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PURPOSE: To perform an environmental scan of the current status of reimbursement for obstetric and gynecology services and identify problematic issues and opportunities for change. The areas that were evaluated include the American Medical Association (AMA) relative value unit assignment process, payer rates (where available), and trends in employment and salary determination for obstetrician-gynecologists (ob-gyns). METHODS: This report was developed by members of the American College of Obstetricians and Gynecologists' (ACOG) Committee on Health Economics and Coding using public-facing payment data from the Medicare Physician Fee Schedule and state Medicaid programs, as well as published research and commentary on payment for physicians, maternal health, and gynecologic surgery. Data from the Centers for Disease Control and Prevention were used to describe typical patient characteristics, and practice survey reports from the AMA were analyzed. Finally, an anonymous online survey was distributed to 27,854 members of ACOG in March 2022, with a response rate of 10.8% (3,018 members) and a CI of ±1.7%. FINDINGS: The evaluation found that payment for ob-gyns is heavily influenced by the values and rates set by third-party payers, a patient case-mix that includes a higher-than-average number of patients with Medicaid insurance, and the increase of employed physicians reliant on salary contracts that include productivity requirements and bonuses. RECOMMENDATIONS: The Committee identified action items, including payment reform for obstetric services; advocating for gynecologic surgery time as a priority for hospital administration; developing resources to assist employed physicians with payment, practice, and business management; developing a business and coding curriculum for students and early-career physicians; and continued advocacy with private and public policymakers who influence physician payment. [ABSTRACT FROM AUTHOR]

Case: This article reports a case of a 72-year-old man with bilateral total hip joint replacements who suffered cuts to his hands while butchering a wild boar. He presented to the emergency department with fevers and unilateral hip pain. Erysipelothrix rhusiopathiae (E. rhusiopathiae) was isolated on hip aspirate and blood cultures. E. rhusiopathiae is a well-recognized zoonotic infection in humans, particularly in at-risk hosts, most commonly infecting swine. Infection is spread by ingestion or through skin abrasion. Conclusion: This illustrates an example of successful operative and perioperative management of prosthetic joint infection secondary to E. rhusiopathiae , particularly microbiological identification, within a multispecialty team of physicians and surgeons. [ABSTRACT FROM AUTHOR]

The article provides information on the nursing clinical shared governance (CSG) at Gillette Children's, a pediatric subspecialty healthcare organization based in St. Paul, Minnesota. Topics discussed include the opportunity being offered by its unique patient population to nurses to be innovative in medical care, the organization's clinic sites in the state and the number of nurses working for the organization, the revision of the CSG model, an evaluation of nurses' satisfaction with CSG.

Background: Although all hospitals aim to deliver high-quality care, there is considerable variation in their adoption of quality management (QM) practices. Organizational and environmental factors are known to drive strategic decision-making in hospitals, but their impact on the adoption of QM practices remains unclear., Purpose: Our study aims to identify multiple organizational and environmental factors that explain variation in the adoption of QM practices among hospitals and to explore mechanisms underlying these relationships., Methodology: We conducted a two-phase, sequential mixed-methods study of German acute care hospitals. The quantitative phase used between-effects regressions to identify factors explaining variation in the number of QM practices adopted by hospitals from 2015 to 2019. The qualitative phase used semistructured interviews with quality managers to gain in-depth insights., Results: The number of QM practices adopted by a hospital was significantly associated with factors like hospital size and the presence of an emergency department or QM steering committee. Our qualitative findings highlighted potential mechanisms such as the presence of an emergency department serving as a proxy for organizational complexity or urgency of case-mix., Conclusion: We provide an overview of factors driving QM adoption in hospitals, extending beyond the focus on single factors in previous research. Future studies could explore additional factors highlighted by our interviewees., Practice Implications: Our results can inform interventions to strengthen QM in hospitals and guide future research on this topic., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

The article discusses the expansion of intensive care unit (ICU) space and equipment to handle coronavirus disease 2019 (COVID-19) patients and the staffing of these pop-up ICUs with skilled nurses in New York in October 2020. Topics covered include the buddy staffing approach which pairs an ICU nurse with a non-ICU nurse to provide patient care, and the neuroscience staffing model. Also noted is the resulting elevation of practice by these nurses during the pandemic.

Background: The purpose of the present study was to assess the impact of the coronavirus disease 2019 (COVID-19) pandemic on orthopaedic and trauma surgery departments in university hospitals in Germany in order to clarify current challenges.Methods: In this cross-sectional study, an online-based anonymous survey was conducted within the Convention of University Professors of Orthopaedic and Trauma Surgery in Germany from April 3 to April 11, 2020. A bipolar 5-point Likert scale (with possible responses of "totally disagree," "rather disagree," "neutral," "rather agree," and "totally agree") was applied. Fifty-two (69.3%) of 75 clinic directors participated.Results: Communication and cooperation with the government, hospital administration, and other departments during the COVID-19 pandemic were mainly perceived as appropriate. However, only 7 respondents (13.7%) totally agreed or rather agreed with the statement that the authorities are supporters of orthopaedic and trauma surgery departments. Substantial financial and personnel changes in orthopaedic and trauma surgery departments of university hospitals were reported, resulting in an average reduction of 49.4% in operating room capacity and an expected 29.3% loss of revenue. In addition, 14.7% of physicians were reallocated from orthopaedic and trauma surgery to other care-delivery environments.Conclusions: Our study demonstrated that the COVID-19 pandemic has had a substantial impact on orthopaedic and trauma surgery departments in German university hospitals. Distinct structural and financial effects were noted. Nevertheless, the present study demonstrates the commitment of our specialty to overcome the pandemic by providing competent personnel as well as close cooperation with the hospital administration and other departments.Clinical Relevance: To our knowledge, this is the first Germany-wide survey among the heads of orthopaedic and trauma surgery departments in university hospitals on the impact of the COVID-19 pandemic. The survey results may help to inform system-wide decision-making in Germany, in Europe, and beyond. [ABSTRACT FROM AUTHOR]

The article explores the concept of resilience and the ways that resilience training can help nurses cope with organizational changes. Topics covered include the negative effects of constant change within an organization, the signs of change fatigue in nurses, and a study which has found that nurses with higher resilience levels had a lower risk of emotional exhaustion.

Objective: To evaluate the feasibility, acceptability, and compliance of a remote blood pressure monitoring protocol implemented as a quality improvement measure at the hospital level for management of hypertension in postpartum women after hospital discharge.Methods: This is an ongoing quality improvement project that included women admitted to the postpartum unit of a single tertiary care hospital. We designed nursing call center-driven blood pressure management and treatment algorithms, which were initiated after hospital discharge until 6 weeks postpartum. Women are eligible to participate if they have a diagnosis of chronic hypertension, superimposed preeclampsia, gestational hypertension, preeclampsia, or postpartum hypertension and have access to a text messaging-enabled smartphone device. After identification by an obstetric care provider, women are enrolled into the program, which is automatically indicated in the electronic medical record. Maternal, obstetric, and sociodemographic data were obtained from the electronic medical record.Results: Between February 2018 and January 2019, we enrolled 499 patients. Here we report on the first 409 enrolled patients. Participants include 168 (41%) with gestational hypertension, 179 (44%) with preeclampsia with no history of chronic hypertension, 49 (12%) with chronic hypertension with superimposed preeclampsia, and 13 (3%) with postpartum preeclampsia. One hundred seventy-one (42%) participants had antihypertensives initiated or titrated through the program. Three hundred forty women (83%) continued the program beyond 3 weeks postpartum, and 360 (88%) attended an in-person 6-week postpartum visit. Two hundred thirty-five out of 250 women who completed a postprogram survey (94%) reported satisfaction with the program.Conclusion: In this study, we detail results from an ongoing remote blood pressure monitoring program. We demonstrate high compliance, retention, and patient satisfaction with the program. This is a feasible, scalable remote monitoring program connected to the electronic medical record. [ABSTRACT FROM AUTHOR]

Background and purpose: The increasing prevalence of chronic diseases is driving health care systems to rethink their operations. Despite numerous studies supporting the advantages of primary health care nurse practitioners (PHCNPs) in chronic disease management, implementing practices that fully use the skills of these practitioners seems impeded in the Canadian province of Quebec. This study explores the views of leaders involved in primary health care regarding the contributions PHCNPs can make in chronic disease management and the challenges they face in doing so. Methods: Through semistructured interviews, an exploratory descriptive qualitative study was conducted with 20 key informants across Quebec who hold a variety of professional positions connected to PHCNPs. Conclusions: Primary health care nurse practitioners were perceived to be able to improve self-management support for chronic diseases. In reality, however, PHCNPs are mainly devoting their time to clientele in acute care, and current regulations governing their practices limit their involvement in chronic disease management. Implications for practice: Integrating PHCNPs offers a unique opportunity for health care settings to redefine the roles of family physicians and registered nurses and to restructure practices toward a chronic disease-oriented system. A clinical manager should be designated to monitor this restructuring process and ensure its success. [ABSTRACT FROM AUTHOR]

Objectives: Percutaneous gastrostomy tube placement is performed in patients requiring long-term enteral nutrition. Although both endoscopic and fluoroscopic techniques may be used, there are inherent risks and potential complications associated with both procedures that are not generally known to referring physicians. The purpose of this study was to compare and contrast indications for placement and procedurally related complications between fluoroscopic and endoscopic gastrostomy tubes techniques at a tertiary care facility.Methods: A retrospective cohort study was performed. All consecutive patients with either percutaneous endoscopic (PEG) or percutaneous radiologic (PRG) gastrostomy tube placement between October 2011 and January 2013 were eligible for inclusion. Basic demographic information, American Society of Anesthesiologists score, procedure indication, laboratory data, and use of anticoagulation were recorded. Both direct and indirect procedural complications were documented if they occurred 30 days after gastrostomy tube placement, and were classified and scored based on severity and need for further intervention.Results: A total of 297 patients met the inclusion criteria, 150 of whom had gastrostomy tubes placed fluoroscopically and 147 of whom had them placed endoscopically. There was no statistically significant difference in direct complications within the first 30 days (PEG 6.8% vs PRG 8%); however, the type of complication observed varied between the two groups. Although superficial wound infections and buried bumpers were more common in the PEG group, bleeding was more common in the PRG group.Conclusions: Placement of gastrostomy tubes either endoscopically or fluoroscopically is relatively safe with similar indications. Although the complication rate between the two groups was not significant, the types of procedural complications observed did vary. [ABSTRACT FROM AUTHOR]

The article offers information on the 47th Society of Critical Care Medicine (SCCM) Critical Care Congress held in San Antonio, Texas in February 2018. Topics include focus of the congress on strategies that can be implemented by hospital administrations to promote health and value of critical care workforce; the SCCM intensive care units (ICU) Liberation program; and the Surviving Sepsis Campaign, which offers guidance on care of patients who have begun sepsis-mediated organ dysfunction.

Hospitals are facing increasing cost pressures due to cutbacks by Medicare, Medicaid, and managed-care organizations. There are also rising concerns that public policy may exacerbate the problem. In lieu of these concerns, nascent innovative ways of generating increased revenues are beginning to appear. In particular, a few hospitals have adopted retail sales practices to generate significant nonmedical services revenues. The hospital retail sales opportunity has been compared with that of the airport industry where nearly 50% of revenues are generated by sales of retail products as opposed to aeronautical-related transactions. This initial investigation included a qualitative interview of a health care retail sales expert and a pilot survey of 100 hospital senior executives to gauge the current state of this phenomenon. The industry expert suggested that only 2% of US hospitals have pursued this initiative in a meaningful way. Of the 44 survey responses, only 9 institutions were engaged in e-commerce or retail sales activities. Questions remain as to why this opportunity remains unrealized, and additional research is proposed. [ABSTRACT FROM AUTHOR]

Background: All-cause 30-day hospital readmission is a heart failure (HF) quality of care metric. Readmission costs the healthcare system $30.7 million annually. Specific structure, process, or patient factors that predispose patients to readmission are unclear. Objective: The aim of this study is to determine whether the addition of unit-level structural factors (attending medical service, patient-to-nurse ratio, and unit HF volume) predicts readmission beyond patient factors. Methods: A retrospective chart review of 425 patients who resided in Maryland and were discharged home in 2011 with the primary diagnosis of HF from a large, urban academic center was conducted. Results: The patients were predominately (66.6%) black/African American, with mean (SD) age of 62.2 (14.8) years. Men represented 48.2% of the sample; 32% had nonischemic HF, 31.3% had preserved ejection fractions, 25.4% had implantable cardioverter defibrillators, and 15.3% had permanent pacemakers. Average length of stay was 6.0 days. All-cause 30-day hospital readmission rate was 20.2%. Inpatient unit HF discharge volume significantly predicted readmission after controlling for patient factors. Conclusions: The study found that discharge from inpatient units with higher HF discharge volume was associated with increased risk of readmission. The findings suggest that in caring for patients with severe HF, inpatient unit HF discharge volume may negatively impact care processes, increasing the odds of hospital readmission. It is unclear what specific care processes are responsible. The discharge period is a vulnerable point in care transition that warrants further investigation. [ABSTRACT FROM AUTHOR]

Objective: Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment.Design: Mixed-methods study.Setting: Medical and surgical ICUs at three large academic hospitals.Participants: Three hundred three nurses, intensivists, and advanced practice providers.Measurements and Main Results: Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships.Conclusions: Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting. [ABSTRACT FROM AUTHOR]

Objective: To describe ICU admission triage and outcomes in octogenarians.Design: Multicenter prospective observational study.Setting: Three nonuniversity hospitals and three university hospitals in Norway.Patients: Patients 80 years old or older who were referred for ICU admission from November 2013 to October 2014.Interventions: None.Measurements and Main Results: Of the 355 included patients, 105 (29.6%) were refused ICU treatment. Risk factors for ICU refusal in patients considered "too ill/old" were advanced age and low functional status. Risk factors for ICU refusal in patients considered "too well" were advanced age, male sex, university hospital admission, comorbidity, and low Simplified Acute Physiology Score 3. Overall ICU survival was 71.6%. Hospital and 1-year survival were 56.0% and 40.0% in the ICU-admitted, 65.2% and 50.0% in the nonadmitted patients considered too well, and 32.7% and 11.5% in patients considered too ill/old, respectively. The adjusted Kaplan-Meier curves showed significantly lower survival for nonadmitted patients considered too ill/old than for ICU-admitted patients and nonadmitted patients considered too well. At follow-up, triage patients had lower health-related quality of life than an age- and sex-matched control group in the domains of self-care, usual care, and anxiety and depression, and a lower EuroQol visual analog scale scores.Conclusions: Overall, 29.6% of the patients were refused ICU treatment. The adjusted survival analyses showed a significantly higher survival for ICU-admitted octogenarians than for nonadmitted patients who were considered too ill/old, indicating a benefit of ICU admission. Overall, the follow-up of triage patients showed lower health-related quality of life than an age- and sex-matched control population. [ABSTRACT FROM AUTHOR]

Ever-increasing complexity and contradiction in the health care industry often leave hospital ad-ministrators wondering whether they can still make a positive difference for patients. In this context, hospital administrators can regain both perspective and enthusiasm by revitalizing their direct connections with the patients, caregivers, and organizations they serve. Hospital administration remains a special calling, and this article profiles 10 core competencies that will keep health professionals close to their customers, colleagues, and the reasons they entered the helping professions. This intimate knowledge of the organization and its resources coupled with the ability to communicate effectively typically trump advanced education or technical skills in successfully navigating genuinely consequential situations. Hospital administrators who master and practice the 10 competencies can indeed make a positive difference for patients and find great personal reward in doing so. competencies can indeed make a positive difference for patients and find great personal reward in doing so. [ABSTRACT FROM AUTHOR]

Strong leadership is critical in disaster situations when “patient surge” challenges a hospital’s capacity to respond and normally acceptable patterns of care are disrupted. Activation of the emergency operations plan triggers an incident command system structure for leadership decision making. Yet, implementation of the emergency operations plan and incident command system protocols is ultimately subject to nursing and hospital leadership at the service- and unit level. The results of these service-/unit-based leadership decisions have the potential to directly impact staff and patient safety, quality of care, and ultimately, patient outcomes. Despite the critical nature of these events, nurse leaders and administrators receive little education regarding leadership and decision making during disaster events. The purpose of this study is to identify essential competencies of nursing and hospital administrators’ leadership during disaster events. An integrative mixed-methods design combining qualitative and quantitative approaches to data collection and analysis was used. Five focus groups were conducted with nurse leaders and hospital administrators at a large urban hospital in the Northeastern United States in a collaborative group process to generate relevant leadership competencies. Concept Systems Incorporated was used to sort, prioritize, and analyze the data (http://conceptsystemsinc.com/). The results suggest that participants’ institutional knowledge (of existing resources, communications, processes) and prior disaster experience increase leadership competence. [ABSTRACT FROM AUTHOR]

Background: The hospital ward system is the core service unit of a hospital and an important aspect of hospital management. The maturity of the hospital ward system represents the level of development and improvement in ward management and services. In order to improve the quality of hospital services, it is significant to assess the maturity of the ward system. Although various assessment methods have been proposed in existing studies, there are some issues such as a single-dimensional factor system, subjectivity in qualitative factor values, and insufficient objectivity in the evaluation methods., Methods: Therefore, based on the data collection of the factors used in the existing literature, this study made correlation analysis, determined the similarity of factors, and established a maturity assessment factor system satisfying distinctiveness and comprehensiveness. Furthermore, an evaluation method for the weights of each factor was proposed based on the fuzzy analytic hierarchy process, while taking account of the ambiguity of expert information. In addition, through the technique for order of preference by similarity to ideal solution method, an objective evaluation method for the maturity of the hospital ward system was established. Finally, a case study involving 6 hospitals in a specific location was conducted., Results: There are a total of 16 factors used to assess the maturity of the hospital ward system, among which the most important is Doctor service. The maturity degree of the 6 researched hospitals are 0.4517, 0.0035, 0.4254, 0.8681, 0.6636, 0.1586, and the maturity degree of the 6 researched hospitals are II, I, II, IV, III, I., Conclusion: The factor system constructed in this study effectively reflected the importance of human-related factors in the development process of ward system. The evaluation results were consistent with the actual situation, demonstrating the effectiveness of the proposed method., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

The article describes the success of the cardiovascular intensive care unit at KentuckyOne Health Jewish Hospital in achieving increased efficiency and nursing satisfaction through improved organization. Topics discussed include the use of the FOCUS-PDSA or find, organize, clarify, understand, select-plant, do, study, act quality improvement model at the unit, the identification of supply efficiency as an area for improvement, and a staff survey which provided suggestions for improvement.

INTRODUCTION: Maternal echocardiography has demonstrated cardiac changes in the setting of preeclampsia; however, its effect on hospital management has not been well studied. The objective of this study was therefore to determine whether abnormal postpartum echocardiography is associated with a change in hospital management in patients with severe preeclampsia. METHODS: This was a retrospective cohort study of patients with severe preeclampsia (20–42 weeks) who received postpartum echocardiogram before discharge at a single academic institution from 2019 to 2021. The decision to obtain an echocardiogram was made by the primary physician. Patients with clinical indications for echocardiography (suspicion of heart failure and cardiomyopathy) were excluded. Hospital management outcomes included length of hospital stay, diuretic use, increasing antihypertensives, hospital readmission, and cardiology consultation. Patients with normal versus abnormal echocardiograms were compared using the chi-square test or Fisher's exact test for categorical data and the two-sample t test or Mann-Whitney test for continuous data, with a value of P <.05 considered significant. RESULTS: One hundred forty five patients with preeclampsia who received maternal echocardiograms were included. Twenty-one (14%) had an abnormal echocardiogram, including left ventricle hypertrophy (n=9, 6%), pulmonary hypertension (n=5, 3.4%), moderate pericardial effusion (n=4, 2.7%), and enlarged atrial size (n=3, 2%). Patients with abnormal maternal echocardiograms were more likely to have a longer hospital stay (median stay of 7 days [5, 10] versus 5 days [4, 6], P =.003) and were more likely to receive diuretics (19.1% versus 4%, P =.03). There was no difference in adjustment of antihypertensives (61.9% versus 49.2%, P =.3), cardiology consultation (9.5% versus 6.5%, P =.6), or hospital readmission (4.8% versus 6.5%, P =1). CONCLUSION: Abnormal echocardiograms were associated with change in hospital management including longer hospital stay and more diuretic use. Abnormal postpartum echocardiography may be used to identify patients with more severe disease and adverse clinical outcomes. Further clinical utility of abnormal echocardiograms in severe preeclampsia should be evaluated. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Obtaining granular data on events and circumstances leading to severe maternal morbidity (SMM) could complement large epidemiologic studies and enable targeted interventions to improve maternal health. This study aims to assess the feasibility of gathering such data from maternity units across Canada through a Canadian Obstetric Survey System (CanOSS). METHODS: The study is a sequential explanatory mixed-methods study, the first step of which is a nationwide survey of maternity unit leads. Semistructured qualitative interviews are being conducted with unit leads that expressed interest in response to the survey. Responses are reported using proportions and percentages. Interviews are being thematically analyzed. This study was approved by the Hamilton Integrated Research Ethics Board (HiREB) #14002. RESULTS: As of October 18, 2022, we have identified 306 maternity units nationally, and sent 218 surveys, with 59 maternity units across 8 provinces completing. Among these, 34 (83%) report having a system in place for reviewing SMM, conducted on an as-needed basis in 61% of units, and most commonly involving a multidisciplinary panel of experts with representation from nursing (85%), maternity unit leadership (79%), and hospital management (74%). A written report is prepared following 76% of meetings. Findings are shared with health care professionals involved in the event and formulated into recommendations in 79% and 82% of units, respectively. Importantly, 78% of respondents would be willing to contribute anonymized data on SMM within a centralized reporting system. Interviews have taken place with 14 unit leads. Interviewed participants unanimously agree that an obstetric survey system is needed. Concerns raised include privacy, resources, funding, and having a clear definition of SMM. CONCLUSION: This feasibility study will facilitate future planning, clarify barriers to be addressed, and resource implications for gathering data on SMM at a national level, and lay the foundations for a future CanOSS. [ABSTRACT FROM AUTHOR]

A key element of an organizational safety culture is maintaining an environment of professionalism that encourages communication and promotes high-quality care. Behavior that undermines a culture of safety, including disruptive or intimidating behavior, has a negative effect on the quality and safety of patient care. Intimidating behavior and disruptive behavior are unprofessional and should not be tolerated. Confronting disruptive individuals is difficult. Co-workers often are reluctant to report disruptive behavior because of fear of retaliation and the stigma associated with "blowing the whistle" on a colleague. Additionally, negative behavior of revenue-generating physicians may be overlooked because of concern about the perceived consequences of confronting them. The Joint Commission requires that hospitals establish a code of conduct that "defines acceptable behavior and behavior that undermines a culture of safety." Clear standards of behavior that acknowledge the consequences of disruptive and intimidating behavior must be established and communicated. Institutions and practices should develop a multifaceted approach to address disruptive behavior. Confidential reporting systems and assistance programs for physicians who exhibit disruptive behavior should be established. A concerted effort should be made within each organization to educate staff (ie, medical, nursing, and ancillary staff) about the potential negative effects of disruptive and inappropriate behavior. A clearly delineated hospital-wide policy and procedure relating to disruptive behavior should be developed and enforced by hospital administration. To preserve professional standing, physicians should understand how to respond to and mitigate the effect of complaints or reports. [ABSTRACT FROM AUTHOR]

Objective: To understand the most important steps required to implement immediate postpartum long-acting reversible contraception (LARC) programs in different Georgia hospitals and the barriers to implementing such a program.Methods: This was a qualitative study. We interviewed 32 key personnel from 10 Georgia hospitals working to establish immediate postpartum LARC programs. Data were analyzed using directed qualitative content analysis principles. We used the Stages of Implementation to organize participant-identified key steps for immediate postpartum LARC into an implementation guide. We compared this guide to hospitals' implementation experiences.Results: At the completion of the study, LARC was available for immediate postpartum placement at 7 of 10 study hospitals. Participants identified common themes for the implementation experience: team member identification and ongoing communication, payer preparedness challenges, interdependent department-specific tasks, and piloting with continuing improvements. Participants expressed a need for anticipatory guidance throughout the process. Key first steps to immediate postpartum LARC program implementation were identifying project champions, creating an implementation team that included all relevant departments, obtaining financial reassurance, and ensuring hospital administration awareness of the project. Potential barriers included lack of knowledge about immediate postpartum LARC, financial concerns, and competing clinical and administrative priorities. Hospitals that were successful at implementing immediate postpartum LARC programs did so by prioritizing clear communication and multidisciplinary teamwork. Although the implementation guide reflects a comprehensive assessment of the steps to implementing immediate postpartum LARC programs, not all hospitals required every step to succeed.Conclusion: Hospital teams report that implementing immediate postpartum LARC programs involves multiple departments and a number of important steps to consider. A stage-based approach to implementation, and a standardized guide detailing these steps, may provide the necessary structure for the complex process of implementing immediate postpartum LARC programs in the hospital setting. [ABSTRACT FROM AUTHOR]

A dynamic health care industry continues to call upon health care leaders to possess not one but multiple competencies. A post hoc review of 3 secondary data sets (previous parallel surveys administered in 2007, 2011, and 2015) was conducted to determine what preferred academic program of study (master of health administration, master of business administration, or a clinical degree preparation) may exist by current hospital executives and potential trending of executive degree preparations over time. In addition, any relationships among individual hospital administrator, individual personal characteristics, and their preferred degree preparations were also investigated at an exploratory level. Findings suggest and support the researchers' hypothesis that the preferred degree preference for a career in hospital administration (master of business administration, master of health administration, or clinical) is highly dependent on an individual executive's graduate degree earned. Many areas for future research are identified from this study that include additional survey analysis and future research questions related to initial findings. [ABSTRACT FROM AUTHOR]

Objective: To determine the influence of admission anthropometry on clinical outcomes in mechanically ventilated children in the PICU.Design: Data from two multicenter cohort studies were compiled to examine the unique contribution of nutritional status, defined by body mass index z score, to 60-day mortality, hospital-acquired infections, length of hospital stay, and ventilator-free days, using multivariate analysis.Setting: Ninety PICUs from 16 countries with eight or more beds.Patients: Children aged 1 month to 18 years, admitted to each participating PICU and requiring mechanical ventilation for more than 48 hours.Measurements and Main Results: Data from 1,622 eligible patients, 54.8% men and mean (SD) age 4.5 years (5.1), were analyzed. Subjects were classified as underweight (17.9%), normal weight (54.2%), overweight (14.5%), and obese (13.4%) based on body mass index z score at admission. After adjusting for severity of illness and site, the odds of 60-day mortality were higher in underweight (odds ratio, 1.53; p < 0.001) children. The odds of hospital-acquired infections were higher in underweight (odds ratio, 1.88; p = 0.008) and obese (odds ratio, 1.64; p < 0.001) children. Hazard ratios for hospital discharge were lower among underweight (hazard ratio, 0.71; p < 0.001) and obese (hazard ratio, 0.82; p = 0.04) children. Underweight was associated with 1.3 (p = 0.001) and 1.6 (p < 0.001) fewer ventilator-free days than normal weight and overweight, respectively.Conclusions: Malnutrition is prevalent in mechanically ventilated children on admission to PICUs worldwide. Classification as underweight or obese was associated with higher risk of hospital-acquired infections and lower likelihood of hospital discharge. Underweight children had a higher risk of mortality and fewer ventilator-free days. [ABSTRACT FROM AUTHOR]

Objective: External validation of prognostic models is crucial but rarely done. Our aim was to externally validate a prognostic model to predict 60-day case fatality after aneurysmal subarachnoid hemorrhage developed from the International Subarachnoid Aneurysm Trial in a retrospective unselected cohort of subarachnoid hemorrhage patients.Design: The model's predictors were age, aneurysm size, Fisher grade, and World Federation of Neurological Surgeons grade. Two versions of the model were validated: one with World Federation of Neurological Surgeons grade scored at admission and the other with World Federation of Neurological Surgeons grade at treatment decision. The outcome was 60-day case fatality. Performance of the model was assessed by studying discrimination, expressed by the area under the receiver operating characteristic curve, and calibration.Setting: University hospital.Patients: We analyzed data from 307 consecutive aneurysmal subarachnoid hemorrhage patients admitted between 2007 and 2011 (validation cohort).Interventions: None.Measurements and Main Results: The observed 60-day case fatality rate was 30.6%. Discrimination was good, and differed between the model with World Federation of Neurological Surgeons grade at treatment decision (area under the receiver operating characteristic curve, 0.89) and at admission (area under the receiver operating characteristic curve, 0.82). Mean predicted probabilities were lower than observed: 17.0% (model with World Federation of Neurological Surgeons grade at admission) and 17.7% (model with World Federation of Neurological Surgeons grade at treatment decision).Conclusions: The model discriminated well between patients who died or survived within 60 days. In addition, we found that using World Federation of Neurological Surgeons grade at moment of treatment decision of the ruptured aneurysm improved model performance. However, since predicted probabilities were much lower than observed probabilities, the International Subarachnoid Aneurysm Trial prediction model needs to be adapted to be used in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: Low tidal volume ventilation lowers mortality in the acute respiratory distress syndrome. Previous studies reported poor low tidal volume ventilation implementation. We sought to determine the rate, quality, and predictors of low tidal volume ventilation use.Design: Retrospective cross-sectional study.Setting: One academic and three community hospitals in the Chicago region.Patients: A total of 362 adults meeting the Berlin Definition of acute respiratory distress syndrome consecutively admitted between June and December 2013.Measurements and Main Results: Seventy patients (19.3%) were treated with low tidal volume ventilation (tidal volume < 6.5 mL/kg predicted body weight) at some time during mechanical ventilation. In total, 22.2% of patients requiring an FIO2 greater than 40% and 37.3% of patients with FIO2 greater than 40% and plateau pressure greater than 30 cm H2O received low tidal volume ventilation. The entire cohort received low tidal volume ventilation 11.4% of the time patients had acute respiratory distress syndrome. Among patients who received low tidal volume ventilation, the mean (SD) percentage of acute respiratory distress syndrome time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to low tidal volume ventilation initiation. Women were less likely to receive low tidal volume ventilation, whereas sepsis and FIO2 greater than 40% were associated with increased odds of low tidal volume ventilation use. Four attending physicians (6.2%) initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset for greater than or equal to 50% of their patients, whereas 34 physicians (52.3%) never initiated low tidal volume ventilation within 1 day of acute respiratory distress syndrome onset. In total, 54.4% of patients received a tidal volume less than 8 mL/kg predicted body weight, and the mean tidal volume during the first 72 hours after acute respiratory distress syndrome onset was never less than 8 mL/kg predicted body weight.Conclusions: More than 12 years after publication of the landmark low tidal volume ventilation study, use remains poor. Interventions that improve adoption of low tidal volume ventilation are needed. [ABSTRACT FROM AUTHOR]

Objective: Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.Design: In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. "Early tracheostomy" was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression.Setting: 2012 National Inpatient Sample.Patients: A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy.Interventions: None.Measurements and Main Results: Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01-1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98-1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9-81.9%) compared with pneumonia/sepsis (14.9-38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home.Conclusion: Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing. [ABSTRACT FROM AUTHOR]

Objectives: To analyze patterns of critical care medicine beds, use, and costs in acute care hospitals in the United States and relate critical care medicine beds and use to population shifts, age groups, and Medicare and Medicaid beneficiaries from 2000 to 2010.Design: Retrospective study of data from the federal Healthcare Cost Report Information System, American Hospital Association, and U.S. Census Bureau.Subjects: None.Interventions: None.Setting: Acute care U.S. hospitals with critical care medicine beds.Measurements and Main Results: From 2000 to 2010, U.S. hospitals with critical care medicine beds decreased by 17% (3,586-2,977), whereas the U.S. population increased by 9.6% (282.2-309.3M). Although hospital beds decreased by 2.2% (655,785-641,395), critical care medicine beds increased by 17.8% (88,235-103,900), a 20.4% increase in the critical care medicine-to-hospital bed ratio (13.5-16.2%). There was a greater percentage increase in premature/neonatal (29%; 14,391-18,567) than in adult (15.9%; 71,978-83,417) or pediatric (2.7%; 1,866-1,916) critical care medicine beds. Hospital occupancy rates increased by 10.4% (58.6-64.6%), whereas critical care medicine occupancy rates were stable (range, 65-68%). Critical care medicine beds per 100,000 total population increased by 7.4% (31.3-33.6). The proportional use of critical care medicine services by Medicare beneficiaries decreased by 17.3% (37.9-31.4%), whereas that by Medicaid rose by 18.3% (14.5-17.2%). Between 2000 and 2010, annual critical care medicine costs nearly doubled (92.2%; $56-108 billion). In the same period, the proportion of critical care medicine cost to the gross domestic product increased by 32.1% (0.54-0.72%).Conclusions: Critical care medicine beds, use, and costs in the United States continue to rise. The increasing use of critical care medicine by the premature/neonatal and Medicaid populations should be considered by healthcare policy makers, state agencies, and hospitals as they wrestle with critical care bed growth and the associated costs. [ABSTRACT FROM AUTHOR]

Objective: Failure to detect clinical deterioration in the hospital is common and associated with poor patient outcomes and increased healthcare costs. Our objective was to evaluate the feasibility and accuracy of real-time risk stratification using the electronic Cardiac Arrest Risk Triage score, an electronic health record-based early warning score.Design: We conducted a prospective black-box validation study. Data were transmitted via HL7 feed in real time to an integration engine and database server wherein the scores were calculated and stored without visualization for clinical providers. The high-risk threshold was set a priori. Timing and sensitivity of electronic Cardiac Arrest Risk Triage score activation were compared with standard-of-care Rapid Response Team activation for patients who experienced a ward cardiac arrest or ICU transfer.Setting: Three general care wards at an academic medical center.Patients: A total of 3,889 adult inpatients.Measurements and Main Results: The system generated 5,925 segments during 5,751 admissions. The area under the receiver operating characteristic curve for electronic Cardiac Arrest Risk Triage score was 0.88 for cardiac arrest and 0.80 for ICU transfer, consistent with previously published derivation results. During the study period, eight of 10 patients with a cardiac arrest had high-risk electronic Cardiac Arrest Risk Triage scores, whereas the Rapid Response Team was activated on two of these patients (p < 0.05). Furthermore, electronic Cardiac Arrest Risk Triage score identified 52% (n = 201) of the ICU transfers compared with 34% (n = 129) by the current system (p < 0.001). Patients met the high-risk electronic Cardiac Arrest Risk Triage score threshold a median of 30 hours prior to cardiac arrest or ICU transfer versus 1.7 hours for standard Rapid Response Team activation.Conclusions: Electronic Cardiac Arrest Risk Triage score identified significantly more cardiac arrests and ICU transfers than standard Rapid Response Team activation and did so many hours in advance. [ABSTRACT FROM AUTHOR]

B Introduction: b In the US over 100,000 patients with organ failure await lifesaving organ transplantation. Two factors in the BDD impact the number of organ available for transplantation: unmodifiable acute or chronic disease, and modifiable acute organ dysfunction. [Extracted from the article]

B Introduction: b Recent reports suggest very low to no hospital survival among COVID-19 patients with in-hospital cardiac arrest (IHCA). Once developing among patients with COVID-19, the short-term survival of IHCA was no longer affected by demographic characteristics, comorbidity burden, or illness severity. B Methods: b We used a statewide data set to identify hospitalizations aged >=18 years in acute care hospitals in Texas with a diagnosis of COVID-19 between April 1st and December 31st, 2020. [Extracted from the article]

Study Design. A mixed-effects model was used to evaluate the effects specific surgical procedure by International Classification of Diseases, Ninth Revision, Clinical Modification, procedure code, patient age, sex, ethnic group, payers for the inpatient hospital stay, and number of additional diagnoses beyond the principal diagnosis that led to the procedure (as a proxy for severity of illness) on the charges for lumbar fusion surgery. Objective. The present research examined the charges and the predictors of the charges for lumbar fusion surgery in Florida hospitals in 2010. Summary of Background Data. The number of spinal fusion surgical procedures in the United States has grown exponentially in recent years despite the procedure's high costs and questionable efficacy for many of the principal diagnoses associated with it. Methods. All records with any of the 5 International Classification of Diseases, Ninth Revision, Clinical Modification, principal procedure codes for lumbar fusion were extracted (cases) from the Florida Agency for Health Care Administration (AHCA) hospital discharge data for the year 2010. A control group was obtained by taking all patients who had the same principal diagnoses as the cases, but who did not have fusion surgery. This produced 16,236 cases and 21,856 controls. Results. The total hospital charges for lumbar fusion surgery in Florida in 2010 were $2,095,413,584. Despite having the same principal diagnoses and a similar number of additional diagnoses, patients who underwent a fusion surgery had 3 times the charges as those incurred by the controls. The number of additional diagnoses, sex, age, payer, and principal procedure, were all found to be statistically significant predictors of charges. Ethnicity was not significant. Of all the predictors, the number of additional diagnoses was the most significant in the model (F = 2577, P < 0.0001). Conclusion. The high incidence and charges for fusion surgical procedures shown in this study emphasize the need for a better understanding of when these surgical procedures are justified and for which patients. [ABSTRACT FROM AUTHOR]

Objectives: Inclusion of select orthopedic problems in the orthopedics observation unit (OOU) may reduce hospital admissions. Our system allows OOU status for 24 hours, but the effect on admissions is unknown. Our primary hypothesis was that we could predict which OOU patients required admission based on the presence of uncontrolled pain. Methods: Data were prospectively collected for all OOU patients in this prospective observational study, including data on extremity cellulitis, fractures, and spine injuries awaiting brace placement. The primary outcome variable was admission to the hospital versus discharge home. The a priori hypotheses were that patients with more persistent or worsening pain would require admission more often and that the OOU would result in fewer patients needing a costlier inpatient admission to the hospital. An a priori power analysis showed adequate power of 80% to detect a difference between admitted and discharged patients. Results: Data were prospectively collected from August 2011 to August 2012 for 199 consecutive OOU patients, 62% of whom were men. Diagnoses included infection (cellulitis or abscess of extremity) in 76%, fracture in 15% and other in 9% of the patients. Sixty-two patients (31%) were admitted and 7 patients (4%) made return visits for the same problem within a 30-day period. No significant relations existed between any of the independent variables and admission on bivariate analysis. Multivariable logistic regression found no significant predictors of hospital admission. Logistic regression was not performed on 30-day returns because of the low event rate (4%). Conclusions: An OOU prevented 138 of 199 (69%) patients from being admitted to a hospital. There were no significant predictors of which patients would require admission. Pain was not a predictor of need for admission. The lack of significant predictors is important in suggesting that without the ability to predict which patients require admission, a system using an OOU can reduce admissions by more than two-thirds. [ABSTRACT FROM AUTHOR]

Objective: ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. Design: Retrospective database review. Setting: Academic, tertiary care, nontrauma surgical CU. Patients: All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. Interventions: None. Measurements and Main Results: Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (1 3.5±17.4 d) versus general surgery (8.7±12.9), transplant (7.8±11.6), oral-maxillofacial surgery (5.5±4.2), and neurosurgery (4.47±9.8) (all p <0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 1 0.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.00 1 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p <0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. Conclusions: Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources. [ABSTRACT FROM AUTHOR]

Background: The potential cost savings and customizability of open source software (OSS) may be particularly attractive for hospitals. However, numerous health-care-specific OSS applications exist, the adoption of OSS health information technology (HIT) applications is not widespread in the United States. Purpose: This disconnect between the availability of promising software and low adoption raises the basic question: If OSS HIT is so advantageous, why are more health care organizations not using it? Methodology: We interviewed the chief information officer, or equivalent position, at 17 not-for-profit and public hospitals across the United States. Through targeted recruitment, our sample included nine hospitals using OSS HIT and eight hospitals not using OSS HIT. The open-ended interview questions were guided by domains included in the fit-viability theory, an organizational-level innovation adoption framework, and those suggested by a review of the literature. Transcripts were analyzed using an inductive and comparative approach, which involved an open coding for relevant themes. Findings: Interviews described the state of OSS use in hospitals. Specifically, general OSS applications were widely used by IT professionals. In addition, hospitals using OSS HIT still relied heavily on vendor support. In terms of why decisions arose to use OSS HIT, several hospitals using OSS HIT noted the cost advantages. In contrast, hospitals avoiding OSS HIT were clear, OSS as a class did not fit with clinical work and posed too much risk. Practice Implications: Perceptions of OSS HIT ranged from enthusiastic embracement to resigned adoption, to refusal, to abandonment. Some organizations were achieving success with their OSS HIT choices, but they still relied on vendors for significant support. The decision to adopt OSS HIT was not uniform but contingent upon views of the risk posed by the technology, economic factors, and the hospital's existing capabilities. [ABSTRACT FROM AUTHOR]

Objectives: Spontaneous awakening trials (SATs) improve outcomes in mechanically ventilated patients, but implementation remains erratic. We examined variation in reported practice, prevalence of attitudes and fears regarding spontaneous awakening trials, and organizational practices associated with routine implementation of spontaneous awakening trials in an ICU quality improvement collaborative. Design: Written survey. Setting: Michigan Health and Hospital Association's Keystone ICU, a quality improvement collaborative of 73 hospitals. Subjects: Attendees of the yearly Keystone ICU meeting, January 2011, including nurses, physicians, hospital administrators, and other healthcare professionals. Intervention: Respondents were asked about institutional characteristics, spontaneous awakening trial practice, attitudes and barriers regarding spontaneous awakening trials, and organizational cultural characteristics that might influence SAT practice. The association of organizational cultural characteristics and attitudes with reported spontaneous awakening trial use was evaluated using logistic regression. Measurements and Main Resutts: Three hundred nineteen participants attended the meeting. The survey response rate was 83.4%. Respondents reported wide variation in approach to spontaneous awakening trial performance and patient selection. 48.6% of respondents reported regular spontaneous awakening trial use, defined as greater than 75% of mechanically ventilated patients undergoing spontaneous awakening trials each day. In bivariable analysis, addressing sedation goals routinely in rounds and having spontaneous awakening trials as part of unit culture were positively associated with regular spontaneous awakening trial use, whereas the perception that spontaneous awakening trials increased shortterm adverse effects, staff fears of spontaneous awakening trials, and the perception that spontaneous awakening trials are hard work were negatively associated with regular spontaneous awakening trial use. In multivariable analysis, only addressing sedation in rounds (odds ratio, 2.85 [95% Cl, 1.55-5.23]), incorporation of spontaneous awakening trials into unit culture (odds ratio, 3.36 [95% Cl, 1.75-6.43]), and the perception that spontaneous awakening trials are hard work (odds ratio, 0.53 [95% Cl, 0.300.961) remained statistically significantly associated with regular spontaneous awakening trial use. Respondents in managerial positions were less likely to perceive spontaneous awakening trials as hard work (odds ratio, 0.44 [95% Cl, 0.22-0.85]). Conclusions: Even in a motivated statewide quality improvement collaborative, spontaneous awakening trial practice varies widely and concerns persist regarding spontaneous awakening trials. Cultural practices may counteract the effect of concerns regarding spontaneous awakening trials and are associated with increased performance of this beneficial intervention. Patient selection should be a focus for continuing medical education. Differences in perception of work between management and staff may also be a focus for improved communication. [ABSTRACT FROM AUTHOR]

Objectives: To study the relationship between case-volume and the use of noninvasive ventilation during acute exacerbations of chronic obstructive pulmonary disease in ICUs. Design: A 13-year multicenter retrospective cohort study of prospectively collected data. Setting: Medical ICUs. Patients: From 1998 to 2010, patients with acute exacerbations of chronic obstructive pulmonary disease were identified through a regional database. Interventions: The characteristics of hospitalization (including the type of mechanical ventilation) and demographic data of the patients were analyzed. ICUs were categorized into tertiles of the running mean annual volume of admissions. A logistic model performed a conditional multivariate analysis of prognostic factors after matching on a propensity score of being admitted to a highvolume unit and on the year of admission. Measurements and Main Results: Fourteen thousand four hundred forty acute exacerbations of chronic obstructive pulmonary disease were identified. The Simplified Acute Physiology Score II and ICU mortality increased during the study period (36 to 41 and 1 2% to 14%, respectively). The proportion of patients receiving any mechanical ventilation support also increased during the study period (from 64% to 86%), with a marked increase in the use of rioninvasive ventilation (from 1 8% to 49%) and a decrease in the use of invasive ventilation (from 340/s to 19%). Participating units were distributed into low-volume (< 25 patients per year), medium-volume (26-47 patients per year), and high-volume (> 47 patients per year) tertiles. There was a significant association between case-volume and 1) the proportion of patients receiving noninvasive ventilation (highest vs lowest case-volume tertiles: odds ratio, 1.43 [95% Cl, 1.23-1 .66]) and 2) lower mortality. Conclusions: Between 1998 and 2010, severity and mortality of acute exacerbations of chronic obstructive pulmonary disease admitted to College des Utilisateurs de Données en Reanimation ICUs increased. There was an increasing use of noninvasive ventilation and a decreasing use of invasive ventilation. Use of nonirivasive ventilation was related to case-volume, suggesting that increasing experience favors the use of noninvasive ventilation and was associated with a strong trend toward decreased mortality. [ABSTRACT FROM AUTHOR]

Background: There is broad recognition that the healthcare crisis in the United States is going to require a response and change in clinical practice. The management structure of Geisinger Health System is unique, and this has the potential to change the dynamics of surgeon-administration alignment. Questions/purposes: Our goal is to summarize and clarify the relationship between orthopaedic surgeons and the healthcare system at Geisinger, evaluate the positive and negative aspects, and consider which components may be reproducible. Methods: This overview arises from a review of management publications, discussions with orthopaedic attendings and administrators, and personal observations and comparison with my previous 15-year university-based practice. Results: The Geisinger Health System has always been physician-run. The overall efficiency and pragmatic approach found at Geisinger relies heavily on changing surgeon behavior to match what is optimal for the system rather than the individual. This approach appears to bring greater stability and more consistent outcomes, but only by removing what some see as the art of medicine and at the loss of perceived provider autonomy. Despite the rigid demands placed on the surgeon, the system remains adaptable to change and appears to retain faculty at a high rate. Conclusions: The Geisinger System is unique in its ability to control an insurance plan, multiple hospitals, and a large physician group. Through clear protocols and behavioral pressure, it demands surgeon alignment with the system as a whole and in return provides a stable work environment. It is not ideal for all surgeons and it is unclear whether it can be reproduced in a less structured setting. [ABSTRACT FROM AUTHOR]

Background: Recently, quality, financial, and regulatory demands have driven physicians to seek alignment opportunities with hospitals. The motivation for alignment on the part of physicians and hospitals is now accelerating because the new paradigm under healthcare reform requires an increased focus on improving quality, cost, and efficiency. Questions/purposes: We (1) identify the key drivers for physician-hospital alignment models; (2) summarize comanagement as a physician-hospital alignment model; and (3) explore a detailed case study of comanagement as an option to better align physicians with hospital goals on quality, safety, and outcomes. Methods: A Medline abstract review was performed that identified 45 references that discuss options for physician-hospital alignment. None of the articles identified provide a detailed example of successful alignment structures. A detailed case study of a successful comanagement alignment program is reviewed. Results: The key drivers for alignment are inpatient growth rates, declining reimbursements, and the opportunity to improve quality, decrease costs, and increase efficiency. Two general strategies of alignment involve noneconomic and/or economic integration. In our example, comanagement with economic integration was chosen as the preferred structure for physician-hospital alignment. Conclusions: The choice of structure will vary depending on the existing relationships and governance of the hospital and the physicians in the targeted area of focus. The measure of success in building physician-hospital alignment is measured in improvements in care for the patient, reduced cost of care delivery, and improved relations between physicians and hospital leadership. [ABSTRACT FROM AUTHOR]

The article presents a study which hypothesized that the delta anion gap defined as difference between critical care initiation standard anion gap and prehospital admission standard anion gap is linked with all cause mortality in the critically ill. It found that delta anion gap was a strong predictor of mortality with a significant risk gradient across delta anion gap quartiles. It showed that delta anion gap has moderate discriminative ability for mortality compared with standard base excess.

Background-Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know whether improvements in door-to-balloon times were shared equally among patient and hospital groups. Methods and Results-This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention (acute myocardial infarction-8) inpatient measure from January 1, 2005, through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure, including the number and percentage in each group, the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minutes in the 3 quarters ending September 30, 2010. There were corresponding increases in the percentage of patients who had times <90 minutes (44.2% to 91.4%) and <75 minutes (27.3% to 70.4%). The declines in median times were greatest among groups that had the highest median times during the first period: patients >75 years of age (median decline, 38 minutes), women (35 minutes), and blacks (42 minutes). Conclusion-National progress has been achieved in the timeliness of treatment of patients with ST-segment-elevation myocardial infarction who undergo primary percutaneous coronary intervention. [ABSTRACT FROM AUTHOR]

The article presents a study on the safety leadership team training program for hospital managers and its effects on behavior change among managers. The study selects 12 management groups from an academic medical center for the experience-based, customized, and integrated multimodal curriculum of the program. It says that following 15 months of training sessions the managers were found to have increased targeted behaviors, awareness, and use of leadership behaviors.

The article presents a study on the relation between hospital board's involvement in strategic decision making, board member expertise, and hospital's strategic orientation. The study used hierarchical regression analysis to assess the relationship between board involvement and strategic focus in 72 nonacademic hospitals. Result shows board of directors' involvement in externally-oriented goals and that breadth of board expertise has greater impact.

The article focuses on hospitals' computerized provider order entry (CPOE) in the U.S. to increase the quality of care they provide and health information technology (HIT) by reducing medical errors. According to the author, CPOE has special electronic signature, workflow and rules engine function. The findings of a study show that hospitals with automated CPOE systems have difference in terms of system membership, ownership, and bed set up.

Hospital care of patients with hip fractures often is managed primarily by either a medicine or orthopaedic service, depending on the institution. Whether complication rates, length of stay, or time to surgery differs on different services is unknown. We therefore determined whether (1) perioperative complication rates, and (2) length of stay and time to surgery for patients undergoing surgical management of hip fractures differed by the specialty of the primary service. We performed a retrospective cohort study at a university-based academic hospital of patients undergoing surgery for hip fracture admitted to medicine and orthopaedic services during 2006. Of the 98 patients included in the analysis, 34% were managed by a medicine service and 66% by orthopaedics. Using multivariable regression models to adjust for patient characteristics and comorbidities, we determined whether service designation predicted the likelihood of severe or intermediate perioperative complications, length of stay, or time to surgery. The rate of severe or intermediate complications for patients undergoing surgical management of hip fractures was 30%. Patients with medicine or orthopaedic services did not differ in the rate of severe or intermediate complications or length of stay in adjusted analysis. However, time to surgery was longer in patients managed by the medical service in adjusted analysis. In our patient cohort, the likelihood of perioperative complications occurring among patients with hip fractures did not differ by service designation in adjusted analysis. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Healthcare costs continue to increase dramatically, while quality remains a significant problem. Reform measures adopted by Congress will fuel expansion of these costs, further stressing taxpayers and employers and forcing hospitals to adopt transformational changes as they adjust to increased demands for services and shrinking reimbursement. Cost control and quality improvement can be achieved through increased competition or greater government intervention. Competition will require unpalatable changes to the healthcare system to decrease costs without further restricting access or decreasing quality. Increased government intervention will result in changes to reimbursement and hospital-physician relations and increased demands for improved care. To improve cost and quality while preserving increased access, we advocate for a universal standard coverage of Americans; accountable healthcare system leadership; leverage of information resources to make utilization decisions and evaluate performance; alignment of physician, hospital, and payer incentives to focus on care outcomes rather than profit maximization; and the use of quasicompetition to allow for consumer choice within this system. [ABSTRACT FROM AUTHOR]

The article discusses the residual paralysis, an unwanted side effect in the immediate postoperative period and a risk factor for respiratory complications. It says that residual paralysis is associated with muscle weakness, pulmonary collapse, and acute respiratory failure that could lead to brain damage and death. It states that the degree of residual paralysis can be evaluated in different ways such as clinical tests, visual or tactile evaluation of responses to train-of-four (TOF), and measurement of the train-of-four ratio (TOFR) with a device. It says that risks could be decreased by the systematic use of neuromuscular monitoring and judicious administration of reversal agents. It adds that residual paralysis is an anesthetic complication that can be avoided by careful management.

The article presents a study on the relationship between nurse staffing and patient outcomes in hospitals. It states that nurse staffing is the process of allocating the appropriate number and mix licensed and unlicensed staff on a medical-surgical unit to meet the needs of the patients. It states that the study is important for the hospital administration as basis in nurse staffing to lessen adverse events and lower the days of hospitalization of the patients.