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We study financial effects of remote product delivery in the healthcare industry. Exploiting staggered law adoption for identification, we find that telehealth provision redistributes hospital operations and access to capital away from rural communities. As urban telehealth providers acquire rural patients, rural hospitals experience decreased revenue and profit, credit rating downgrades, increased cost of capital, and ultimately risk of closure. Although telehealth reduces travel costs, some communities lose access to acute care. Overall, we conclude that remote healthcare services have financial consequences as well as real effects, and their benefits are unequally distributed. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the association of inpatient maternal mortality with variability in healthcare services delivery such as hospital size, urban/rural designation, teaching/non-teaching status, regional location, and insurance coverage. METHODS: This is a pooled, cross-sectional analysis of the National Inpatient Sample (2012–2014). Information on maternal demographics, clinical conditions, and birth outcomes were identified using respective ICD9-CM codes. Bivariate and multivariate analysis using logistic regression models were used to describe maternal characteristics and to calculate the risk of mortality with each independent variable RESULTS: The weighted sample included 12,409,939 hospital records (82.6% are 18–34-year-old and 49.5% are Caucasians). Maternal death during hospitalization occurred in 1310 cases (12/100,000 live birth). Women with cardiovascular disorders, hemorrhage or sepsis were 33.6, 4.7, and 5.4 times more likely to suffer inpatient maternal mortality. Compared to small-sized hospitals, delivery at medium or large size hospitals is associated with higher mortality, adjusted odds ratios (aOR) 1.8 (1.4–2.3), and 2.2 (1.8–2.8), respectively. Adjusted OR for inpatient maternal mortality in urban non-teaching or urban teaching compared to rural hospitals were 2.2 (1.7–3.0) and 2.9 (2.2–3.9), respectively. Women in the South have higher maternal mortality compared to Northeast, aOR 1.7 (1.5–2.1). Women coved with public insurance experience higher inpatient maternal mortality compared to those with private insurance, aOR: 2.6 (2.1–3.2) and 1.9 (1.6–2.1), respectively. CONCLUSION: Factors related to variability in healthcare delivery may play a role in inpatient maternal mortality. Some could be explained by the case mix and the clinical conditions affecting birthing outcomes. A qualitative analysis is needed to explore how these factors relate to increased maternal mortality in certain hospital settings. [ABSTRACT FROM AUTHOR]

Outcomes among acute kidney injury (AKI) patients are poor in United Kingdom (UK) hospitals, and electronic alerts and care bundles may improve them. We implemented such a system at West Suffolk Hospital (WSH) called the 'AKI order set'. We aimed to assess its impact on all-cause mortality, length of stay (LOS) and renal function among AKI patients, and its utilization. Retrospective, single-center cohort study of patients ≥ 18 years old with AKI at WSH, a 430-bed general hospital serving a rural UK population of approximately 280,000. 7243 unique AKI events representing 5728 patients with full data were identified automatically from our electronic health record (EHR) between 02 September 2018 and 1 July 2021 (median age 78 years, 51% male). All-cause mortality, LOS and improvement in AKI stage, demographic and comorbidity data, medications and AKI order set use were automatically collected from the EHR. The AKI order set was used in 9.8% of AKI events and was associated with 28% lower odds of all-cause mortality (multivariable odds ratio [OR] 0.72, 95% confidence interval [CI] 0.57–0.91). Median LOS was longer when the AKI order set was utilized than when not (11.8 versus 8.8 days, p <.001), but was independently associated with improvement in the AKI stage (28.9% versus 8.7%, p <.001; univariable OR 4.25, 95% CI 3.53–5.10, multivariable OR 4.27, 95% CI 3.54–5.14). AKI order set use led to improvements in all-cause mortality and renal function, but longer LOS, among AKI patients at WSH. [ABSTRACT FROM AUTHOR]

Background: Despite medication being the most common healthcare intervention and medication-related incidents being common in hospitals, many rural and remote hospitals in Australia lack onsite pharmacy services due to resource constraints. A Virtual Clinical Pharmacy Service (VCPS) staffed by two senior, rural generalist hospital pharmacists assigned to four hospitals each was implemented in rural and remote facilities to determine whether the VCPS increased adherence to National Safety and Quality Health Service Standards (NSQHS). Methods: A stepped-wedge randomised controlled trial was employed to sequentially implement a telehealth pharmacy service at one-month intervals in eight hospitals. The primary outcomes were patient-level medication reconciliation completion rates on admission and discharge. Secondary measures evaluated compliance with other NSQHS standards (including Best Possible Medication History, Medication Reconciliation and venous thromboembolism risk assessment), patient outcomes (including representation within 48 h, readmission within 28 days and length of stay), and detection of potential medication-related harms (including pharmacist identified medication related problems, reported medication errors and falls). Patients were invited to complete a patient-reported experience questionnaire. Data were collected from electronic medical records and analysed using mixed logistic regression models to estimate the effectiveness of the VCPS. Antimicrobial usage, falls, and medication errors were analysed at the facility level, while other data were analysed at the patient level. Results: Compared to control (n = 535), patients in the intervention period (n = 527) were more likely to have an admission medication reconciliation completed (Odds Ratio (OR) 11.16, 95% confidence interval (CI) 5.59–22.30, p < 0.001) in models adjusted for the study period. A similar improvement was observed for discharge medication reconciliation completion (OR 4.07, CI 2.38–6.95, p < 0.001), whereas a 33-fold improvement was seen in Best Possible Medication History completion (OR 33.27, CI 17.53–63.14, p < 0.001). The VCPS documented 879 medication related problems, with 61% of patients having at least one medication-related problem documented by a pharmacist. There was no change in length of stay, falls, readmission rates or reported medication error rates; however, the study was not powered to detect these changes. Patient feedback was positive and comparable to in-person care, with 95% (179/189) reporting their overall experience as 'good' or 'very good.' No unintended harms were reported. Conclusions: The VCPS improved compliance with national standards for medication safety, had high patient acceptability and resulted in the detection of clinically relevant medication-related issues in rural and remote settings. The applicability of virtual pharmacy should be explored in further rural and remote locations in addition to other settings such as metropolitan locations with no onsite clinical pharmacists. Ethics number: GWHREC 2019/ETH13355. Trial registration: ANZCTR registration number ACTRN12619001757101. Registered on 11/12/2019. Published trial protocol: A stepped wedge trial of efficacy and scalability of a virtual clinical pharmacy service (VCPS) in rural and remote NSW health facilities. [ABSTRACT FROM AUTHOR]

Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation. A retrospective cohort analysis was conducted using the National Inpatient Sample 2016–2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes. The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07–12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3–3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2–1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US. Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes. • Patient's demographics and socioeconomic status are not associated with the risk of post-TAVR pacemaker except for age. • Compared to New England hospitals, Middle Atlantic hospitals are associated with the highest post-TAVR PPM risk. • Pacific, Mountain, and East North Central US hospitals are also associated with higher post-TAVR PPM risk than New England. [ABSTRACT FROM AUTHOR]

This article describes an 8-week pilot project implementing virtual reality (VR) technology as a stress relief intervention for nurses at a rural hospital. It highlights how VR allowed nurses to temporarily disconnect from their stressful work environment and experience calming virtual scenarios during break times. [ABSTRACT FROM AUTHOR]

Serial neonatal encephalopathy (NE) examinations are difficult to perform in rural community hospitals as on-site experts are not readily available. We implemented a synchronous, acute care model of teleconsultation—the Maine Neonatal Encephalopathy Teleconsultation program (Maine NET)—to provide remote, joint assessment of NE by pediatric neurology and neonatology at nine community hospitals and one tertiary care center. We performed a qualitative study to interview clinicians about their experience of this program. From April 2018 to October 2022, we employed a semistructured interview format with 16 clinicians representing all participating hospitals. We utilized deductive analysis to assign a set of predefined codes to the transcribed interviews. Thematic analysis supported the anticipated benefits of Maine NET, demonstrating that clinicians felt resource utilization, collaborative decision making, communication, and continuity of care were improved. Clinicians overwhelmingly supported the program: "This program has truly saved babies' lives and future function. I have not met any parents through this journey, who aren't incredibly grateful for the care that is provided" and emphasized the benefit of collaboration between all care team members. Teleconsultation was felt to be "more than adequate to [assess] NE." Connectivity issues were cited as a limitation. Maine NET has positively impacted care delivery for newborns with clinical concerns for NE. Additionally, the program has improved resource allocation, collaborative decision making, communication, and equity of care. Addressing technological challenges will be vital to the success and sustainability of the planned Maine NET expansion. [ABSTRACT FROM AUTHOR]

Background: Early diagnosis and antibiotic therapy in patients with sepsis reduce morbidity and mortality, thus pre-hospital management is likely to affect patient outcomes. Pre-hospital administration may increase the risk of unnecessary use of broad-spectrum antibiotics, but identification of an infectious focus enables more targeted antibiotic therapy. The aim of this study was to investigate how paramedics, with or without the assistance of general practitioners, can administer empiric intravenous antibiotic treatment against sepsis in a timely manner. Methods: Cohort study of patients with suspected sepsis that received pre-hospital intravenous antibiotics and were transported to hospital. The setting was mainly rural with long average distance to hospital. Patients received targeted antibiotic treatment after an assessment based on clinical work-up supported by scoring systems. Patients were prospectively included from May 2018 to August 2022. Results are presented as median or absolute values, and chi-square tests were used to compare categorical data. Results: We included 328 patients. Median age was 76 years (IQR 64, 83) and 48.5% of patients were female. 30-days all-cause mortality was 10.4%. In cases where a suspected infectious focus was determined, the hospital discharge papers confirmed the pre-hospital diagnosis focus in 195 cases (79.3%). The presence of a general practitioner during the pre-hospital assessment increased the rate of correctly identified infectious focus from 72.6% to 86.1% (p = 0.009). Concordance between pre-hospital identification of a tentative focus and discharge diagnosis was highest for lower respiratory tract (p = 0.02) and urinary tract infections (p = 0.03). Antibiotic treatment was initiated 44 min (median) after arrival of ambulance, and median transportation time to hospital was 69 min. Antibiotic therapy was started 76 min (median) before arrival at hospital. Conclusions: Pre-hospital identification of infectious focus in suspected sepsis was feasible, and collaboration with primary care physicians increased level of diagnostic accuracy. This allowed initiation of intravenous focus-directed antibiotics more than one hour before arrival in hospital in a rural setting. The effect of pre-hospital therapy on timing was much stronger than in previous studies from more urban areas. [ABSTRACT FROM AUTHOR]

Background: Production of extended-spectrum β-lactamases (ESBLs) is a common resistance mechanism in Enterobacteriaceae, leading to serious hospital-acquired infections. This study aimed to assess phenotypic, phylogenetic, and antibiotic resistance patterns among ESBL-producing Escherichia coli isolates recovered from two rural tertiary hospitals in Thailand. Results: Among 467 Enterobacteriaceae isolates, E. coli was the most prevalent 356 (76.2%) followed by K. pneumoniae 88 (18.8%), K. aerogenes 8 (1.7%), K. variicola 3 (0.6%), K. quasipneumoniae 1 (0.2%%), K. oxytoca 1 (0.2%), and unidentified 9 (1.9%). Of the 202 cephalosporin-resistant E. coli isolates, 195 (96.5%) were ESBL-producing and 7 (3.5%) were non-ESBL-producing. Clermont typing revealed that phylogroup B2 was predominant (43.3%), followed by phylogroups F (11.3%), D (10.3%), C (9.7%), and A (8.7%). Among the beta-lactamase-encoding genes, blaCTX−M (83.6%) and blaTEM (81.0%) were widely found among the isolates, and blaCTX−M−1 (60.7%) was the most common among the five blaCTX−M subgroups detected. The predominant ESBL was blaCTX−M−15 (58.3%). All isolates were resistant to cefotaxime (100%) and ampicillin (100%), followed by ciprofloxacin (91.3 %), ceftazidime (72.8 %), and tetracycline (64.1%). Conclusion: Our findings show that phylogroup B2 was the most prevalent phylogroup among ESBL-producing E. coli isolates in northeastern Thailand. Notably, the isolates mostly carried the blaCTX−M gene(s). [ABSTRACT FROM AUTHOR]

Background: Worldwide about 2.3 million newborns still die in the neonatal period and the majority occurs in low- and middle-income countries (LMICs). Intrapartum-related events account for 24% of neonatal mortality. Of these events, intrapartum birth asphyxia with subsequent neonatal encephalopathy is the main cause of child disabilities in LMICs. Data on neurodevelopmental outcome and early risk factors are still missing in LMICs. This study aimed at investigating the factors associated with mortality, risk of neurodevelopmental impairment and adherence to follow-up among asphyxiated newborns in rural Tanzania. Methods: This retrospective observational cohort study investigated mortality, neurodevelopmental risk and adherence to follow-up among asphyxiated newborns who were admitted to Tosamaganga Hospital (Tanzania) from January 2019 to June 2022. Neurodevelopmental impairment was assessed using standardized Hammersmith neurologic examination. Admission criteria were Apgar score < 7 at 5 min of life and birth weight > 1500 g. Babies with clinically visible congenital malformations were excluded. Comparisons between groups were performed using the Mann-Whitney test, the Chi-square test, and the Fisher test. Results: Mortality was 19.1% (57/298 newborns) and was associated with outborn (p < 0.0001), age at admission (p = 0.02), lower Apgar score at 5 min (p = 0.003), convulsions (p < 0.0001) and intravenous fluids (IV) (p = 0.003). Most patients (85.6%) were lost to follow-up after a median of 1 visit (IQR 0–2). Low adherence to follow-up was associated with female sex (p = 0.005). The risk of neurodevelopmental impairment at the last visit was associated with longer travel time between household and hospital (p = 0.03), female sex (p = 0.04), convulsions (p = 0.007), respiratory distress (p = 0.01), administration of IV fluids (p = 0.04), prolonged oxygen therapy (p = 0.004), prolonged hospital stay (p = 0.0007) and inappropriate growth during follow-up (p = 0.0002). Conclusions: Our findings demonstrated that mortality among asphyxiated newborns in a rural hospital in Tanzania remains high. Additionally, distance from home to hospital and sex of the newborn correlated to higher risks of neurodevelopmental impairment. Educational interventions among the population about the importance of regular health assessment are needed to improve adherence to follow-up and for preventive purposes. Future studies should investigate the role of factors affecting the adherence to follow-up. [ABSTRACT FROM AUTHOR]

The study reported here investigated what enables emergency department (ED) staff to support domestic violence victim-survivors of strangulation, which poses potentially life-threatening medical and psychosocial risks. Informed by Appreciative Inquiry, interviews were conducted with twelve staff from eight emergency departments in New South Wales, Australia. Doctors, nurses, and social workers with experience in supporting victim-survivors of domestic violence-related strangulation were interviewed. De-identified transcripts were analysed using inductive thematic analysis. Themes identified from the data were the importance of recognising strangulation injuries, that understanding experiences of violence improves ED staff’s responses to victim-survivors of strangulation, the value of social work in multidisciplinary response, and that informal support sustains staff in this work. These themes highlight the need for emergency department staff education in identifying and responding to domestic violence and strangulation, which enables informed responses, positive patient engagement, and effective multidisciplinary care.IMPLICATIONS Multidisciplinary care for health and safety assessments are essential for domestic violence victim-survivors of strangulation presenting to emergency departments.24-hour access to social workers in emergency departments facilitates safety planning and may mitigate the risks of escalating violence.Strangulation and domestic violence education is essential for emergency department staff.There is an evident need for increased social work roles in EDs, especially in rural hospitals, to support victim-survivors and to apply a social work approach to train ED staff to respond appropriately.Formalising supportive structures through enhancing social work and domestic violence education in emergency departments whilst encouraging informal support networks for staff may enhance safety for victims-survivors and maximise staff emotional wellbeing.Multidisciplinary care for health and safety assessments are essential for domestic violence victim-survivors of strangulation presenting to emergency departments.24-hour access to social workers in emergency departments facilitates safety planning and may mitigate the risks of escalating violence.Strangulation and domestic violence education is essential for emergency department staff.There is an evident need for increased social work roles in EDs, especially in rural hospitals, to support victim-survivors and to apply a social work approach to train ED staff to respond appropriately.Formalising supportive structures through enhancing social work and domestic violence education in emergency departments whilst encouraging informal support networks for staff may enhance safety for victims-survivors and maximise staff emotional wellbeing. [ABSTRACT FROM AUTHOR]

Introduction: We sought to streamline cataract surgery post-operative care when COVID-19 hit by discontinuing the 1-day post-operative visit. We wanted to know if this change was safe and beneficial to our patients by reducing patients' time and transportation burden, opening appointment slots allowing providers to see more patients and reducing greenhouse gas emissions. By minimising intraoperative use of dispersive viscoelastic, increasing irrigation/aspiration time at the end of the surgery and using intraocular pressure (IOP) lowering medications such as carbachol, brimonidine and acetazolamide routinely, we posit that post-operative day 1 IOP spikes can be avoided, thereby eliminating the need for the 1st post-operative day visit. We also sought to show the positive environmental impact of eliminating that 1st day. Methods: We retrospectively reviewed cataract surgeries performed before COVID-19 to determine the incidence of serious pathology discovered at the post-operative day 1 visit. Subsequently, we examined all the cataract surgeries performed in 2023 by our practice. Results: One hundred and ninety-three cataract surgeries performed before COVID-19 and 832 performed in 2023 were reviewed. We found that the post-operative day 1 visit after cataract surgery is unnecessary in most routine uncomplicated cases. Conclusion: By eliminating hundreds of post-operative day 1 visits for a busy rural practice annually, patients, their friends and relatives are spared an extra trip to the office (that can be 100 km each way), the office schedule is open to accommodate more patients, and the patients' carbon footprint of travel to the office is reduced. Introduction: Nous avons cherché à rationaliser les soins postopératoires de la chirurgie de la cataracte lors de l'arrivée de la Covid en supprimant la visite postopératoire d'un jour. Nous voulions savoir si ce changement était sécuritaire et bénéfique pour nos patients en réduisant le temps et la charge de transport des patients, en ouvrant des créneaux de rendez-vous permettant aux prestataires de voir plus de patients et en réduisant les émissions de gaz à effet de serre. En minimisant l'utilisation peropératoire de viscoélastique dispersif, en augmentant le temps d'irrigation/aspiration à la fin de l'opération et en utilisant systématiquement des médicaments abaissant la PIO, tels que le carbachol, la brimonidine et l'acétazolamide, nous pensons que les PIO postopératoire du premier jour peuvent être évitées, éliminant ainsi la nécessité d'une première visite de jour postopératoire. Nous avons également cherché à démontrer l'impact environnemental positif de l'élimination de ce premier jour. Méthodes: Nous avons examiné rétrospectivement opérations de la cataracte réalisées avant la Covid afin de déterminer l'incidence des pathologies graves découvertes lors de la visite postopératoire du premier jour. Par la suite, nous avons examiné toutes les opérations de la cataracte réalisées en 2023 par notre cabinet. Résultats: 193 opérations de la cataracte réalisées avant la Covid et 832 réalisées en 2023 ont été examinées. Nous avons constaté que la visite postopératoire du premier jour après la chirurgie de la cataracte n'est pas nécessaire dans la plupart des cas de routine sans complications. Conclusion: En éliminant des centaines de visites postopératoires du premier jour dans une région rural, les patients, leurs amis et leurs proches n'ont pas à SE rendre au cabinet (ce qui peut représenter des centaines de kilomètres aller-retour). L'emploi du temps du cabinet est libéré pour accueillir davantage de patients et l'empreinte carbone des patients liée à leur déplacement au cabinet est réduite. [ABSTRACT FROM AUTHOR]

Introduction: We sought to determine the difference between Canadian CT Head Rule (CCHR) indicated imaging rates and actual imaging rates for patients with mild traumatic brain injuries (mTBIs) at a rural emergency department (ED) without in-house computed tomography (CT). In addition, we compared CCHR adherence at a hospital without CT to previous publications from centres with CT to determine if rural populations receive less CT imaging for minor head traumas when indicated by the CCHR. Methods: This retrospective chart review explored individuals who presented to a rural ED (no in-house CT scanner) with a primary diagnosis of mild head injury or concussion between 1 January 2017 and 31 December 2021. Information regarding CCHR criteria, transfer status and patient demographics was collected. Descriptive analyses were completed to determine the percentage of patients who received appropriate transfer for imaging, did not receive transfer for imaging when indicated and received unnecessary transfer. Results: A total of 124 charts met our inclusion criteria (17 [12.1%] charts excluded), with 25.8% transferred to the nearest hospital for CT imaging. After applying the CCHR criteria to our charts, 62.1% were indicated for CT. Of the 62.1%, only 35.1% were transferred for imaging (51.2% of high-risk and 16.7% of medium-risk). Conclusion: By exploring CT rates for mTBIs in a rural Canadian ED, we found low transfer rates (35.1%) of CCHR-indicated patients for imaging needed to guide further healthcare decisions. This work highlights a discrepancy within the Canadian healthcare system between rural and urban centres and allows for opportunities to help narrow the gap in health care. Introduction: Nous avons cherché à déterminer la différence entre les taux d'imagerie indiqués par le Canadian CT Head Rule (CCHR, règlement canadien relatif à la tomodensitométrie de la tête) et les taux d'imagerie réels pour les patients souffrant de traumatismes craniocérébraux légers (TCCL) dans un service d'urgence rural ne disposant pas d'une tomographie par ordinateur interne. En outre, nous avons comparé l'adhésion au CCHR dans un hôpital sans tomographie par ordinateur à des publications antérieures provenant de centres avec tomographie par ordinateur afin de déterminer si les populations rurales reçoivent moins d'imagerie par tomodensitométrie pour les traumatismes crâniens mineurs lorsque le CCHR l'indique. Méthodes: Cette étude rétrospective des dossiers a exploré les personnes qui SE sont présentées à une urgence rurale (sans tomodensitomètre interne) avec un diagnostic primaire de traumatisme crânien léger ou de commotion cérébrale entre le 1er janvier 2017 et le 31 décembre 2021. Les informations concernant les critères du CCHR, l'état de transfert et les données démographiques des patients ont été recueillies. Des analyses descriptives ont été réalisées pour déterminer le pourcentage de patients ayant reçu un transfert approprié pour l'imagerie, n'ayant pas reçu de transfert pour l'imagerie quand c'était indiqué et ayant reçu un transfert inutile. Résultats: Au total, 124 dossiers répondaient à nos critères d'inclusion [17 (12,1%) dossiers exclus], dont 25,8% ont été transférés à l'hôpital le plus proche pour une imagerie par tomodensitométrie. Après avoir appliqué les critères du CCHR à nos dossiers, 62,1% d'entre eux étaient indiqués pour une tomodensitométrie. Sur ces 62,1%, seuls 35,1% ont été transférés pour imagerie (51,2% de haut risque, 16,7% de risque moyen). Conclusion: En explorant les taux de tomodensitométrie pour les TCCL dans un service d'urgence rural canadien, nous avons constaté de faibles taux de transfert (35,1%) des patients recommandés par le CCRH pour une imagerie nécessaire dans le but de guider les décisions de soins de santé ultérieures. Ce travail met en évidence un écart dans le système de santé canadien entre les centres ruraux et urbains et offre des opportunités pour aider à réduire l'écart dans les soins de santé. [ABSTRACT FROM AUTHOR]

Introduction: Oral Submucous Fibrosis (OSMF) is a longterm condition characterised by the gradual buildup of fibrous tissue in the oral cavity, often extending to the throat and upper oesophagus. The primary symptoms include progressive limitation in mouth opening due to the formation of stiff fibrous bands in the oral mucosa, accompanied by muscle atrophy. However, the most concerning aspect of this restriction, known as trismus, is its hindrance to effective cancer monitoring. Surgical approaches typically aim to release these fibrotic bands, while medical interventions focus on managing inflammation and preventing further fibrosis. Need of the Study: A modification of the nasolabial flap has been suggested for the reconstruction of intraoral defects following ablative surgery for OSMF. The study will assess its merits in comparison to the conventional nasolabial flap. Aim: To evaluate and compare the aesthetic and functional outcomes of the rima oris between the Conventional Nasolabial Flap and the Nasolabial Flap with Fishtail Modification in patients undergoing surgical intervention for OSMF. Materials and Methods: A prospective, double-blinded, randomised controlled trial will be conducted in the Department of Oral and Maxillofacial Surgery at Acharya Vinoba Bhave Rural Hospital, associated with Jawaharlal Nehru Medical College, Wardha, Maharashtra, India, from November 2023 to November 2024. Patients older than 18 years of age diagnosed with OSMF, without any superimposing cancerous lesions, will be included in the study. They will be divided into two groups: Group A will be treated with bilateral fibrotomy, coronoidotomy and reconstruction with the conventional nasolabial flap, while Group B will undergo the same surgical intervention, except that the reconstruction will be performed using the fishtail modification of the nasolabial flap. The parameters that will be compared include interincisal mouth opening, intercommissural width, dehiscence and flap necrosis. The analysis will be conducted using the Chi-square test and Fisher's-exact test for categorical data and the independent t-test for continuous data that follow a normal distribution. These statistical tests will help evaluate the association between different demographic, clinical and etiological factors and the outcomes under consideration. A p-value of <0.05 will be considered statistically significant. [ABSTRACT FROM AUTHOR]

Background Chemical eye injuries are a critical ophthalmic emergency requiring urgent treatment. This study aims to examine the demographic and clinical profile and evaluate the visual outcomes of patients with ocular chemical injuries in a rural medical setting. Methods A hospital-based cross-sectional observational study was conducted at a tertiary rural medical hospital from June 2022 to May 2023. The study included 24 patients with chemical ocular injuries. Data were collected on demographics, clinical presentation, type of chemical involved, and visual outcomes. Injuries were classified using the Roper-Hall classification system. Statistical analysis was performed using SPSS 17.0. Results Of the 24 patients, 71% were males, with a mean age of 40.29 years. The majority of injuries were unilateral (71%) and occurred at home (41.66%) and construction sites (33.33%). Alkali injuries were the most common (58.33%), followed by acid injuries (33.33%). According to the Roper-Hall classification, 50% of injuries were Grade I, 38% were Grade II, 8% were Grade III, and 4% were Grade IV. At presentation, 29% of patients had mild or no visual impairment, 54% had moderate impairment, 13% had severe impairment, and 4% were blind. Post-treatment, 88% of patients achieved mild or no impairment, 8% had moderate impairment, 4% had severe impairment, and none remained blind. Conclusion Chemical ocular injuries pose a major risk of visual impairment, particularly in occupational settings. Early intervention and preventive measures are crucial for improving visual outcomes and reducing the incidence of these injuries. Public health initiatives focusing on safety protocols and awareness campaigns are essential to mitigate the risks associated with chemical eye injuries. [ABSTRACT FROM AUTHOR]

Background: The demographics and geography of Australia and New Zealand (ANZ), with few metropolitan centres and vast, sparsely populated rural areas, represent a challenge to providing equal care to all patients. This study aimed to compare rectal cancer care at rural and urban hospitals in ANZ. Methods: From the Bowel Cancer Outcomes Registry (BCOR, formerly known as the Bi‐National Colorectal Cancer Audit; BCCA), rectal cancer patients treated between 2007 and 2020 were compared based on hospital location (urban versus rural). Propensity‐score matching was performed to correct for differences in baseline characteristics between groups. Results: A total of 9385 rectal cancer patients were identified from the BCOR: 1329 (14.2%) were treated at rural hospitals and 8056 (85.8%) at urban hospitals. Propensity‐score matching resulted in 889 patients in each group, matched for age, ASA score, hospital type (public/private), tumour height from the anal verge, and pre‐treatment cT‐ and cAJCC‐stage. Rural patients had fewer pre‐treatment MRIs (67.9% versus 74.7%; P = 0.002), and underwent less neoadjuvant therapy (44.7% versus 50.9%; P = 0.01). Rural patients underwent fewer ULARs (39.4% versus 45.6%; P = 0.03), and fewer anastomoses were formed (67.9% versus 74.4%; P = 0.05). CRM rates and postoperative AJCC stages (P = 0.19) were similar between groups (P = 0.87). Fewer rural patients received adjuvant chemotherapy (37.8% versus 43.3%; P = 0.02). Conclusion: There are significant differences in pre‐treatment MRI rates, (neo)adjuvant treatment rates and surgical procedures performed between rectal cancer patients treated at rural and urban hospitals in ANZ, while CRM rates and postoperative AJCC stages are similar. [ABSTRACT FROM AUTHOR]

Introduction: As the rural–urban cancer mortality gap widens, centering care around the needs of rural patients presents an opportunity to advance equity. One barrier to delivering patient‐centered care at rural hospitals stems from limited analytic capacity to leverage data and monitor patient outcomes. This case study describes the experience of a public health cancer surveillance system aiming to fill this gap within the context of a rural cancer network. Methods: To support the implementation of a novel network model intervention in Iowa, the Iowa Cancer Registry began generating hospital‐specific and catchment area reports. Then, the Iowa Cancer Registry supported adapting the network model to fit the context of Iowa's cancer care delivery system by performing data monitoring and reporting functions. Informed by a gap analysis, the Iowa Cancer Registry then identified which quality accreditation standards could be achieved with public health surveillance data and analytic support. Results: The network intervention in Iowa supported 5 rural cancer centers across the state, each concurrently pursuing quality accreditation standards. The Iowa Cancer Registry's hospital and catchment‐specific reports illuminated the cancer burden and needs of rural cancer centers within the network. Our team identified 19 (of the 36 total) quality standards that can be supported by public health surveillance functions typically performed by the registry. These standards encompassed data‐driven quality improvement, patient monitoring, and reporting guideline‐concordant care standards. Conclusions: As rural hospitals continue to face resource constraints, multisectoral efforts informed by data from centralized public health surveillance systems can promote quality improvement initiatives across rural communities. While our work remains preliminary, we predict that analytic support provided by the Iowa Cancer Registry will enable the rural network hospitals to focus their capacity toward developing the infrastructure necessary to deliver high‐quality care and serve the unique needs of rural cancer patients. [ABSTRACT FROM AUTHOR]

Little is known about spiritual care in small hospitals and critical access hospitals (CAHs), essential sources of health care in rural areas of the US. Using interview-administered surveys with spiritual care providers, we examined spiritual care services in 19 facilities, including seven small hospitals, nine CAHs, and three freestanding emergency departments, in one religiously-owned healthcare system. We identified four groups of facilities based on intensity/frequency of chaplain availability. A central finding was the variation in spiritual care services provided in these diverse facilities. Of the 16 hospitals in the sample, 11 of them (69%) offered spiritual care from professional chaplains at least three days per week. Support for staff was an important priority in all the facilities. Needs identified include virtual training and support for the spiritual care providers in these settings. Future research should replicate this study in a representative sample of hospitals that serve the rural US population. [ABSTRACT FROM AUTHOR]

Low-titer O-positive whole blood was used extensively by the military during operations in Iraq and Afghanistan. Studies have consistently shown that this therapy is feasible, safe, and effective in the management of hemorrhagic shock in trauma patients, and it is now the standard of care across the US military Joint Trauma System. The military's success in using low-titer O-positive whole blood has renewed the practice in the civilian setting, with recent research confirming its safety and efficacy. In a few short years, use of this treatment for hemorrhagic shock has expanded to more than 80 US level I and level II trauma centers. However, its use is still relatively rare in the rural hospital setting. This article describes the benefits for patients, staff members, and the overall trauma system of using low-titer O-positive whole blood in rural hospitals. [ABSTRACT FROM AUTHOR]

About 10 million individuals in USA presented annually in the emergency department (ED) with chest pain or with signs and symptoms of acute coronary syndrome (ACS). The advent of point of care (POC) devices, able to measure high sensitivity troponin, are a very interesting tool in the ED setting for its rapid turnaround time (<10 min). The present study evaluates the diagnostic performance of the Atellica VTLi (Siemens) in real life setting using the clinical data derived from integrated diagnoses of emergency room staff and cardiologist and in comparison with standard laboratory hs-cTnT assay (Cobas 8000, Elecsys, Roche). 966 patients admitted to the emergency department of "G. Mazzini Hospital" in Teramo, Italy, from July 27, 2022, through June 09, 2023, were enrolled. The diagnostic performance of POC hs-cTnI was evaluated. An appropriate POC hs-cTnI threshold values <4 ng/L supplied a sensitivity and an NPV of 100 % (95 % CI: 99.5–100) in order to achieve rapid rule out for MI through a single measurement at patient presentation in the ED. Furthermore, a derivation POC hs-cTnI concentration >54 ng/L provided a specificity of 97.2 % (95 % CI: 95.9–98.1) and a PPV of 43.5 % (95 % CI: 40.3–46.7) for ruling in MI. This platform showed comparable diagnostic performance for myocardial infarction to the central laboratory. Our data suggest the possible use of the Atellica VTLi hs-cTnI POC assay either in emergency department of urban medical centre, either in rural hospital for triage and patient management. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Rural hospitals are threatened by workforce shortages and financial strain. To optimize regional critical care delivery, it is essential to understand what types of patients receive intensive care in rural and urban hospitals. DESIGN: A retrospective cohort study. SETTING AND PATIENTS: All fee-for-service Medicare beneficiaries in the United States who were 65 years old or older hospitalized in an ICU between 2010 and 2019 were included. Rural and urban hospitals were classified according to the 2013 National Center For Health Statistics Urban-Rural Classification Scheme for Counties. Patient comorbidities, primary diagnoses, organ dysfunction, and procedures were measured using the International Classification of Diseases , 9th and 10th revisions diagnosis and procedure codes. Standardized differences were used to compare rural and urban patient admission characteristics. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 12,224,097 ICU admissions between 2010 and 2019, and 1,488,347 admissions (12.2%) were to rural hospitals. The most common diagnoses in rural hospitals were cardiac (30.3%), infectious (24.6%), and respiratory (10.9%). Patients in rural ICUs had similar organ dysfunction compared with urban hospitals (mean organ failures in rural ICUs 0.5, SD 0.8; mean organ failures in urban ICUs 0.6, SD 0.9, absolute standardized mean difference 0.096). Organ dysfunction among rural ICU admissions increased over time (0.4 mean organ failures in 2010 to 0.7 in 2019, p < 0.001). CONCLUSIONS: Rural hospitals care for an increasingly complex critically ill patient population with similar organ dysfunction as urban hospitals. There is a pressing need to develop policies at federal and regional healthcare system levels to support the continued provision of high-quality ICU care within rural hospitals. [ABSTRACT FROM AUTHOR]

Introduction: Telemedicine infectious diseases consultations (tele-ID consults) improves access to healthcare for underserved/resource-limited communities. However, factors promoting or hindering implementation of tele-ID consults in low-resource settings are understudied. This study sought to fill this gap by describing perceived barriers and facilitators tele-ID consults at three rural hospitals in southeastern Missouri. Methods: Twelve in-depth, semi-structured interviews were conducted with a purposively sampled group of information-rich hospital stakeholders from three rural, southeastern Missouri hospitals with partial or no on-site availability of ID physicians. Our literature-informed interview guide elicited participants' knowledge and experience with tele-ID consults, perceptions on ID consultation needs, and perceived barriers to and facilitators of tele-ID consults. Interview transcripts were coded using an iterative process of inductive analysis to identify core themes related to barriers and facilitators. Results: Perceived barriers to adopting and implementing tele-ID consults included logistical challenges, technology and devices, negative emotional responses, patient-related factors, concerns about reduced quality of care when using telemedicine, lack of acceptance or buy-in from physicians or staff, and legal concerns. Key facilitators included perceived need, perceived benefits to patients and physicians, flexibility and openness to change among staff members and patients, telemedicine champions, prior experiences, and enthusiasm. Discussion: Our findings demonstrate that rural hospitals need tele-ID consults and have the capacity to implement tele-ID consults, but operational and technical feasibility challenges remain. Adoption and implementation of tele-ID consults may reduce ID-physician shortage-related service gaps by permitting ID physician's greater geographic reach. [ABSTRACT FROM AUTHOR]

Introduction: Cancer rates are rising in low- and middle-income countries. While point-of- care ultrasound is now available globally and could serve to mitigate against this rise, its use in diagnosing cancers is inconsistent in lower-resourced healthcare contexts. This proof-of-concept study investigates the feasibility of an ultrasound training concept in a low-resource setting. It evaluates whether this educational concept led to improved knowledge and application of ultrasound diagnostics, cancer screening and staging and patient care. Material and methods: The curriculum was developed through expert exchange and is based on the World Health Organisation's Manual of Diagnostic Ultrasound. It consisted of two didactic components: an on-site training phase across 5 days for a total of 24 hours, and a digital follow-up phase involving the meeting of a bi-weekly tumor board online. The learning objectives of the on-site training were normal imaging and recognition of common pathologies of the abdominal organs, vessels, lymph nodes, female breasts and lungs. The virtual tumour boards met to discuss cases and ultrasound findings, thus aiding continuing professional development after the training sessions had concluded. The face-to-face course component was accompanied by tests given before and after training as well as an evaluation sheet (Likert-scale with 1 = 'completely/very good' and 7 'not at all/very poor'). Results: Of 20 participants from a rural hospital in Tanzania, a total of 16 were included in the analysis (clinical officers n = 6; medical officers n = 10). A significant increase in knowledge (p < 0.01) was measured both in the subjective self-assessment and in the theoretical competence tests. In multivariate linear regression, the status 'medical officers yes' (β = 5.4; p = 0.04) had a significant influence on theory test results at T2. During the 24 virtual tumour board meetings, 28 cases were discussed and a continuous improvement in image acquisition quality was observed. Conclusion: The ultrasound education concept comes with a sustainable increase in clinical competence and improved oncological ultrasound screening locally. There is potential for the transfer of the concept to other locations, which can be explored in the future. [ABSTRACT FROM AUTHOR]

Safeguarding the elderly population in the countryside is an inherent requirement for alleviating social conflicts in rural areas and effectively carrying out China's Rural Revitalization. The existing spatial mismatch between rural elderly service facilities and population distribution in China aggravates the imbalance of facility resource space, how to improve the accuracy of demand and supply results and better measuring the spatial fairness of elderly service is significant to realize the optimal allocation of rural elderly service. Based on the above, this study pays attention to the refined needs of the elderly population, and focuses on the spatial equity of the rural elderly facilities, to make up for the short boards of the basic public services in the countryside and realize the all-round rural revitalization. This study takes Huanxian County in the hilly loess area of Longdong, China as an example and explores the spatial equity of rural elderly services by using the Urban Spatial Network Analysis (UNA) to measure the accessible quantity and supply capacity of elderly services. The results found that there were 553 rural eldercare service facilities in Huanxian County, including 285 eldercare facilities and 268 medical and health facilities, and the spatial distribution is characterized by a southward shift in the east and uneven regional distribution. Overall, the supply capacity of rural pension services was generally good, with the township center as the gathering point and spreading out in a faceted manner, with nearby townships forming a contiguous area; however, there were strong contrasts and obvious differences in the strength of supply capacity. However, the spatial equity of rural eldercare service was poor. In 42.05% of the elderly population grid cells, eldercare service spatial equity was extremely low. The spatial distribution also presented a northern preference over the southern, a western preference over the eastern, and a concentration along the highway. The study explored the realization of spatial equity in the optimal allocation of rural elderly services based on paying attention to the refined needs of the rural elderly population, a vulnerable group, to provide a reference for solving the shortcomings of basic public services in rural areas. The fair allocation of rural elderly services demands that the spatial optimization of facility layout be organically coordinated with policy, management, and post-maintenance, and all elements in the rural territorial system be fully mobilized to achieve the basic guarantee of China's rural elderly problems. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the accuracy and validity of ocular trauma scores (OTS) among patients with open globe injury (OGI) in rural hospital settings and to identify the determinants predicting poor visual outcomes. Materials and Methods: A single-center retrospective cohort study was conducted through a chart review of OGI patients between July 2018 and June 2023 at Bueng Kan Hospital. Demographic and preoperative factors affecting the final visual outcome were evaluated. OTS score for each patient was calculated and categorized. Final visual acuity (VA) after 6 months was compared to the predicted VA from OTS study. Poor visual outcome was defined as legal blindness after 6 months of treatment. Results: Thirty-nine eyes from patients with a mean age of 44.05 years were evaluated. Most subjects were male (94.87%), and workplace injuries were the most common (78.38%). Compared to the OTS study, patients in OTS category 2 achieved a significantly higher percentage of better final VA, while categories 3 and 4 showed similar outcomes. OTS category 1 patients had a lower proportion of no light perception (NLP) outcomes, though the difference was not significant. Poor visual outcomes were predicted by initial VA (OR=4.64), wound extension ≥10 mm (OR=20.66), and lens injury (OR=7.44). Conclusion: OTS is beneficial for predicting final vision in patients with OGI, particularly with less severe trauma. Severe cases can sometimes result in better-than-expected visual outcomes, emphasizing the need for cautious management and counseling by ophthalmologists. Factors that estimate poor visual outcomes involve poor initial VA, wound extension ≥10 mm, and lens damage. [ABSTRACT FROM AUTHOR]

Violence and abuse in rural America are exacerbated by limited access to support services for victims of intimate partner violence (IPV) due to family connections with people in positions of authority, geographic isolation, transportation barriers, stigma of abuse, lack of available shelters and affordable housing, poverty as a barrier to care, and other challenges. Victims of abuse who live in small communities may be well-acquainted with local health care providers and often voter-elected law enforcement officers. Individuals may fear being seen walking into a mental health clinic, with subsequent (and reality-based) fear that deter them from seeking help. Thus, advances in technology are becoming a much-needed option. Although telehealth has been used for some time in rural health settings, only in more recent years has there been an increase toward quality trauma-informed care. With increasing focus on the impact of social determinants of health, agencies continue to shift to telehealth to provide virtual support. Specifically, telehealth visits can potentially extend the reach of the limited number of primary care and mental health providers to those who are significantly in need of services. [Journal of Psychosocial Nursing and Mental Health Services, 62(10), 25–30.] [ABSTRACT FROM AUTHOR]

The article discusses the implementation of the Arizona ECMO Protocol, which aimed to improve the coordination and equity of COVID-19 extracorporeal membrane oxygenation (ECMO) transfers in Arizona. The protocol addressed shortcomings in the existing transfer process, such as lack of effective workflow, situational awareness, referral transparency, and equitable access to care. The protocol involved the centralized collection and distribution of standardized referral forms to all ECMO programs, allowing for a fair evaluation of patients' eligibility for ECMO. The results showed that the protocol significantly increased the proportion of patients evaluated by all ECMO programs and improved transparency and trust among all parties involved. The authors suggest that a similar protocol could be replicated in other regions to enhance equitable access to life-saving resources during times of healthcare strain. [Extracted from the article]

Abstract Ensuring workplace safety for healthcare workers is vital considering the important role they play in various societies which is to save life. Healthcare workers face different risks when performing tasks in various departments within hospitals, hence there is a need to assess work safety analysis procedures among healthcare workers. As a result, this study aims to assess the effectiveness of work safety analysis procedures among healthcare workers at Muvonde and Driefontein Sanatorium rural hospitals in Chirumanzu district. The research applied the descriptive cross-sectional design, combining quantitative and qualitative data collection methods. A questionnaire with both closed and open ended questionnaire was used for data collection among 109 healthcare workers at Muvonde hospital and 68 healthcare workers at Driefontein Sanatorium hospital. Secondary data sources, observations and interviews were also included as data collection methods. Quantitative data collected during the study was analysed using SPSS version 25. Braun and Clarke (2006)’s six phase framework was applied for qualitative data analysis. Ethical approval form was obtained from the District Medical Officer and Midlands State University. Findings of the study indicated that risks identified at Muvonde and Driefontein Sanatorium rural hospitals are classified as ergonomic, physical, chemical, psychosocial and biological risks. Respondents specified that these risks occur as a result of inadequate equipment, poor training, negative safety behaviour, poor management and pressure due to high workload. Safety inspection, safety workshops and monitoring of worker’s safety behaviour were mentioned as measures to manage risks. However, the strengths and weaknesses of the current safety procedures need to be assessed to highlight areas for improvement to reduce occurrence of risks within the hospitals.

Background: In Japan, local governments have rural clinics designated for areas without physicians (RCDA) to secure physicians for rural medical care. Moreover, a medical policy of dispatching physicians between the RCDA and core hospitals for rural areas (CHRA) exists. This study aimed to assess the actual situation of physician migration from RCDAs and those who migrated, and examine the factors associated with their migration. Methods: This retrospective cohort study used biennial national physicians' survey data from 2012 to 2018. It targeted physicians who worked at RCDAs in 2012 and participated in all four surveys (n = 510). The physicians were divided into two groups. One group consisted of physicians who worked continuously at the RCDA over the four study periods (retained physicians, n = 278), and the other included physicians who migrated to other institutions midway through the study period (migrated physicians, n = 232). We tracked the types of facilities where RCDA physicians worked from 2012 to 2018, also examined the factors associated with their migration. Results: Among physicians from RCDAs who migrated to other institutions (n = 151) between 2012 and 2014, many migrated to hospitals (n = 87/151, 57.6%), and some migrated to CHRA (n = 35/87, 40.2%). Physicians in their 40s (Hazard ratio 0.32 [95% CI 0.19–0.55]), 50s (0.20 [0.11–0.35]), and over 60 years (0.33 [0.20–0.56]) were more likely to remain at RCDAs. Changes in their area of practice (1.82 [1.34–2.45]) and an increase in the number of board certifications held by physicians between 2012 and 2018 (1.50 [1.09–2.06]) were associated with migration. Conclusions: Many migrating physicians choose to work at hospitals after migrating from RCDAs. It was seemed that the physician dispatch system between RCDA and CHRA has been a measure to secure physicians in rural areas. Young age, obtaining board certification, and changes in areas of practice were associated with physician migration from RCDAs. [ABSTRACT FROM AUTHOR]

Objective Data Sources/Study Setting Study Design Data Collection/Extraction Methods Principal Findings Conclusions To develop a method of consistently identifying interfacility transfers (IFTs) in Medicare Claims using patients with ST‐Elevation Myocardial Infarction (STEMI) as an example.100% Medicare inpatient and outpatient Standard Analytic Files and 5% Carrier Files, 2011–2020.Observational, cross‐sectional comparison of patient characteristics between proposed and existing methods.We limited to patients aged 65+ with STEMI diagnosis using both proposed and existing methods.We identified 62,668 more IFTs using the proposed method (86,128 versus 23,460). A separately billable interfacility ambulance trip was found for more IFTs using the proposed than existing method (86% vs. 79%). Compared with the existing method, transferred patients under the proposed method were more likely to live in rural (p < 0.001) and lower income (p < 0.001) counties and were located farther away from emergency departments, trauma centers, and intensive care units (p < 0.001).Identifying transferred patients based on two consecutive inpatient claims results in an undercount of IFTs and under‐represents rural and low‐income patients. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim Design Method Results Conclusion Implications for the Profession and/or Patient Care Impact Patient or Public Contribution To explore clinician, child and parent acceptability and usability of the Smileyscope VR device in the context of addressing the unique pain and distress needs of young burn patients.A survey comprising closed and open‐ended questions.Descriptive statistics analysed participant characteristics, pain and analgesia. Qualitative content was collected from April 2022–August 2022 and analysed to identify barriers and enablers. Categories were then mapped onto the Capabilities, Opportunities and Motivation‐Behaviour Wheel (COM‐B) framework.Smileyscope was found to be effective for reducing pain and anxiety during dressing changes by both patients (n = 39) and parents (n = 37). Clinicians (n = 35) reported high self‐efficacy and willingness to reuse the device. However, concerns arose regarding the device's fit and the need for age‐appropriate programmes.Smileyscope demonstrated promise in reducing procedural pain and distress. The device is well accepted by all participants implying ease of implementation. Feedback suggests further program development and fitting optimisation is required.Improved procedural pain has proven to decrease wound healing times, decreasing possible need for further scar management and long‐term consequences after sustaining a burn injury. Smileyscope use in rural hospitals presents valuable opportunities for optimising early paediatric burn pain.Increased burn pain can delay wound healing and have long term physical and psychological impact on patients. Smileyscope was well received within this cohort; however, improvements in device design and programmes were suggested. This study shows the potential for use of Smileyscope as a non‐pharmacological approach to improving paediatric burn pain and distress.While our study included patients, parents and clinicians as research participants, there was no patient or public contribution in the design or conduct of the study, analysis or interpretation of the data. [ABSTRACT FROM AUTHOR]

Breast cancer is a prevalent global health concern affecting millions of women annually. Breast cancer diagnosis can lead to impairment in multiple areas of psychosocial well-being, including physical, social, and emotional functioning. Most of the articles discuss about the treatment aspects but the psychological needs are not much discussed. We carried out 17 semi-structured interview questions in English with women aged 35 to 65 who had been diagnosed with stage I-IV invasive breast cancer within the last four years in 10 participants. Ten participants were recruited from a large rural hospital in India. The findings unveil the emotional turmoil, support systems, coping mechanisms, communication challenges, preparation strategies, and financial considerations that shape the cancer journey. Notably, patients exhibit resilience amidst emotional upheaval, relying on familial and professional support networks. The study emphasizes the importance of structured psychosocial interventions and patient-centered care to address these needs, ultimately enhancing patients' resilience throughout their treatment journey. Possibilities for future research and implications for clinical practice are addressed. [ABSTRACT FROM AUTHOR]

Socioecological determinants of health (SEDOHs) influence disparities in surgical outcomes. However, SEDOHs are challenging to measure, limiting our ability to address disparities. Using a validated survey (SEDOH-88), we assessed SEDOHs in three rural communities in Alabama. We hypothesized that SEDOHs would vary significantly across sites but measuring them would be acceptable and feasible. This was a retrospective review of a prospectively maintained database involving surgical patients who completed the SEDOH-88 and a secondary survey assessing it's acceptability or feasibility from August 2021 to July 2023. Included patients underwent endoscopic, minimally invasive, or open surgery at three rural hospitals: Demopolis (DM), Alexander City (AC), and Greenville (GV). The 107 participants comprised 48 (44.9%) from DM, 27 (25.2%) from AC, and 32 (29.9%) from GV, respectively. The median age was 64 y, and 65.6% were female. When comparing DM to AC and GV by individual factors, DM had the largest Black population (78.7 versus 22.2 versus 48.3%, P < 0.001) and more often required help reading hospital materials (20.5 versus 3.7 versus 10.3%, P = 0.007). When comparing DM to AC and GV by structural and environmental factors, DM had more Medicaid enrollees (27.3 versus 3.7 versus 6.9%, P = 0.033) and lacked fresh produce (18.2 versus 25.9 versus 39.3%, P = 0.033) and internet access (63.6 versus 100.0 versus 86.2%, P < 0.001). The SEDOH-88 had an overall 90.9% positive acceptability and feasibility score. SEDOHs varied significantly across rural communities regarding individual (race or health literacy), structural (insurance), and environmental-level factors (nutritious food or internet access). The high acceptability and feasibility of the SEDOH-88 shows it's potential utility in identifying targets for future disparity-reducing interventions. [ABSTRACT FROM AUTHOR]

Goal: To document shifts in rural hospital service line offerings between 2010 and 2021 and to assess the resulting impacts on hospital profitability. Methods: We used annual Medicare cost report data for all rural hospitals that did not change payment classifications between 2010 and 2021. We documented changes in the percentages of hospitals offering each of the 37 inpatient or ancillary service lines included in the data. We then used panel event studies to assess effects on hospital operating margin for specific service lines that changed most prominently during this period. Principal Findings: Twelve service lines changed by more than 5% during our period of analysis. These are highlighted by hospitals adding rural health clinics (+32%) and CT scans (+20%) and removing delivery rooms (-21%) and skilled nursing facilities (-19%). Panel event studies demonstrated that the addition or subtraction of most services did not have statistically significant impacts on future hospital operating margins. Notable exceptions were the addition of rural health clinics and the removal of delivery services, both of which positively affected future operating margins. The addition of occupational therapy services had a positive effect on operating margin in the near term, but adding MRI services had a negative effect. Practical Applications: The finding that only a select few service line changes resulted in meaningful impacts to hospital operating margins suggests that hospital leaders should be wary of implementing such changes as a means of improving financial viability. [ABSTRACT FROM AUTHOR]

An interview with Jefferson Community Health and Life chief executive officer (CEO) Burke Kline is presented. Topics mentioned include the state of health care in rural areas, some ways on how to determine and attract successful service lines in rural hospitals, the challenges faced by rural health care providers in managing critical access hospitals (CAH) and the difference between Jefferson and CAH.

The article discusses an evidence-based practice strategy employed by a rural hospital emergency department to successfully decrease the patients who left without being seen (LWBS) and nurse vacancy rates. Cited are the positive impact of a team-based model of care on emergency department (ED) patient wait times and LWBS rates, the effectiveness of the strategy in resolving the underlying issues impacting care delivery, and the study implications for nurse leaders.

Background: Pneumonia stands as a significant global contributor to mortality, particularly in South Africa, where it ranks as the second leading cause of death. The country's high prevalence of HIV infection compounds this issue, significantly increasing mortality rates associated with community-acquired pneumonia (CAP). Objective: This study aimed to audit CAP patient management at a regional rural hospital in KwaZulu-Natal. Method: A retrospective review of patient files from September to December 2016 was undertaken. Data extraction from clinical files, conducted according to inclusion criteria, was transferred to a data collection sheet and analyzed using SPSS version 21. Results: The review encompassed 124 patient files over four months, revealing that 117 (94.4%) patients were not managed by the Standard Treatment Guidelines and Essential Medicines List for South Africa. Of the patients admitted with CAP, 54% were HIV positive, and 49 (39.5%) patients succumbed to the illness. Notably, none of the patients underwent assessment using a severity score. Conclusion: The findings underscore a need for more adherence to South African guidelines for managing CAP among staff at the rural regional hospital. This leads to severe consequences, exemplified by the high mortality rate. Urgent intervention is required to incorporate severity assessment scores into pneumonia evaluations, thus enabling appropriate clinical management. Contribution: This study sheds light on the significant impact of CAP within the South African hospital context, delineating critical gaps in clinical care and emphasizing the imperative to address clinical inertia. [ABSTRACT FROM AUTHOR]

Time off work after traumatic hand injury not only affects individuals but also has socioeconomic repercussions, becoming a serious problem from the viewpoint of labor shortages. In depopulated rural areas, the impact of labor shortages due to time off work is more serious than in urban areas; however, few studies have examined return to original work in rural areas. The purpose of this study was to investigate the patient demographics at the time of hand injury that affect return to original work in a rural area of Japan. We retrospectively examined 246 patients with traumatic hand and/or forearm injuries who were working at the time of injury, and who underwent surgical operations and postoperative rehabilitation in a level II hospital in a rural agricultural area. We examined patients' initial demographic data, including gender, age, occupation (white or blue collar), employment status (self-employed, full-time, or part-time workers), complications other than hand injury, workers' compensation, dominant hand injury, and injury severity as determined using the modified Hand Injury Severity Score. Multivariate logistic regression analysis examined the association between initial patient demographics and return to original work within 150 days after injury. In total, 186 patients (76 %) were able to return to original work within 150 days. A multivariate logistic regression analysis showed that three explanatory variables (i.e., severity of injury, complications other than hand injury, and female gender) significantly compromised return to original work. In the treatment of traumatic hand injury, intensive support should be provided for return to original work for patients who are expected to have difficulty returning to work quickly. In addition, labor shortages can be mitigated by sharing information with the workplace about patients' prospects of return to original work. [ABSTRACT FROM AUTHOR]

This evidence-based project was implemented and evaluated the impact of using the nurse champion model to increase compliance and facilitate best practices for developmental positioning in the NICU. Education provided by a newly developed nurse champion team reinforced the knowledge and skills needed to use developmental positioning. Measurements included compliance with documentation about positioning, nurse champions' effectiveness, and intent to use the nurse champion model. Participants included twenty-five female NICU registered nurses with varying levels of experience. The focus was on nurses caring for preterm infants that were 35 weeks or less. Electronic medical record data indicated compliance with developmental positioning for the target population. A postimplementation survey indicated participants supported use of nurse champions to implement change. The nurse champion model influenced change in electronic medical record documentation of developmental positioning and support for nurse champions. [ABSTRACT FROM AUTHOR]

The research team assessed community acceptability of prehospital stroke telemedicine services in rural O‘ahu communities. Tools were developed to evaluate patient-centered goals about implementing ambulance-based telemedicine which aimed to retain appropriate patients in community hospitals and improve thrombolytic treatment times. Using a mixed methods approach, the team surveyed well-appearing adults (ie, able to complete survey and interview) at O‘ahu community events. Participants were asked to complete a short Likert-scale questionnaire (n=263) followed by a semi-structured interview (n=29). Data were summarized by descriptive and inferential statistics. Comparisons between rural and urban groups were made by chi-square analysis and Wilcoxon rank-sum 2-tailed test. Interviews were transcribed, coded, and analyzed using inductive and deductive methods. The findings suggest that use of prehospital telemedicine for specialty care is viewed favorably by both rural and urban respondents. Additionally, most respondents felt comfortable staying at their local hospital if they had access to a specialist by telemedicine. However, mistrust in rural hospitals may be a potential barrier to implementation. Compared to urban respondents, rural respondents were less confident in their local hospital’s resources and capabilities for stroke care. The findings identified a potential misalignment of the project’s goal with some patients’ goal to use emergency medical services (EMS) to bypass rural hospitals for stroke care. Future community outreach efforts are needed to encourage activation of EMS and highlight the advantages of utilizing prehospital telemedicine for accessing specialty care thereby improving treatment times. [ABSTRACT FROM AUTHOR]

Objective: Fatal overdoses are the third leading cause of death in the pediatric population. Substance use disorders (SUD) screening is not routinely done in primary care practices. Early screening and intervention for adolescent SUD could mitigate future harm. Methods: We conducted a 3-month pilot adapting universal screening using the CRAFFT tool in patients aged 12 to 17 presenting to an urban and a rural primary care practice during well-child and acute/sick-child visits. We collaborated with our pediatric addiction service to ensure access availability for further assessment and treatment for all positively screened patients; this was broadly communicated to primary care providers. Results: There was a higher CRAFFT completion rate in the urban site (90%, vs 52.6% in our rural site). The majority of CRAFFT questionnaires were completed during acute/sick-child visits in both study sites. Moreover, we found a higher positive screen rate in our rural practice (14.6%, vs 2.4% in our urban practice). Only 27% of positively screened patients had substance use addressed by their providers. No pediatric addiction referrals were made. Conclusions: Findings suggest provider-level barriers exist despite having adequate specialty referral sources and institutional encouragement. Future work is needed to explore these barriers. [ABSTRACT FROM AUTHOR]

Purpose: While limited resources can make high‐quality, comprehensive, coordinated cancer care provision challenging in rural settings, rural cancer patients often rely on local hospitals for care. To develop resources and strategies to support high‐quality local cancer care, it is critical to understand the current experiences of rural cancer care physicians, including perceived strengths and challenges of providing cancer care in rural areas. Methods: Semi‐structured interviews were conducted with 13 cancer providers associated with all 12 non‐metropolitan/rural Iowa hospitals that diagnose or treat >100 cancer patients annually. Iterative thematic analysis was conducted to develop domains. Findings: Participants identified geographic proximity and sense of community as strengths of local care. They described decision‐making processes and challenges related to referring patients to larger centers for complex procedures, including a lack of dedicated navigators to facilitate and track transfers between institutions and occasional lack of respect from academic physicians. Participants reported a desire for strengthening collaborations with larger urban/academic cancer centers, including access to educational opportunities, shared resources and strategies to collect and monitor data on quality, and clinical trials. Conclusions: Rural cancer care providers are dedicated to providing high‐quality care close to home for their patients and would welcome opportunities to increase collaboration with larger centers to improve coordination and comprehensiveness of care, collect and monitor data on quality of care, and access continuing education opportunities. Further research is needed to develop implementation approaches that will extend resources, services, and expertise to rural providers to facilitate high‐quality cancer care for all cancer patients. [ABSTRACT FROM AUTHOR]

Purpose: Hospitals are increasingly the target of cybersecurity threats, including ransomware attacks. Little is known about how ransomware attacks affect care at rural hospitals. Methods: We used data on hospital ransomware attacks from the Tracking Healthcare Ransomware Events and Traits database, linked to American Hospital Association survey data and Medicare fee‐for‐service (FFS) claims data from 2016 to 2021. We measured Medicare FFS volume and revenue in the inpatient, outpatient, and emergency room setting—at the hospital‐week level. We then conducted a stacked event study analysis, comparing hospital volume and revenue at ransomware‐attacked and nonattacked hospitals before and after attacks. Findings: Ransomware attacks severely disrupted hospital operations—with comparable effects observed at rural versus urban hospitals. During the first week of the attack, inpatient admissions volume fell by 14.7% at rural hospitals (P =.04) and 16.9% at urban hospitals (P =.01)—recovering to preattack levels within 2‐3 weeks. Outpatient visits fell by 35.3% at rural hospitals (P<.01) and 22.0% at urban hospitals (P =.03) during the first week. Emergency room visits fell by 10.0% at rural hospitals (P =.04) and 19.3% at urban hospitals (P =.01). Travel time and distance to the closest nonattacked hospital was 4‐7 times greater for rural ransomware‐attacked hospitals than for urban ransomware‐attacked hospitals. Conclusions: Ransomware attacks disrupted hospital operations in rural and urban areas. Disruptions of similar magnitudes may be more detrimental in rural areas, given the greater distances patients must travel to receive care and the outsized impact that lost revenue may have on rural hospital finances. [ABSTRACT FROM AUTHOR]

Purpose: The federal 340B Drug Pricing Program allows eligible hospitals, including critical access hospitals (CAHs), to obtain outpatient drugs at a discounted rate. CAHs likely benefit from 340B participation because they are often under‐resourced and serve at‐risk patient populations. The objective of this study was to understand predictors of 340B program participation among CAHs, and how participation varies with community‐level social vulnerability. Methods: We used a cross‐sectional study design to assess the relationship between 340B participation in 2019 and community vulnerability status using 2018 data from the CDC's social vulnerability index (SVI) among acute care CAHs. Analyses used linear probability models adjusted for hospital‐level characteristics. Findings: In bivariate analyses, CAHs participating in the 340B program had lower overall social vulnerability scores, relative to nonparticipating, eligible, and ineligible CAHs, respectively (43.8 vs. 48.7 vs. 64.7, p < 0.10). In adjusted regression models, greater community vulnerability rankings due to socioeconomic status (–0.129, p < 0.05) and minority status and language (–0.092, p < 0.05) were associated with decreased 340B participation. Higher hospital operating margin was associated with increased 340B participation (0.163, p < 0.05). Although the number of for‐profit CAHs ineligible for 340B was small, they had the highest community‐level social vulnerability score and lowest hospital operating margin on average. Conclusions: CAHs located in areas of high community vulnerability are less likely to participate in the 340B program. Some vulnerable patient populations served by CAHs may be excluded from 340B program benefits. [ABSTRACT FROM AUTHOR]

Introduction. Rural hospitals provide secondary care for much of the rural New Zealand population. Little is known about community perspectives of the health and social contribution. Aim. This descriptive qualitative study aimed to explore community views on the role of their rural hospital in a low socioeconomic rural district with a high Māori and Pacific population. Methods. Semi-structured individual and focus group interviews were conducted with rural community members about the perceived role of their rural hospital. Iterative thematic analysis was undertaken. Results. In total, 22 participants were interviewed. Thematic analysis yielded four themes: (i) rural hospitals as a safety net – providing access to emergency care and mitigating limited primary care access; (ii) providing personalised, culturally aware care; (iii) facilitating family/whanau support; and (iv) doing the best with limited resources. The latter included pragmatism about resource constraints, but a preference for the hospital to remain open. Discussion. Rural hospitals contribute to community safety by enhancing access to emergency care and mitigating difficulties in access to primary care. The local contextual knowledge of rural hospital providers allows personalised, family-centred and culturally-responsive care. Despite service centralisation, rural hospitals are wanted by their communities. Rural health planners should consider how to maximise the breadth of locally-provided services to reduce the impacts of travel and transfer for care [ABSTRACT FROM AUTHOR]

Until recently, most syringe services programs (SSPs) in the United States operated in metropolitan areas. This study explores how SSP implementers at rural health departments in Kentucky secured support for SSP operations. In late 2020, we conducted in-depth, semi-structured interviews with 18 people involved with rural SSP implementation in Kentucky. Participants were asked to reflect on their experiences building support for SSP operations among rural health department staff and community members. Participants reported that attitudes and beliefs about SSP implementation among rural health department staff shifted quickly following engagement in educational activities and interaction with SSP clients. Participants explained that successful SSP implementation at rural health departments required sustained educational activities among community members and authorizing authorities. Future work should explore how rural communities may advocate for low-threshold and evidence-based policies that support the provision of harm reduction services. [ABSTRACT FROM AUTHOR]

Background. Paediatric patients in Australia experience lengthy wait times for Primary and Allied Healthcare Service (PAHCS) appointments. This results in a lack of satisfaction and adverse health outcomes. However, very few studies have explored wait times for appointments with PAHCSs in Australia. This study explored the length of wait time and associated barriers to timely access to paediatric PAHCSs in Australia. Methods. The scoping review followed PRISMA‐ScR guidelines for Preferred Reporting Items for Systematic Reviews and Meta‐Analyses. We comprehensively searched for relevant studies from five databases, including Scopus, Emcare, Medline (via Ovid), CINAHL, and Google Scholar in August 2023 without any time limitations. Studies that reported qualitative findings on the wait times and associated barriers to timely accessing to PAHCSs were selected in this scoping review. We performed a reflexive thematic analysis using NVivo software in this review. Results. A total of seven studies out of ninety‐one retrieved records were eligible to be included in this review. Studies show that Australian children, in general, had to wait more than one year for health assessments and interventions in PAHCSs. The long waiting times were perceived as frustrating and worrying by caregivers of children. Several overarching themes related to the barriers of timely accessing to paediatric PAHCSs in Australia were identified, such as strict appointment criteria for children, disparity between demand and provision, parental unawareness, and inadequate public funding in rural PAHCSs. Conclusion. Australian paediatric patients are severely burdened with long wait times for appointments with PAHCSs, primarily, due to the poor government initiatives in rural PAHCSs. This study suggested that the criteria for booking an appointment in PAHCSs need to be simplified. Besides, adequate public health funding and the provision of resources are required in rural PAHCSs. [ABSTRACT FROM AUTHOR]

The purpose of this study was to examine the effect of psychological well-being on job performance among nurses and midwives in rural and urban hospitals in Ghana amidst COVID-19. The study adopted a purely quantitative approach, using the explanatory research design. Data were collected from 262 nurses and midwives in two selected hospitals in the Central Region of Ghana. The Structural Equation Modelling was used to analyze the data collected. The results revealed that the levels of psychological well-being and job performance were high in both hospitals amidst the pandemic. Further, it was observed that although psychological well- being had significant influence on job performance among the nurses and midwives in both rural and urban communities, the effect was more significant in the urban settlements. Given these findings, the study recommended that in order to effectively improve the job performance of nurses and midwives, management must adopt policies such as, flexible work arrangements, leave policy, and counselling services to support their psychological well-being. [ABSTRACT FROM AUTHOR]

Objective Introduction Setting Participants Design Results Conclusions To understand the motivations of champions who worked to bring about system and practice change that supported routine screening for intimate partner violence (IPV) in two rural emergency departments (EDs).Practice changes are required to achieve routine and effective identification and response to IPV. Nurses play a significant role in affecting such practice change. This paper identifies the motivations of champions in the ED setting who successfully brought about such change.The EDs of two Level 5 tertiary hospitals within a rural Local Health District (LHD) of New South Wales, Australia.Twenty‐three individuals who identified as champions and worked to introduce routine IPV screening in two rural hospital EDs.Qualitative longitudinal semi‐structured interviews employing a process of constant comparison and an interpretive framework to analyse data thematically. Interviews were carried out between June and August 2017 and again between July and August 2019.Over the period of the study, routine screening was established, and screening rates steadily increased from a low baseline to a significantly higher rate. Three aspects of champion motivation emerged from the analysis: formation of an identity as a champion, making a difference to a significant social justice issue and providing quality and community‐relevant care.This study is the first study to report on champions and their motivation as they supported IPV practice change in the ED. The findings highlight the capacity for innovation in rural health services, with important implications for other settings looking to translate similar programs. Understanding motivating factors may assist in improved utilisation and support for champions. This is vital if champions are to bring about required practice change within their service and ensure the needs of individuals experiencing IPV are effectively met. [ABSTRACT FROM AUTHOR]