) in the Prevention/Risk category; 4.1 (t = 3.668, P < .001) in the Staging category; and 10.5 (t = 7.938, P < .001) in the Wound Description category. CONCLUSIONS: By testing pressure injury knowledge before developing a program, investigators created a tailored, education program that addressed knowledge gaps. Posttest results provided insight into the program's success and opportunities for future improvement.

Hospital Costs and Reimbursement Model for a Geriatric Emergency Department.

OBJECTIVES: The American College of Emergency Physicians' geriatric emergency department (GED) guidelines recommend additional staff and geriatric equipment, which may not be financially feasible for every ED. Data from an accredited Level 1 GED was used to report equipment costs and to develop a business model for financial sustainability of a GED. METHODS: Staff salaries including the cost of fringe benefits were obtained from a Midwestern hospital with an academic ED of 80,000 annual visits. Reimbursement assumptions included 100% Medicare/Medicaid insurance payor and 8-hour workdays with 4.5 weeks of leave annually. Equipment costs from hospital invoices were collated. Operational and patient safety metrics were compared before and after the GED. RESULTS: A geriatric nurse practitioner in the ED is financially self-sustaining at 7.1 consultations, a pharmacist is self-sustaining at 7.7 medication reconciliation consultations, and physical and occupational therapist evaluations are self-sustaining at 5.7 and 4.6 consults per workday, respectively. Total annual equipment costs for mobility aids, delirium aids, sensory aids, and personal care items for the GED was $4,513. Comparing the 2 years before and after, in regard to operational metrics the proportions of patients with lengths of stay > 8 hours and patients placed in observation did not change. In regard to patient safety, the rate of falls decreased from 0.60/1,000 patient visits to 0.42/1,000 in the ED observation unit and 0.42/1,000 to 0.36/1,000 in the ED. ED recidivism at 7 and 30 days did not change. Estimated cost savings from the reduction in falls was $80,328. CONCLUSION: The additional equipment and personnel costs for comprehensive geriatric assessment in the ED are potentially financially justified by revenue generation and improvements in patient safety measures. A geriatric ED was associated with a decrease in patient falls in the ED but did not decrease admissions or ED recidivism.

What explains the quality and price of GP services? An investigation using linked survey and administrative data.

We examine patient socioeconomic status, the strength of the patient-doctor relationship and local area competition as determinants of the quality and price of GP services. We exploit a large-sample patient data set in Australia and its linkage to administrative databases. The sample contains over 260,000 patients and over 12,600 GPs, observed between 2005 and 2010. Controlling for GP fixed effects and patient health, we find no strong evidence that quality differs by patient age, gender, country of origin, health concession card status and income, but quality is increased by stronger patient-doctor relationship. Using a competition measure that is defined at the individual GP level and not restricted to a local market, we find that competition lowers quality. Price is increasing in patient income, whereas competition has a small impact on price.

Private and public patients in public hospitals in Australia.

INTRODUCTION: The nature of the private-public mix in health insurance and in health care is a major issue in most health systems. OBJECTIVE: To compare the hospitalization characteristics of private and public patients hospitalized in public hospitals. METHODS: We focused on planned, overnight and same-day admissions, discharged during 2004-2005 from the public New South Wales hospitals, and run fixed-effects regressions in order to identify the effect of accommodation status (private/public) on the hospitalization characteristics. RESULTS: Private patients have one third less waiting days than public patients, and they are assigned higher urgency of admission. Length of stay and length of visit are both unrelated to the accommodation status, however, private patients tend to have more hours in ICU and more procedures performed during the hospitalization. In-hospital mortality and the number of transfers (wards) are not affected by the accommodation status. CONCLUSIONS: Private patients are treated differently than public patients in public hospitals, reinforcing the private health insurance-related inequity in inpatient care identified by others. Two health policy issues emerge from the findings: the role of private health insurance in the Australian socialized medicine system, and in particular, in the public hospitals; and the way public hospitals are reimbursed for private patients.

Comparison of cook loss, shear force, and sensory descriptive profiles of boneless skinless white meat cooked from a frozen or thawed state.

Four replications were conducted to compare quality measurements, cook loss, shear force, and sensory quality attributes of cooked boneless skinless white meat, broiler breast fillets (pectoralis major) prepared directly from a frozen state or prepared from a thawed state. In each replication, fresh broiler fillets (removed from carcasses 6-8 h postmortem) were procured from a local commercial processing plant and stored in a -20°C freezer until use. On the sensory evaluation date, fillets were cooked to an endpoint temperature of 78°C either directly from the frozen state (thawing during cooking) or after the frozen samples were thawed in a refrigerator (2°C) overnight (thawing before cooking). Cook loss and Warner-Bratzler (WB) shear force were used as indicators for instrumental quality measurements. Sensory quality measurements were conducted by trained descriptive panelists using 0 to 15 universal intensity scales for 8 texture and 10 flavor attributes. Results show that there were no differences (P > 0.05) in measurements for sensory descriptive flavor attributes of cooked fillets between the 2 sample thawing methods, indicating that the sensory flavor profiles of both methods were similar to each other. However, WB shear force (36.98 N), cook loss (21.2%), sensory texture attributes of cohesiveness (intensity score was 5.59), hardness (5.14), rate of breakdown (5.50), and chewiness (5.21) of the breast fillets cooked directly from the frozen state were significantly higher (P < 0.05) than those of the breast meat cooked after being thawed (30.56 N, 19.0%, 5.19, 4.78, 5.29, and 5.02, respectively). These results indicate that cookery directly from frozen boneless skinless white meat can result in different measurement values of cook loss, shear force, and sensory descriptive texture attributes compared with cookery after frozen fillets are thawed.

Discovering unhealthiness: evidence from cluster analysis.

PURPOSE: This study examines information on an array of health limitations, chronic conditions, treatments, and drug consumptions to reveal the prevalence and severity of unhealthiness that are not directly observed. METHODS: Cluster analysis is applied to 265,468 individuals who participated in the 45 and Up Study in Australia. RESULTS: Among the study participants, 8% of those age 45-54 years, 10% of those age 55-64, 13% of those age 65-74, and 17% of those age 75 and older were classified as unhealthy. For the youngest individuals, unhealthiness is characterized by moderate-to-high mental distress, a poor physical health score equivalent to the score associated with having four major limitations in physical functioning, teeth health less than good, and having been diagnosed with at least two chronic conditions. The oldest individuals also suffer from these limitations, as well as dependence on at least three different drug groups and two medical treatments, but they are in better mental health state. CONCLUSIONS: Understanding unhealthiness across population groups will result in more effective allocation of health resources. Older populations require more resources to be devoted to the management of physical health and chronic illnesses.

Preference heterogeneity and selection in private health insurance: the case of Australia.

A basic prediction of theoretical models of insurance is that if consumers have private information about their risk of suffering a loss there will be a positive correlation between risk and the level of insurance coverage. We test this prediction in the context of the market for private health insurance in Australia. Despite a universal public system that provides comprehensive coverage for inpatient and outpatient care, roughly half of the adult population also carries private health insurance, the main benefit of which is more timely access to elective hospital treatment. Like several studies on different types of insurance in other countries, we find no support for the positive correlation hypothesis. Because strict underwriting regulations create strong information asymmetries, this result suggests the importance of multi-dimensional private information. Additional analyses suggest that the advantageous selection observed in this market is driven by the effect of risk aversion, the ability to make complex financial decisions and income.

The effect of lifestyle choices on emergency department use in Australia.

BACKGROUND: Much attention has been paid to patient access to emergency services, focusing on hospital reforms, yet very little is known about the characteristics of those presenting to emergency departments. OBJECTIVES: By exploiting linkage of emergency records and a representative survey of the 45 and older population in Australia, we provide unique insights into the role of lifestyle in predicting emergency presentations. METHODS: A generalized linear regression model is used to estimate the impact of lifestyles on emergency presentations one year ahead. We control for extensive individual characteristics and area fixed-effects. RESULTS: Not smoking, having healthy body weight, taking vitamins, and exercising vigorously and regularly can reduce emergency presentations and also prevent subsequent admissions from emergency. There is no evidence that heavy drinking leads to more frequent emergency visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of emergency visits. CONCLUSIONS: Targeted public health interventions on smoking, body mass and exercise may reduce emergency visits. Effective public health interventions which target body mass, exercise, current smoking and smoking initiation, may have the effect of reducing ED usage and subsequent admission. Individual-level data linking a survey of the population 45 and older in Australia with their emergency department (ED) records is exploited to provide unique insights into the role of lifestyle in predicting emergency care. Controlling for demographic and socioeconomic characteristics, as well as chronic conditions, we find that being a non-smoker, having a healthy body weight, taking vitamins, and doing a vigorous exercise at least once a week can prevent ED presentations. Being a non-smoker, taking vitamins and exercising also prevent subsequent admissions from ED. We do not find a similar protective effect from complying with dietary recommendations. There is no evidence that heavy drinking alone leads to more frequent ED visits, but we find a high tendency for heavy drinkers to smoke and be in poor health, which are both major predictors of ED visits. These results suggest that targeted public health interventions on smoking, body mass and exercise can reduce ED visits. The use of linked data provides important insight into the characteristics of potential ED users which in turn is valuable for the planning of health services.

Explaining health care expenditure variation: large-sample evidence using linked survey and health administrative data.

Explaining individual, regional, and provider variation in health care spending is of enormous value to policymakers but is often hampered by the lack of individual level detail in universal public health systems because budgeted spending is often not attributable to specific individuals. Even rarer is self-reported survey information that helps explain this variation in large samples. In this paper, we link a cross-sectional survey of 267 188 Australians age 45 and over to a panel dataset of annual healthcare costs calculated from several years of hospital, medical and pharmaceutical records. We use this data to distinguish between cost variations due to health shocks and those that are intrinsic (fixed) to an individual over three years. We find that high fixed expenditures are positively associated with age, especially older males, poor health, obesity, smoking, cancer, stroke and heart conditions. Being foreign born, speaking a foreign language at home and low income are more strongly associated with higher time-varying expenditures, suggesting greater exposure to adverse health shocks.

Emergency admissions and elective surgery waiting times.

An average patient waits between 2 and 3 months for an elective procedure in Australian public hospitals. Approximately 60% of all admissions occur through an emergency department, and bed competition from emergency admission provides one path by which waiting times for elective procedures may be lengthened. In this article, we investigated the extent to which public hospital waiting times are affected by the volume of emergency admissions and whether there is a differential impact by elective patient payment status. The latter has equity implications if the potential health cost associated with delayed treatment falls on public patients with lower ability to pay. Using annual data from public hospitals in the state of New South Wales, we found that, for a given available bed capacity, a one standard deviation increase in a hospital's emergency admissions lengthens waiting times by 19 days on average. However, paying (private) patients experience no delay overall. In fact, for some procedures, higher levels of emergency admissions are associated with lower private patient waiting times.

Discrimination in a universal health system: explaining socioeconomic waiting time gaps.

One of the core goals of a universal health care system is to eliminate discrimination on the basis of socioeconomic status. We test for discrimination using patient waiting times for non-emergency treatment in public hospitals. Waiting time should reflect patients' clinical need with priority given to more urgent cases. Using data from Australia, we find evidence of prioritisation of the most socioeconomically advantaged patients at all quantiles of the waiting time distribution. These patients also benefit from variation in supply endowments. These results challenge the universal health system's core principle of equitable treatment.

Waiting times for elective surgery and the decision to buy private health insurance.

More than 45% of Australians buy health insurance for private treatment in hospital. This is despite having access to universal and free public hospital treatment. Anecdotal evidence suggests that avoidance of long waits for public treatment is one possible explanation for the high rate of insurance coverage. In this study, we investigate the effect of waiting on individual decisions to buy private health insurance. Individuals are assumed to form an expectation of their own waiting time as a function of their demographics and health status. We model waiting times using administrative data on the population hospitalised for elective procedures in public hospitals and use the parameter estimates to impute the expected waiting time and the probability of a long wait for a representative sample of the population. We find that expected waiting time does not increase the probability of buying insurance but a high probability of experiencing a long wait does. On average, waiting time has no significant impact on insurance. In addition, we find that favourable selection into private insurance, measured by self-assessed health, is no longer significant once waiting time variables are included. This result suggests that a source of favourable selection may be aversion to waiting among healthier people.

Run for cover now or later? The impact of premiums, threats and deadlines on private health insurance in Australia.

Between 1997 and 2000 the Australian government introduced three policy reforms that aimed to increase private health insurance coverage and reduce public hospital demand. The first provided income-based tax incentives; the second gave an across-the-board 30% premium subsidy; and the third introduced selective age-based premium increases for those enrolling after a deadline. Together the reforms increased enrolment by 50% and reduced the average age of enrollees. The deadline appeared to induce consumers to enroll now rather than delay. We estimate a model of individual insurance decisions and examine the effects of the reforms on the age and income distribution of those with private cover. We interpret the major driver of the increased enrollment as a response to a deadline and an advertising blitz, rather than a pure price response.