Retrospective matched cohort study of incidence rates and excess length of hospital stay owing to pressure injuries in an Asian setting.

Background: Little is known about stage 1 and 2 pressure injuries that are health care-acquired. We report incidence rates of health care-acquired stage 1 and stage 2 pressure injuries, and, estimate the excess length of stay using four competing analytic methods. We discuss the merits of the different approaches. Methods: We calculated monthly incidence rates for stage 1 and 2 health care-acquired pressure injuries occurring in a large Singapore acute care hospital. To estimate excess stay, we conducted unadjusted comparisons with a control cohort, performed linear regression and then generalized linear regression with a gamma distribution. Finally, we fitted a simple state-based model. The design for the cost attribution work was a retrospective matched cohort study. Results: Incidence rates in 2016 were 0.553% (95% confidence interval [CI] 0.55, 0.557) and 0.469% (95% CI 0.466, 0.472) in 2017. For data censored at 60 days' maximum stay, the unadjusted comparisons showed the highest excess stay at 17.68 (16.43-18.93) days and multi-state models showed the lowest at 1.22 (0.19, 2.23) days. Conclusions: Poor-quality methods for attribution of excess length of stay to pressure injury generate inflated estimates that could mislead decision makers. The findings from the multi-state model, which is an appropriate method, are plausible and illustrate the likely bed-days saved from lowering the risk of these events. Stage 1 and 2 pressure injuries are common and increase costs by prolonging the length of stay. There will be economic value investing in prevention. Using biased estimates of excess length of stay will overstate the potential value of prevention.

The impact of community nursing program on healthcare utilization: A program evaluation.

BACKGROUND: The role of nurses has evolved to meet the dynamic needs of an aging population. Community nursing has been established in Singapore with the aim to anchor population health and provide sustainable healthcare services beyond the hospital to the community. Community nurses provide health services to residents at the Community Nurse Posts (CNP) situated within the heartland residential estates. OBJECTIVE: To investigate the effect on healthcare utilization six months pre and post first community nurse visit in older adults, and if the effect is modified by the presence of two or more community nurse visits or absence of a polyclinic chronic disease diagnosis. DESIGN: A single-group pretest-posttest study SETTING(S): Fifty-one SingHealth CNPs at the southeast and east regions of Singapore PARTICIPANTS: Community-dwelling older adults aged ≥ 60 years, seen at any of the SingHealth CNPs between 1 April and 30 November 2019. METHODS: The number of emergency department (ED) visits, unplanned inpatient admissions, length of inpatient stay, specialist outpatient clinic (SOC) and polyclinic visits at SingHealth institutions six months from the first community nurse visit were compared to six months prior. Negative binomial generalized estimating equations were used to model healthcare utilization events, adjusting for baseline age, gender, and race. RESULTS: 1,600 community-dwelling participants were included, of whom 1,561 (median age of 71 years) survived the post-test period. There was a population-average 23% lower rate of ED visits (incidence rate ratio 0.77, 95% confidence interval 0.68 to 0.87, p<0.001) and 15% lower rate of unplanned inpatient admissions (0.85, 0.75 to 0.96, p=0.011). A trend towards a lower rate of inpatient length of stay and a higher rate of SOC and polyclinic visits was also observed. The reduction in acute care utilization may have been greater among adults with two or more community nurse visits. Participants with no recent polyclinic chronic disease diagnosis had a greater increase in SOC visits. CONCLUSIONS: Community nursing services are associated with reduced acute care utilization, especially for older adults with two or more community nurse visits. The trend of a higher rate of SOC visits could be attributed to the community nurses' referrals for undiagnosed/ new conditions and/or treatment of suboptimal health issues. There is a potential role for community nursing towards a sustainable healthcare system.

Audit of the appropriateness and accuracy of fluid intake and output monitoring: experience in a tertiary hospital.

BACKGROUND: The current practice of fluid intake and output monitoring for hospitalised patients in one local acute care tertiary hospital was unclear and inconsistent. Inaccurate fluid balance monitoring and poor documentation can result in poor clinical outcomes. AIM: To provide an overview of the current practice of ordering, monitoring and documentation of patient fluid intake and output during hospitalisation. METHODS: Electronic charts of 2199 adults were reviewed for appropriateness and accuracy of monitoring and documentation of the fluid balance records. Data retrieved for each patient included: (1) Was daily fluid balance monitoring clinically indicated? (2) Was daily fluid balance monitoring prescribed by the doctors or initiated by the nurses? (3) Was the daily fluid balance documentation accurate for the entire admission? FINDINGS: Of the reviewed patients, 68% were on fluid balance monitoring, of whom 31% were prescribed by medical teams and 69% were nurse-initiated. Among patients who were receiving fluid balance monitoring, 78% were clinically indicated (35% prescribed by doctors), and 22% had no clinical indications (18% prescribed by doctors). Overall, documentation accuracy of the intake and output charts was 77%, with 100% accuracy in the oral and intravenous fluid intake, and 21% accuracy in the output documentation. Among the inaccurate documentation of monitoring with no quantifiable amount, 'void in toilet' was the most inaccurately documented (93.3%). CONCLUSIONS: It is vital to address the current disparities in hospital practice, which include prescribing fluid balance monitoring for patients without a clinical indication and documenting incomplete or poor quality information in patients' intake and output charts. Future quality improvement and research work is needed to improve patient safety and outcomes.

A flexible multiplexed immunosensor for point-of-care in situ wound monitoring.

Chronic wounds arise from interruption of normal healing due to many potential pathophysiological factors. Monitoring these multivariate factors can provide personalized diagnostic information for wound management, but current sensing technologies use complex laboratory tests or track a limited number of wound parameters. We report a flexible biosensing platform for multiplexed profiling of the wound microenvironment, inflammation, and infection state at the point of care. This platform integrates a sensor array for measuring inflammatory mediators [tumor necrosis factor-α, interleukin-6 (IL-6), IL-8, and transforming growth factor-ß1], microbial burden (Staphylococcus aureus), and physicochemical parameters (temperature and pH) with a microfluidic wound exudate collector and flexible electronics for wireless, smartphone-based data readout. We demonstrate in situ multiplexed monitoring in a mouse wound model and also profile wound exudates from patients with venous leg ulcers. This technology may facilitate more timely and personalized wound management to improve chronic wound healing outcomes.

Pressure injuries among admissions to a hospital in the tropics.

We report incidence rates for pressure injuries seen in an acute hospital in Singapore that were classified as Stage 3 or Stage 4. The characteristics of patients and the factors that explain variation in the primary outcome of duration of hospital stay are summarized. Existing data were available from Singapore General Hospital for all admissions from January 2016 to December 2019. Univariable analysis was done and a multivariable Poisson regression model estimated. Incidence rates declined from 4.05 to 3.4 per 1000 admissions in the 48 months between 2016 and 2019. The vast majority were community acquired with 75% in admission from the patients' home. Factors that explain variation in length of stay were, ethnicity; site of injury; community versus healthcare associated; inter-hospital transfer; fracture as reason for admission; and the number of days between admission and assessment of wound by specialist nurse. Stage 3 and 4 injuries arise in a home environment most often and are subsequently managed in acute hospital at high cost. These are novel epidemiological data from a hospital in the tropics where the potential to improve outcomes, implement screening and prevention, and thus increase the performance of health services is strong.

Factors associated with postsurgical wound infections among breast cancer patients: A retrospective case-control record review.

Women with non-metastatic breast cancer will be offered surgery as their first option. Unfortunately, studies have shown that the most common postoperative complication is surgical wound infection (SWI). We investigated the prevalence of SWI in breast cancer patients and identified the factors predictive of its development. The study was conducted at the breast cancer centre in Singapore. A retrospective case-control review of medical records was used. During the 2013 to 2016 study period, there were 657 postsurgical breast cancer patients with only 105 records eligible for the study. The sample consisted of one to four case:control (21:84), matched according to their age at the time of their surgery. Patients presenting with SWI were grouped into cases, while those without SWI were grouped into the controls. Chi-square test and Mann-Whitney U test were used to identify risk factors associated with SWI. Regression analysis of predictive variables from the univariate analyses was included. These variables were type of breast surgery, implants, comorbidities, previous surgery, previous chemotherapy, surgical drains, seroma, blood transfusion, surgeon department, and length of stay. The prevalence of SWI was 9%. Demographic, clinical, and comorbidities were not associated with SWI. However, multivariate analysis found that "surgeon department," "discharged with surgical drains," and "postoperative seroma" were predictive of SWI. Monitoring SWI is indispensable to minimise burdens on individuals and institutions. Health care professionals should identify high-risk patients based on the identified predictive variables. A cross-institutional record review of SWI in postoperative breast cancer patients should be conducted.

Evaluation of infrared technology to detect category I and suspected deep tissue injury in hospitalised patients.

OBJECTIVE: To evaluate the use of an infrared thermography device in assessing skin temperature among category I pressure ulcer (PU) and/or suspected deep tissue injuries (SDTI) with intact skin. METHODS: An observational cross-sectional study design was used. Adult inpatients (cases) who had a category I PU or suspected deep tissue injury (skin intact) on the sacral or heel during the study period (March to April 2018) were recruited. Patients without a PU were also recruited to act as control. Thermal images of the patient's PU site and non-PU site were taken within 24 hours of PU occurrence. Thermal images of the control patients (no PU) were also taken. Each PU case was matched to three control patients in terms of age, gender, race and anatomical sites. All thermal images were taken using a portable CAT S60 Thermal Imaging Rugged Smartphone (Caterpillar Inc., US) that provided readings of the skin temperature in degrees Celsius. RESULTS: A total of 17 cases and 51 controls were recruited. Among the cases, the mean difference in skin temperature between the PU site (mean: 31.14°C; standard deviation [SD]: 1.54) and control site within the cases (mean: 28.93°C; SD: 3.47) was significant (difference: 2.21±3.66°C; p=0·024). When comparing between all cases and controls, the mean temperature difference was non-significant. When comparing between the category I PU and suspected deep pressure injury cases, the mean difference was also non-significant. CONCLUSION: Using infrared thermography technology at the bedside to measure skin temperature will support the clinical diagnosis of patients with skin types I to III. However, there is a need for a more accurate and objective measurement to identify and diagnose early category I PU or suspected deep tissue injury in adult patients with darker skin types 4 and above, enabling early initiation of preventive measures in the hospital acute care setting.

A systematic survey of the methods literature on the reporting quality and optimal methods of handling participants with missing outcome data for continuous outcomes in randomized controlled trials.

OBJECTIVE: To conduct (1) a systematic survey of the reporting quality of simulation studies dealing with how to handle missing participant data (MPD) in randomized control trials and (2) summarize the findings of these studies. STUDY DESIGN AND SETTING: We included simulation studies comparing statistical methods dealing with continuous MPD in randomized controlled trials addressing bias, precision, coverage, accuracy, power, type-I error, and overall ranking. For the reporting of simulation studies, we adapted previously developed criteria for reporting quality and applied them to eligible studies. RESULTS: Of 16,446 identified citations, the 60 eligible generally had important limitations in reporting, particularly in reporting simulation procedures. Of the 60 studies, 47 addressed ignorable and 32 addressed nonignorable data. For ignorable missing data, mixed model was most frequently the best on overall ranking (9 times best, 34.6% of times tested) and bias (10, 55.6%). Multiple imputation was also performed well. For nonignorable data, mixed model was most frequently the best on overall ranking (7, 46.7%) and bias (8, 57.1%). Mixed model performance varied on other criteria. Last observation carried forward (LOCF) was very seldom the best performing, and for nonignorable MPD frequently the worst. CONCLUSION: Simulation studies addressing methods to deal with MPD suffered from serious limitations. The mixed model approach was superior to other methods in terms of overall performance and bias. LOCF performed worst.

A systematic survey on reporting and methods for handling missing participant data for continuous outcomes in randomized controlled trials.

OBJECTIVE: To assess analytic approaches randomized controlled trial (RCT) authors use to address missing participant data (MPD) for patient-important continuous outcomes. STUDY DESIGN AND SETTING: We conducted a systematic survey of RCTs published in 2014 in the core clinical journals that reported at least one patient-important outcome analyzed as a continuous variable. RESULTS: Among 200 studies, 187 (93.5%) trials explicitly reported whether MPD occurred. In the 163 (81.5%) trials that reported the occurrence of MPD, the median and interquartile ranges of the percentage of participants with MPD were 11.4% (2.5%-22.6%).Among the 147 trials in which authors made clear their analytical approach to MPD, the approaches chosen included available data only (109, 67%); mixed-effect models (10, 6.1%); multiple imputation (9, 4.5%); and last observation carried forward (9, 4.5). Of the 163 studies reporting MPD, 16 (9.8%) conducted sensitivity analyses examining the impact of the MPD and (18, 11.1%) discussed the risk of bias associated with MPD. CONCLUSION: RCTs reporting continuous outcomes typically have over 10% of participant data missing. Most RCTs failed to use optimal analytic methods, and very few conducted sensitivity analyses addressing the possible impact of MPD or commented on how MPD might influence risk of bias.