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Balancing is an essential challenge in healthcare systems that requires effective strategies. This study aims to address this crucial issue by suggesting a practical approach. We show the potential of balancing a regional healthcare system to improve its utility. We consider a regional healthcare system comprising multiple hospitals with different sizes, capacities, quality of service, and accessibility. We define a utility function for the system based on the sectorization concept, which endeavors to form a balance between hospitals in terms of essential outputs such as waiting times and demands. The dynamic nature of the system means that this balance degrades over time, necessitating periodic sectorization, which is called resectorization. Our methodology stands out for incorporating resectorization as a dynamic strategy, enabling more flexible and responsive adaptations to continuously changing healthcare needs. Unlike previous studies, based on a system-oriented approach, our resectorization scenarios include the periodic closure of some hospitals. This enables us to enhance both the capacity and quality of healthcare facilities. Furthermore, in contrast to other studies, we investigate the states of diminishing demand throughout the resectorization process. To provide empirical insights, we conduct a simulation using data from a real-world case study. Our analysis spans multiple time periods, enabling us to dynamically quantify the utility of the healthcare system. The numerical findings demonstrate that substantial utility improvements are attainable through the defined scenarios. The study suggests a practical solution to the critical challenge of balancing issues in regional healthcare systems. [ABSTRACT FROM AUTHOR]

Surge management is important to hospital operations, yet surge literature has mostly focused on the addition of resources (e.g., 25% more beds) during events like pandemics. Such views are limiting, as meeting surge demands requires hospitals to engage in practices tailored to a surge's unique contingencies. We argue that a dynamic view of surge management should include surge management capability, which refers to how resources are deployed to respond to surge contingencies. To understand this capability, we qualitatively studied five hospital systems experiencing multiple surges due to COVID-19 between April 2020 and March 2022. We develop a framework showing that managing surges involves preserving capacity, expanding capacity, smoothing capacity demand, and enabling surge management. We contribute to surge literature by identifying practices hospitals can adopt to address surges and offering a better understanding of surge conditions (e.g., degree of novelty) that make some surge management practices more appropriate than others. [ABSTRACT FROM AUTHOR]

Background: Inpatient falls in hospitals are an acknowledged indicator of quality of care. International comparisons could highlight quality improvement potential and enable cross-national learning. Key to fair cross-national comparison is the availability of a risk adjustment model validated in an international context. This study aimed to 1) ascertain that the variables of the inpatient fall risk adjustment model do not interact with country and thus can be used for risk adjustment, 2) compare the risk of falling in hospitals between Switzerland and Austria after risk adjustment. Methods: The data on inpatient falls from Swiss and Austrian acute care hospitals were collected on a single measurement day in 2017, 2018 and 2019 as part of an international multicentre cross-sectional study. Multilevel logistic regression models were used to screen for interaction effects between the patient-related fall risk factors and the countries. The risks of falling in hospital in Switzerland and in Austria were compared after applying the risk-adjustment model. Results: Data from 176 hospitals and 43,984 patients revealed an inpatient fall rate of 3.4% in Switzerland and 3.9% in Austria. Two of 15 patient-related fall risk variables showed an interaction effect with country: Patients who had fallen in the last 12 months (OR 1.49, 95% CI 1.10–2.01, p = 0.009) or had taken sedatives/psychotropic medication (OR 1.40, 95% CI 1.05–1.87, p = 0.022) had higher odds of falling in Austrian hospitals. Significantly higher odds of falling were observed in Austrian (OR 1.38, 95% CI 1.13–1.68, p = 0.002) compared to Swiss hospitals after applying the risk-adjustment model. Conclusions: Almost all patient-related fall risk factors in the model are suitable for a risk-adjusted cross-country comparison, as they do not interact with the countries. Further model validation with additional countries is warranted, particularly to assess the interaction of risk factors "fall in the last 12 months" and "sedatives/psychotropic medication intake" with country variable. The study underscores the crucial role of an appropriate risk-adjustment model in ensuring fair international comparisons of inpatient falls, as the risk-adjusted, as opposed to the non-risk-adjusted country comparison, indicated significantly higher odds of falling in Austrian compared to Swiss hospitals. [ABSTRACT FROM AUTHOR]

Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs. [ABSTRACT FROM AUTHOR]

• The MIP bi-objective model can reduce food waste by 19.70 % and cost by 32.66 %. • On average, children waste 35.43 % of their meals, and eat 41.32 g less than adults. • The pediatric ward has the most food waste per meal, leading to a 20 % reduction. • The vegetarian diet exhibits the highest food waste and meal-building cost. • In areas of greatest waste and cost, the models achieved the greatest improvements. Food waste contributes significantly to greenhouse emissions and represents a substantial portion of overall waste within hospital facilities. Furthermore, uneaten food leads to a diminished nutritional intake for patients, that typically are vulnerable and ill. Therefore, this study developed mathematical models for constructing patient meals in a 1000-bed hospital located in Florida. The objective is to minimize food waste and meal-building costs while ensuring that the prepared meals meet the required nutrients and caloric content for patients. To accomplish these objectives, four mixed-integer programming models were employed, incorporating binary and continuous variables. The first model establishes a baseline for how the system currently works. This model generates the meals without minimizing waste or cost. The second model minimizes food waste, reducing waste up to 22.53 % compared to the baseline. The third model focuses on minimizing meal-building costs and achieves a substantial reduction of 37 %. Finally, a multi-objective optimization model was employed to simultaneously reduce both food waste and cost, resulting in reductions of 19.70 % in food waste and 32.66 % in meal-building costs. The results demonstrate the effectiveness of multi-objective optimization in reducing waste and costs within large-scale food service operations. [ABSTRACT FROM AUTHOR]

OBJECTIVES: In the context of traditional nurse-to-patient ratios, ICU patients are typically paired with one or more copatients, creating interdependencies that may affect clinical outcomes. We aimed to examine the effect of copatient illness severity on ICU mortality. DESIGN: We conducted a retrospective cohort study using electronic health records from a multihospital health system from 2018 to 2020. We identified nurse-to-patient assignments for each 12-hour shift using a validated algorithm. We defined copatient illness severity as whether the index patient's copatient received mechanical ventilation or vasoactive support during the shift. We used proportional hazards regression with time-varying covariates to assess the relationship between copatient illness severity and 28-day ICU mortality. SETTING: Twenty-four ICUs in eight hospitals. PATIENTS: Patients hospitalized in the ICU between January 1, 2018, and August 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main analysis included 20,650 patients and 84,544 patient-shifts. Regression analyses showed a patient's risk of death increased when their copatient received both mechanical ventilation and vasoactive support (hazard ratio [HR]: 1.30; 95% CI, 1.05-1.61; p = 0.02) or vasoactive support alone (HR: 1.82; 95% CI, 1.39-2.38; p < 0.001), compared with situations in which the copatient received neither treatment. However, if the copatient was solely on mechanical ventilation, there was no significant increase in the risk of death (HR: 1.03; 95% CI, 0.86-1.23; p = 0.78). Sensitivity analyses conducted on cohorts with varying numbers of copatients consistently showed an increased risk of death when a copatient received vasoactive support. CONCLUSIONS: Our findings suggest that considering copatient illness severity, alongside the existing practice of considering individual patient conditions, during the nurse-to-patient assignment process may be an opportunity to improve ICU outcomes. [ABSTRACT FROM AUTHOR]

Rapid urbanization and population growth have increased the need for optimizing the location of health services in highly urbanized countries like Kingdom of Saudi Arabia (KSA). This study employs a multiple-criteria decision making (MCDM) approach, e.g., fuzzy overlay technique by combining the P-Median location-allocation model, for optimizing health services. First, a geodatabase, containing public hospitals, road networks and population districts, was prepared. Next, we investigated the location and services of five public hospitals in Jeddah city of KSA, by using a MCDM model that included a fuzzy overlay technique with a location-allocation model. The results showed that the allocated five hospitals served 94 out of 110 districts in the study area. Our results suggested additional hospitals must be added to ensure that the entire city is covered with timely hospital services. To improve the existing situation, we prioritized demand locations using the maximize coverage (MC) location problem model. We then used the P-Median function to find the optimal locations of hospitals, and then combined these two methods to create the MC-P-Median optimizer. This optimizer eliminated any unallocated or redundant information. Health planners can use this model to determine the best locations for public hospitals in Jeddah city and similar settings. [ABSTRACT FROM AUTHOR]

In the U.S., multihospital systems (MHSs) charge significantly higher prices for hospital services than stand-alone hospitals. Rivalry restraint theory suggests that MHS with multimarket contact (MMC) can tacitly collude and mutually forebear from price competition to keep their prices above competitive levels. We posit that the success of such MMC-induced rivalry restraints (the truce) is affected by two conflicting roles of IT at the corporate level and market unit levels, respectively. The corporate parent seeks to standardize IT applications enterprise-wide to coordinate market units as a means of jointly implementing the rivalry restraint strategy and keeping prices high enterprise-wide. However, market units, i.e., the member hospitals of MHS clustered in geographic patient markets, face competitive pressures to reduce their service costs. Market units seek to use differentiated IT applications to achieve cost reductions, which then fuel price competition in local markets, jeopardize the sustainability of the truce, and weaken the enterprise-wide price effects of the corporate parent's rivalry restraint strategy. In a longitudinal study of 195 multihospital systems in the U.S. in the 2005-2013 time period, we found support for these ideas. The corporate-wide standardization of the operational IT of MHS complements the rivalry restraint strategy to increase enterprise-wide prices. Market units' use of differentiated analytical IT reduces costs in local markets and weakens the price effects of the rivalry restraint strategy. The study advances IS research and practice by theorizing how the corporate-level and the market unit-level IT of a multi-unit, multimarket (MUMM) organization can have opposing moderating effects on the link between MMC and the average prices charged by the MUMM organization. [ABSTRACT FROM AUTHOR]

The rapid increase of rates of change, disruptive events, risk and uncertainty increasingly threaten the long-term utilisation of hospital buildings. This challenge calls for an evolution in the lifecycle thinking that has always been integral to the hospital building design processes; or an approach that is termed 'future proofing'. Yet the implementation of future proofing as an emerging design requirement is impeded by lack of holistic understanding of the concept, and clarity about its objectives. As such, this research aims to provide a conceptualisation of future proofing via a taxonomic hierarchy. We interviewed sixteen experienced hospital architects from leading consultant firms across Australia to explore their general perceptions, and implementation in practice, of future proofing. The semi-structured interviews were informed by and indeed tested a theoretical model of future proofing previously constructed via literature review and were analysed and validated via thematic analysis and member checking. Our findings align theoretical understanding with hospital architects' practice-based perceptions and experiences of future proofing; elucidating future proofing as a dynamic meta-capability involving a multi-purpose hierarchy. Accordingly, a hierarchical integrated model of future proofing in practice was developed based on three axes (Survive, Evolve and Thrive), respectively defining three sets of spectrums with two extremes ranging from passivity to activity (Resilience-Mitigation, Maintainability-Improvement, and Changeability-Transition). While in previous research future proofing has been oversimplified and perceived largely in terms of adaptability, our findings support a more expansive definition of future proofing that includes various lifecycle design considerations. [ABSTRACT FROM AUTHOR]

Background: Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. Methods: This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants—after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). Discussion: The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. Trial registration: ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021. [ABSTRACT FROM AUTHOR]

Objectives: The presence of nodal metastases in patients with papillary thyroid carcinoma (PTC) has both staging and treatment implications. However, lymph nodes are often not removed during thyroidectomy. Prior work has demonstrated the capability of artificial intelligence (AI) to predict the presence of nodal metastases in PTC based on the primary tumor histopathology alone. This study aimed to replicate these results with multi-institutional data. Methods: Cases of conventional PTC were identified from the records of 2 large academic institutions. Only patients with complete pathology data, including at least 3 sampled lymph nodes, were included in the study. Tumors were designated "positive" if they had at least 5 positive lymph node metastases. First, algorithms were trained separately on each institution's data and tested independently on the other institution's data. Then, the data sets were combined and new algorithms were developed and tested. The primary tumors were randomized into 2 groups, one to train the algorithm and another to test it. A low level of supervision was used to train the algorithm. Board-certified pathologists annotated the slides. HALO-AI convolutional neural network and image software was used to perform training and testing. Receiver operator characteristic curves and the Youden J statistic were used for primary analysis. Results: There were 420 cases used in analyses, 45% of which were negative. The best performing single institution algorithm had an area under the curve (AUC) of 0.64 with a sensitivity and specificity of 65% and 61% respectively, when tested on the other institution's data. The best performing combined institution algorithm had an AUC of 0.84 with a sensitivity and specificity of 68% and 91% respectively. Conclusion: A convolutional neural network can produce an accurate and robust algorithm that is capable of predicting nodal metastases from primary PTC histopathology alone even in the setting of multi-institutional data. [ABSTRACT FROM AUTHOR]

Introduction Polypharmacy can lead to drug–drug interactions (DDIs), especially with ART. The burden of co-medications, including over-the-counter (OTC) drugs and self-medications, could be underestimated. We aimed to investigate the proportion of people living with HIV (PLHIV) with declared and undeclared co-medications, as well as their potential burden. Methods We conducted a national, multicentre, 1 week cross-sectional study between 10 December and 16 December 2019 in 23 French hospitals amongst consecutive adult PLHIV presenting for a routine outpatient visit. A standardized questionnaire filled in by the physicians assessed all medications and other active chemical substances taken by the PLHIV. Results Overall we enrolled 496 participants from 23 centres. Median age was 50.6 years; ART regimens included an integrase inhibitor in 61% (n  = 302), an NNRTI in 34% (n  = 169) and a PI in 14% (n  = 70) of the cases. Co-medications involved 392 (79%) PLHIV, among which 85 (17%) received polypharmacy (≥5 medications). Previously unknown co-medications or other active substances were found for 32% (n  = 159) of the participants. Corticosteroids (9%, n  = 46) and proton pump inhibitors (10%, n  = 50) were frequently administered. These co-medications did not differ according to age range. Illegal drug use was declared by 11% (n  = 54) and OTC drugs by 23% (n  = 113) of PLHIV. Potential DDIs were discovered for 11% (n  = 53), leading to treatment modifications in 47% (25/53) of cases. Conclusions Potential DDIs that lead to therapeutic modifications remain significant whatever the age of PLHIV. More devoted time to identify co-medications and OTC treatment is needed in all PLHIV. [ABSTRACT FROM AUTHOR]

Introduction: Ethylene glycol (EG) is a frequently considered toxicant in poisoned patients. Definitive diagnosis relies on gas chromatography (GC), but this is unavailable at most hospitals. A glycerol dehydrogenase (GDH)-based assay rapidly detects EG. A rapid turnaround time and wide availability of necessary instrumentation suggest this method could facilitate the rapid detection of EG. Methods: This is a prospective, observational analysis of banked, remnant serum samples submitted to the laboratory of a large, multi-hospital healthcare system. Samples were submitted over a 12-month period for the explicit purpose of testing for suspected EG ingestion. All samples underwent GC and the GDH-based assay. Results: Of the 118 analyzed samples, 88 had no EG detected by GC, and 30 were "positive." At the manufacturer's threshold of 6 mg/dL EG, there was 100% (95%CI; 88.7–100) positive percent agreement (PPA) and 98% (92.1-99.6) negative percent agreement (NPA). Adjusted to a threshold of 9 mg/dL, both the PPA and NPA were 100%. Deming regression of the observed concentrations revealed a slope of 1.16 (1.01 to 1.32) and intercept of −5.3 (−8.9 to −1.7). Conclusions: The GDH assay provides a sensitive and specific method for the detection and quantification of EG that is comparable to a GC-based method. More widespread use of this rapid, inexpensive assay could improve the care of patients with suspected toxic alcohol exposure. Further study is needed to evaluate the test performance in real-time patient treatment decisions. [ABSTRACT FROM AUTHOR]

Real-world data sources can facilitate essential understanding of the epidemiological features of anaphylaxis. However, the accuracy of case-identifying definitions based on diagnosis codes for anaphylaxis in healthcare databases remains understudied. We conducted a cross-sectional study analyzing claims data from the largest multi-institutional healthcare system in Taiwan during 2017–2021. We included patients with incident anaphylaxis identified by either ICD-10-CM codes for anaphylaxis (Group 1) or ICD-10-CM codes for severe allergic or drug adverse events and additional modifier codes for acute allergy events (Group 2). We randomly selected 20% of the cases to determine the positive predictive value (PPV) of anaphylaxis case-identifying definitions in Groups 1 and 2 after review of electronic medical records by two physicians. From the original cohort (n = 2,176), we randomly selected 433 patients with either a diagnosis of anaphylaxis (Group 1), or a diagnosis of severe allergic and drug adverse events with additional modifier codes for acute allergy events (Group 2). In Group 1, we judged 135 / 170 patients as true anaphylaxis cases, giving a PPV of 79.4% (95% CI: 73.3–85.5). In Group 2, we judged 47 / 263 patients as true anaphylaxis cases, giving a PPV of 17.9% (95% CI: 13.3–22.5). In conclusion, acceptable PPVs were observed when anaphylaxis cases were identified by ICD-10-CM codes for anaphylaxis, but not by ICD-10-CM codes for severe allergic or drug adverse event with additional modifier codes for acute allergy events. Our multi-institutional findings could serve as a fundamental reference for further studies of anaphylaxis based on real-world healthcare databases. [ABSTRACT FROM AUTHOR]

Objective: Despite marked improvements in the accessibility of childhood vaccines, knowledge gaps remain about the vaccination of children in special risk groups (SRG). This study aimed to analyze the clinical data of children vaccinated in SRG in a single-center unit to contribute to the clinical evidence for the specific planning of immunization of children in SRG. The secondary aim is to present institutional consensus on the vaccination of children in SRG. Materials and Methods: This retrospective study was conducted at a single-center pediatric vaccination clinic. Patient charts between 2018 and 2021 were retrospectively reviewed, and clinical and laboratory data were extracted. Serial joint meetings with multiple healthcare professionals were performed to develop an institutional protocol for vaccination. Results: There were 479 children vaccinated between 2018 and 2021 for reasons such as postchemotherapy, after hematopoietic stem cell transplantation, before/after solid organ transplantation, allergies, and chronic diseases. Of these, 298 (62.2%) children vaccinated in the unit due to a history of food or vaccine allergies were excluded. One hundred eighty-one children were vaccinated at a median age of 11 [7-15] years. Most children were vaccinated after treatment for malignancies. Solid tumors were the most frequent malignancy (67%), followed by acute lymphoblastic leukemia (29.0%) and acute myeloid leukemia (4.0%). Institutional vaccination protocols for cancer survivors, hematopoietic stem cells, and solid organ recipient children were developed and presented. Conclusion: There is a need to prepare national guidelines for vaccinating children with altered immunocompetence. Sharing vaccination practices by multidisciplinary vaccination units might increase and provide knowledge to develop national policies. [ABSTRACT FROM AUTHOR]

Home health care (HHC) services provide the elderly, disabled, and those with chronic diseases health services in their homes. The demand for HHC services has increased due to the growth of the elderly population, the increase in hospital occupancy rates during the pandemic, and developments in medical device technologies. In this study, team formation is taken into consideration in a multi-period and multi-objective HHC assignment, scheduling and routing problem. The team and the assigned patients to this team must be compatible with skill levels and operational requirements. The objective functions are minimization of total completion time and maximum working time overall caregivers. To evaluate our approach, an HHC service unit in a state hospital is adopted as the operational scenario, and we propose a multi-objective mathematical model to solve the problem. In this model, HHC teams are formed, the patients are assigned to the teams, and the route of each team is determined in an integrated manner. The variable neighborhood search algorithm is modified to solve the multi-objective optimization model and is improved with a local search algorithm. The proposed algorithm has been compared with the state-of-the-art multi-objective algorithms in the literature over test problems. Current results show that the model to be an effective means of estimating and predicting system behavior in this complex environment. [ABSTRACT FROM AUTHOR]

This study investigates whether inequalities in the utilization of resection and/or ablation for synchronous colorectal liver metastases (SCLM) between patients diagnosed in expert and non-expert hospitals changed since a multi-hospital network started. Patients diagnosed with SCLM between 2009 and 2020 were included. The likelihood of receiving ablation and/or resection was analyzed in the prenetwork (2009–2012), startup (2013–2016), and matured-network (2017–2020) periods. Nationwide, 13.981patients were diagnosed between 2009 and 2020, of whom 1.624 were diagnosed in the network. Of patients diagnosed in the network's expert hospitals, 36.7% received ablation and/or resection versus 28.3% in nonexpert hospitals (p < 0.01). The odds ratio (OR) of receiving ablation and/or resection for patients diagnosed in expert versus nonexpert hospitals increased from 1.38 (p = 0.581, pre-network), to 1.66 (p = 0.108, startup), to 2.48 (p = 0.090, matured-network). Nationwide, the same trend occurred (respectively OR 1.41, p = 0.011; OR 2.23, p < 0.001; OR 3.20, p < 0.001). Patients diagnosed in expert hospitals were more likely to receive ablation and/or resection for SCLM than patients diagnosed in non-expert hospitals. This difference increased over time despite the startup of a multi-hospital network. Establishing a multi-hospital network did not have an effect on reducing the existing unequal odds of receiving specialized treatment. Specialized oncology treatments are increasingly provided through multi-hospital networks. However, scant empirical evidence on the effectiveness of these networks exists. This study analyzes whether a regional multi-hospital network was able to improve equal access to specialized oncology treatments. [ABSTRACT FROM AUTHOR]

Purpose Challenges with monitoring and detecting drug diversion in healthcare facilities continue to be a trending topic amid the opioid epidemic. This article aims to provide insight into the expansion of an academic medical center's drug diversion and controlled substances compliance program. The justification and structure of a multihospital, centralized program are discussed. Summary Establishing dedicated controlled substances compliance and drug diversion resources has become increasingly common as awareness of the widespread healthcare impact has grown. One academic medical center recognized the value in expanding from 2 dedicated full-time equivalents (FTEs) with a scope of one facility to multiple FTEs with a scope of 5 facilities. The expansion included considering current practices at each facility, establishing the centralized team's scope, gaining organizational support, recruiting a diverse team, and forming an effective committee structure. Conclusion There are multiple organizational benefits from establishing a centralized controlled substances compliance and drug diversion program, including standardization of processes, associated efficiencies, and effective risk mitigation by identifying inconsistent practices across the multifacility organization. [ABSTRACT FROM AUTHOR]

Background: Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA. Methods: We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis. Results: All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values. Conclusion: This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making. [ABSTRACT FROM AUTHOR]

To assess the value of screening for Clostridioides difficile colonization (CDC) at hospital admission in an endemic setting. A multi-centre study was conducted at four hospitals located across the Netherlands. Newly admitted patients were screened for CDC. The risk of development of Clostridioides difficile infection (CDI) during admission and 1-year follow-up was assessed in patients with and without colonization. C. difficile isolates from patients with colonization were compared with isolates from incident CDI cases using core genome multi-locus sequence typing to determine whether onwards transmission had occurred. CDC was present in 108 of 2211 admissions (4.9%), whereas colonization with a toxigenic strain (toxigenic Clostridoides difficile colonization [tCDC]) was present in 68 of 2211 admissions (3.1%). Among these 108 patients with colonization, diverse PCR ribotypes were found and no 'hypervirulent' PCR ribotype 027 (RT027) was detected (95% CI, 0–0.028). None of the patients with colonization developed CDI during admission (0/49; 95% CI, 0–0.073) or 1-year follow-up (0/38; 95% CI, 0–0.93). Core genome multi-locus sequence typing identified six clusters with genetically related isolates from patients with tCDC and CDI; however, in these clusters, only one possible transmission event from a patient with tCDC to a patient with CDI was identified based on epidemiological data. In this endemic setting with a low prevalence of 'hypervirulent' strains, screening for CDC at admission did not detect any patients with CDC who progressed to symptomatic CDI and detected only one possible transmission event from a patient with colonization to a patient with CDI. Thus, screening for CDC at admission is not useful in this setting. [ABSTRACT FROM AUTHOR]

Background: Patients hospitalized with cirrhosis, ascites, and elevated INR often experience delays in timely diagnostic paracentesis. Aims: Identify whether delays in diagnostic paracentesis were associated with adverse outcomes in a hospital system serving a large disadvantaged population. Methods: Retrospective cohort analysis of patients admitted from January 2017 to October 2019 with cirrhosis, ascites, and INR ≥ 1.5 across a multi-hospital health system in central Texas. We examined demographic and clinical characteristics of patients with diagnostic paracentesis (1) ≤ 24 h; (2) > 24 h; (3) therapeutic only or no paracentesis. We used logistic regression to examine differences in clinical outcomes controlling for confounders. Results: 479 patients met inclusion criteria. 30.0% (N = 143) were Latino, 6.7% (N = 32) African American, and 67.8% (N = 325) under or uninsured. 54.1% of patients received a diagnostic paracentesis ≤ 24 h of admission and 21.1% did not receive a diagnostic paracentesis during the hospitalization. Undergoing diagnostic paracentesis > 24 h of admission was associated with a 2.3 day increase in length of stay (95% CI 0.8–3.8), and OR 1.7 for an Emergency Room visit within 30 days of discharge (95% CI 1.1–2.7) compared to receiving a diagnostic paracentesis ≤ 24 h. Patients receiving diagnostic paracentesis in radiology were more likely to have a delay in procedure OR 5.8 (95% CI 2.8–8.6). Conclusion: Delayed diagnostic paracentesis is associated with increased preventable healthcare utilization compared with timely diagnostic paracentesis. Health systems should support efforts to ensure timely diagnostic paracentesis for patients with advanced liver disease, including performance at the bedside. [ABSTRACT FROM AUTHOR]

To estimate the prevalence of, and identify risk factors associated with, endometrial hyperplasia and/or cancer (EH/EC) in patients ≤45 years old undergoing endometrial sampling for abnormal uterine bleeding (AUB). We performed a retrospective cohort study of patients 18–45 years old with AUB who underwent endometrial sampling between 2016 and 2019 within a US-based multi-hospital system using billing code queries. We used multivariable Poisson regression to identify factors associated with EH/EC and calculated prevalence stratified by these factors. We estimated predicted probabilities within combinations of characteristics in order to examine the range of risk in this population. Among 3175 patients, median age was 39 years (interquartile range [IQR]:35–43) and BMI was 29.7 kg/m2 (IQR: 24.2–36.9). Thirty-nine percent were non-Hispanic White, 41% non-Hispanic Black, 9% Hispanic, and 11% Asian/Other/Unknown. BMI and polycystic ovarian syndrome (PCOS) were associated with higher EH/EC risk; non-Hispanic Black race was associated with lower risk. EH/EC prevalence ranged from 2% in BMI <25 to 16% in BMI ≥50 kg/m2 (p-trend <0.001). These prevalence estimates differed by race/ethnicity with the lowest estimates in non-Hispanic Black patients (0.5% BMI <25 vs. 9% BMI ≥50) and highest in Hispanic patients (1.5% BMI <25 vs. 33% BMI ≥50). Accounting for combinations of risk factors, predicted probabilities were highest – 34–36% – among patients with PCOS, diabetes, BMI ≥50, and Hispanic or Asian/Other/Unknown race/ethnicity. When accounting for combinations of key risk factors, risk of EH/EC in patients ≤45 years old with AUB ranges widely; the more nuanced estimates of risk presented here could help inform clinical decision-making about endometrial sampling in this population. • Recommendations for biopsy in patients ≤45 years old with abnormal uterine bleeding (AUB) are guided by very little data. • In patients ≤45 years old with AUB undergoing biopsy, risk of endometrial hyperplasia/cancer (EH/EC) ranged from <1% to 36%. • Polycystic ovarian syndrome, magnitude of obesity, and race/ethnicity were independent risk factors for EH/EC. • Combinations of risk factors provided more nuanced estimates of estimated risk of endometrial hyperplasia/cancer. • Practical figures demonstrate the range of risk and could be used in shared decision-making regarding endometrial sampling. [ABSTRACT FROM AUTHOR]

Background: The adoption and accessibility of laparoscopy have been serious issues in countries with limited resources, and for varied reasons. This study assessed resource capacity and barriers to the effective practice of laparoscopic surgery in training hospitals affiliated with the College of Surgeons of East, Central and Southern Africa (COSECSA). Methods: A multi-country survey was conducted from January 2021 to October 2021 using a questionnaire distributed to surgeons in COSECSA hospitals located in 16 different countries. Available resources and surgical volume were assessed, and the barriers to routinely performing laparoscopy were determined. Results: Ninety-four surgeons working in 44 different hospitals from 16 countries participated in the survey. The majority of respondents were general surgeons (n = 75, 79.7%). Other specialties included urology (n = 12, 12.8%) and pediatric surgery (n = 7, 7.4%). Senior surgeons accounted for 60.6% of participants, more than 40% had a managerial position and approximately 20% were surgical trainees. Most respondents practiced in public hospitals (n = 66, 70.2%). A median of three surgeons per hospital performed laparoscopic surgery with, on average, two laparoscopic towers and two sets of laparoscopic instruments available. A median of 10 procedures was carried out per month. The cost of laparoscopic procedures and laparoscopic consumables were reported as being covered by some health insurance payments in 76.9% and 48.4% of cases, respectively. Cholecystectomy was the most commonly reported laparoscopic procedure performed. The five top barriers to performing laparoscopic surgery were: a lack of consumables, a limited quantity of equipment, a lack of skilled surgeons, the high cost of laparoscopic procedures and complicated cases. In addition, having access to skilled anesthesiologists and anesthesia equipment, carbon dioxide, a consistent electric power supply and equipment maintenance were cited as significant challenges. Conclusion: The practice of laparoscopy is currently limited in COSECSA countries due to a scarcity of skilled staff and the lack of a funding plan to make laparoscopic services accessible. Therefore, policymakers and stakeholders should take strategic measures to respond to this need. [ABSTRACT FROM AUTHOR]

Milwaukee has become home to one of the largest US populations of Rohingya refugees, who face barriers to health care, including poor service integration impeded by the absence of a formal written language. Clinicians also face barriers to delivering adequate, culturally attuned health services, so suboptimal outcomes are common. This article describes a community-based intervention using an interprofessional, multi-organizational, and ethnographically focused approach to address Rohingya refugee health needs that incorporates Rohingya participants’ making educational videos in their native language. Mutually beneficial outcomes are outlined for Rohingya, students, and clinicians. [ABSTRACT FROM AUTHOR]

Objective: Little is known about the efficacy of using artificial intelligence (AI) to identify laryngeal carcinoma from images of vocal lesions taken in different hospitals with multiple laryngoscope systems. This multicentre study aimed to establish an AI system and provide a reliable auxiliary tool to screen for laryngeal carcinoma. Study design: Multicentre case–control study. Setting: Six tertiary care centres. Participants: Laryngoscopy images were collected from 2179 patients with vocal fold lesions. Outcome measures: An automatic detection system of laryngeal carcinoma was established and used to distinguish malignant and benign vocal lesions in 2179 laryngoscopy images acquired from 6 hospitals with 5 types of laryngoscopy systems. Pathological examination was the gold standard for identifying malignant and benign vocal lesions. Results: Out of 89 cases in the malignant group, the classifier was able to correctly identify laryngeal carcinoma in 66 patients (74.16%, sensitivity). Out of 640 cases in the benign group, the classifier was able to accurately assess the laryngeal lesion in 503 cases (78.59%, specificity). Furthermore, the region‐based convolutional neural network (R‐CNN) classifier achieved an overall accuracy of 78.05%, with a 95.63% negative predictive value and a 32.51% positive predictive value for the testing data set. Conclusion: This automatic diagnostic system has the potential to assist clinical laryngeal carcinoma diagnosis which may improve and standardise the diagnostic capacity of laryngologists using different laryngoscopes. [ABSTRACT FROM AUTHOR]

Purpose: In addition to opioid abuse and dependency, opioid use can lead to opioid related adverse drug events (ORADEs). ORADEs are associated with increased length of stay, cost of care, 30-day readmission rate, and inpatient mortality. The addition of scheduled non-opioid analgesic medications has shown to be effective in reducing opioid utilization in post-surgical and trauma populations, but evidence in entire hospital patient populations is limited. The objective of this study was to determine the effects of a multimodal analgesia order set on opioid utilization and adverse drug events in adult hospitalized patients. Methods: This retrospective pre/post implementation analysis was conducted at 3 community hospitals and a level II trauma center between January 2016 and December 2019. Patients included were 18 years of age or older, admitted for greater than 24 hours, and had at least one opioid ordered during hospital admission. The primary outcome of this analysis was the average oral morphine milligram equivalents (MME) used on days 1 through 5 of hospitalization. Secondary outcomes included the percentage of hospitalized patients with an opioid ordered for analgesia who received a scheduled non-opioid analgesic medication, the average number of ORADEs recorded in nursing assessments on hospitalization days 1 through 5, length of stay, and mortality. Multimodal analgesic medications included acetaminophen, gabapentinoids, non-steroidal anti-inflammatory drugs, muscle relaxants, and transdermal lidocaine. Results: The pre- and post-groups included 86 535 patients and 85 194 patients, respectively. The average oral MMEs used on days 1 through 5 were lower in the post-group (P <.0001). Utilization of multimodal analgesia as measured by the percentage of patients with 1 or more scheduled multimodal analgesia agent ordered increased from 33% to 49% at the end of the analysis. Conclusion: Utilization of a multimodal analgesia order set was associated with a decrease in opioid use and an increase in multimodal analgesia use in an entire hospital adult population. [ABSTRACT FROM AUTHOR]

There is growing interest in developing causal inference methods for multi‐valued treatments with a focus on pairwise average treatment effects. Here we focus on a clinically important, yet less‐studied estimand: causal drug‐drug interactions (DDIs), which quantifies the degree to which the causal effect of drug A is altered by the presence versus the absence of drug B. Confounding adjustment when studying the effects of DDIs can be accomplished via inverse probability of treatment weighting (IPTW), a standard approach originally developed for binary treatments and later generalized to multi‐valued treatments. However, this approach generally results in biased results when the propensity score model is misspecified. Motivated by the need for more robust techniques, we propose two empirical likelihood‐based weighting approaches that allow for specifying a set of propensity score models, with the second method balancing user‐specified covariates directly, by incorporating additional, nonparametric constraints. The resulting estimators from both methods are consistent when the postulated set of propensity score models contains a correct one; this property has been termed multiple robustness. In this paper, we derive two multiply‐robust estimators of the causal DDI, and develop inference procedures. We then evaluate their finite sample performance through simulation. The results demonstrate that the proposed estimators outperform the standard IPTW method in terms of both robustness and efficiency. Finally, we apply the proposed methods to evaluate the impact of renin‐angiotensin system inhibitors (RAS‐I) on the comparative nephrotoxicity of nonsteroidal anti‐inflammatory drugs (NSAID) and opioids, using data derived from electronic medical records from a large multi‐hospital health system. [ABSTRACT FROM AUTHOR]

This research proposes a novel mobile health-based hospital selection framework for remote patients with multi-chronic diseases based on wearable body medical sensors that use the Internet of Things. The proposed framework uses two powerful multi-criteria decision-making (MCDM) methods, namely fuzzy-weighted zero-inconsistency and fuzzy decision by opinion score method for criteria weighting and hospital ranking. The development of both methods is based on a Q-rung orthopair fuzzy environment to address the uncertainty issues associated with the case study in this research. The other MCDM issues of multiple criteria, various levels of significance and data variation are also addressed. The proposed framework comprises two main phases, namely identification and development. The first phase discusses the telemedicine architecture selected, patient dataset used and decision matrix integrated. The development phase discusses criteria weighting by q-ROFWZIC and hospital ranking by q-ROFDOSM and their sub-associated processes. Weighting results by q-ROFWZIC indicate that the time of arrival criterion is the most significant across all experimental scenarios with (0.1837, 0.183, 0.230, 0.276, 0.335) for (q = 1, 3, 5, 7, 10), respectively. Ranking results indicate that Hospital (H-4) is the best-ranked hospital in all experimental scenarios. Both methods were evaluated based on systematic ranking and sensitivity analysis, thereby confirming the validity of the proposed framework. [ABSTRACT FROM AUTHOR]

Broad availability and cost-effectiveness of 99Mo/99mTc generators worldwide support the use, and thus the development, of novel 99mTc-labelled radiopharmaceuticals. In recent years, preclinical and clinical developments for neuroendocrine neoplasms patient management focused on somatostatin receptor subtype 2 (SST2) antagonists, mainly due to their superiority in SST2-tumour targeting and improved diagnostic sensitivity over agonists. The goal of this work was to provide a reliable method for facile preparation of a 99mTc-labelled SST2 antagonist, [99mTc]Tc-TECANT-1, in a hospital radiopharmacy setting, suitable for a multi-centre clinical trial. To ensure successful and reproducible on-site preparation of the radiopharmaceutical for human use shortly before administration, a freeze-dried three-vial kit was developed. The final composition of the kit was established based on the radiolabelling results obtained during the optimisation process, in which variables such as precursor content, pH and buffer, as well as kit formulations, were tested. Finally, the prepared GMP-grade batches met all predefined specification parameters together with long-term kit stability and stability of the product [99mTc]Tc-TECANT-1. Furthermore, the selected precursor content complies with micro-dosing, based on an extended single-dose toxicity study, where histopathology NOEL was established at 0.5 mg/kg BW, being more than 1000 times higher than the planned human dose of 20 µg. In conclusion, [99mTc]Tc-TECANT-1 is suitable to be advanced into a first-in-human clinical trial. [ABSTRACT FROM AUTHOR]

Purpose Over the past decade there has been increased attention on the need for highly skilled and trained pharmacy technicians; however, few best practices to assist health-system pharmacies in meeting technician workforce challenges have been identified. These challenges have been further revealed since 2019 through rising inflation, increased cost of living, and competing opportunities for skilled technical workers. This article describes an 18-hospital academic health system's experience implementing an innovative pharmacy technician career structure focused on increasing pharmacy technician engagement as well as improving recruitment and retention. Methods Prior to creating a new career structure, the department of pharmacy had one development track for pharmacy technicians, which included only 2 nonsupervisory job titles. Due to recruitment, retention, and employee engagement challenges, the department of pharmacy, in collaboration with the human resources department, developed a new pharmacy technician structure that included 3 pharmacy technician tracks and 4 nonsupervisory levels. Outcomes collected to determine the success of the program included pharmacy technician engagement survey scores, annual voluntary turnover rate, rolling 12-month voluntary turnover rate, monthly vacancy rate, and average years of service at termination. The monthly discharge prescription capture rate was also measured to support efforts to keep the cost of the new structure budget neutral. Conclusion The change in career structure assisted in the improvement of each outcome identified. The close collaboration of the departments of pharmacy and human resources can lead to positive solutions of national problems and have a sustained impact on department operations. [ABSTRACT FROM AUTHOR]

Early in the pandemic, New York City's public hospital system partnered with multiple philanthropic foundations to offer an unconditional cash transfer program for low-income New Yorkers affected by COVID-19. The $1000 cash transfers were designed to help people meet their most immediate health and social needs and were incorporated into healthcare delivery and contact tracing workflows as a response to the public health emergency. To better understand program recipients' experiences, researchers conducted 150 telephone surveys with randomly sampled cash transfer recipients and 20 in-depth qualitative interviews with purposefully sampled survey participants. Survey participants were predominantly Latinx (87%) and women (65%). The most common reported uses of the $1000 were food and rent. Most participants (79%) reported that without the $1000 cash transfer they would have had difficulty paying for basic expenses or making ends meet, with specific positive effects reported related to food, housing, and ability to work. The majority of survey participants reported that receiving the cash assistance somewhat or greatly improved their physical health (83%) and mental health (89%). Qualitative interview results generally supported the survey findings. [ABSTRACT FROM AUTHOR]

Background: Solid organ transplant (SOT) recipients are predicted to have worse COVID-19 outcomes due to their compromised immunity. However, this association remains uncertain because published studies have had small sample sizes and variability in chronic comorbidity adjustment. Methods: In this retrospective cohort study conducted at a multihospital health system, we compared COVID-19 outcomes and survival up to 60 days following hospital admission in SOT recipients taking baseline immunosuppressants versus hospitalized control patients. Results: The study included 4,562 patients who were hospitalized with COVID-19 (108 SOT recipients and 4,454 controls) from 03/2020 to 08/2020. Mortality at 60 days was higher for SOT recipients (17% SOT vs 10% control; unadjusted odds ratio (OR) = 1.74, 95% confidence interval (CI) 1.04–2.91, P = 0.04). We then conducted a 1:5 propensity matched cohort analysis (100 SOT recipients; 500 controls) using age, sex, race, body mass index, hypertension, diabetes, chronic kidney disease, liver disease, admission month, and area deprivation index. Within 28 days of admission, SOT recipients had fewer hospital-free days (median; 17 SOT vs 21 control; OR = 0.64, 95%CI 0.46–0.90, P = 0.01) but had similar ICU-free days (OR = 1.20, 95%CI 0.72–2.00, P = 0.49) and ventilator-free days (OR = 0.91, 95%CI 0.53–1.57, P = 0.75). There was no statistically significant difference in 28-day mortality (9% SOT vs 12% control; OR = 0.76, 95%CI 0.36–1.57, P = 0.46) or 60-day mortality (16% SOT vs 14% control; OR = 1.15, 95%CI 0.64–2.08, P = 0.64). Conclusions: Hospitalized SOT recipients appear to need additional days of hospital care but can achieve short-term mortality outcomes from COVID-19 that are similar to non-SOT recipients in a propensity matched cohort study. [ABSTRACT FROM AUTHOR]

Background: In the hospital environment, to achieve an optimum level of operations and service, it is necessary to develop adequate inventory management system. Stocks can be managed, amongst other ways, through inputs classification, which is generally carried out based on a single criterion, such as monetary value, demand or criticality, which does not fully address the complexity of a hospital's inventory management system. Thus, the present study proposes a multi-criteria decision support model to help classify the stock of medicines and materials, enabling a more effective inventory management system for hospitals. Methods: Methodologically, the study followed 3 stages: (1) preliminary phase; (2) modelling and choice phase; and (3) finalization phase. Each stage had a set of specific steps that were followed. The first stage identified the actors of the process, objectives, criteria and alternatives, establishing 5 criteria and 48 alternatives; the second stage was the choice and execution of the multi-criteria decision method to solve the problem. It was decided to use the Flexible and Interactive Tradeoff method for the sorting problematic. Finally, in the third stage, the sensitivity analysis for the developed model and the validation of the results with decision makers were carried out. In the study, 48 medicines and materials were included to validate the proposed model; however, the model could be used for more items. Results: From the total of 48 medicines and hospital medical materials selected for the study, the classification of 34 of these alternatives to a single class was obtained through modelling and the other 14 alternatives were destined to two possible classes; moreover, the sensitivity analysis performed showed robust results. The items classified in class W should receive special attention by the stock manager; therefore, they should be monitored weekly. Items classified in class B should be monitored biweekly and finally, items classified in class M, should be monitored monthly. Conclusions: The classification of medicines and materials developed according to the inventory demands allowed more efficient purchasing decisions, optimizing the stock of materials and medicines at the hospital while optimizing the inventory manager's activities, saving time. Consequently, the proposed model can support the development of other multicriteria models in different hospital scenarios. [ABSTRACT FROM AUTHOR]

This article presents the findings of a study on the amount of waste generated during gastrointestinal endoscopic examinations in German hospitals and offices. The study aimed to calculate the recycling potential of this waste. Over a four-week period, waste was collected and categorized into residual waste, accessories, personal protective equipment, plastics, and paper. The study found that an average of 1.15 kg of waste was generated per examination, with 69.9% being residual waste. Although the recycling potential for plastic and paper was low, it could still contribute to reducing the amount of residual waste. [Extracted from the article]

Waiting in line is now becoming a common problem in our daily life and long waiting in queues results in loss of customers, bad reputation etc. Hence queuing and waiting time analysis is particularly important in service systems. Management of queues plays a critical role in the health care management as it deals with the issue of treatment of patients to provide better assistance. This research aims to study the outpatient department of a multi-specialty hospital in Kerala using a single line multiple server queue. For the study, we have collected the data on arrivals, waiting time, service pattern and departures during 7 days (considering 3 servers) from 9.00 am to 3.00 pm and used them as input data in the M/M/C model. The computation of performance measures corresponding to M/M/1, M/M/2 and M/M/3 queuing models shows the average waiting time of patients in the queue and system, the average length of queue and system, the percentage of server utilization, etc. can be reduced by incrementing the number of servers. Also, the plot of delay probability with the number of servers and arrival rate shows that delay probability decreases if the number of servers increases and increases with the increase of arrival rate. The analysis of the study of hospital data using queuing models shows that instead of having three doctors at present there is a need for a minimum of seven doctors to reduce the delay time of patients and thus get the facility immediately. [ABSTRACT FROM AUTHOR]

Background: Although frequently used in the early pandemic, data on the effectiveness of COVID-19 convalescent plasma (CCP) remain mixed. We investigated the effectiveness and safety of CCP in hospitalized COVID-19 patients in real-world practices during the first two waves of the pandemic in a multi-hospital healthcare system in Texas. Methods and findings: Among 11,322 hospitalized patients with confirmed COVID-19 infection from July 1, 2020 to April 15, 2021, we included patients who received CCP and matched them with those who did not receive CCP within ±2 days of the transfusion date across sites within strata of sex, age groups, days and use of dexamethasone from hospital admission to the match date, and oxygen requirements 4–12 hours prior to the match date. Cox proportional hazards model estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for effectiveness outcomes in a propensity score 1:1 matched cohort. Pre-defined safety outcomes were described. We included 1,245 patients each in the CCP treated and untreated groups. Oxygen support was required by 93% of patients at the baseline. The pre-defined primary effectiveness outcome of 28-day in-hospital all-cause mortality (HR = 0.85; 95%CI: 0.66,1.10) were similar between treatment groups. Sensitivity and stratified analyses found similar null results. CCP-treated patients were less likely to be discharged alive (HR = 0.82; 95%CI: 0.74, 0.91), and more likely to receive mechanical ventilation (HR = 1.48; 95%CI: 1.12, 1.96). Safety outcomes were rare and similar between treatment groups. Conclusion: The findings in this large, matched cohort of patients hospitalized with COVID-19 and mostly requiring oxygen support at the time of treatment, do not support a clinical benefit in 28-day in-hospital all-cause mortality for CCP. Future studies should assess the potential benefits with specifically high-titer units in perhaps certain subgroups of patients (e.g. those with early disease or immunocompromised). [ABSTRACT FROM AUTHOR]

Introduction: Poly-adenosine diphosphate ribose polymerase inhibitors (PARPi) have become a cornerstone of therapy in the management ovarian cancer and other cancers. PARPi are associated with significant toxicities and management strategies are primarily founded on clinical trial experience. This study aimed to provide an evaluation of patients receiving PARPi therapy within an academic health-system. Methods: A retrospective, observational study of adult patients with gynecologic malignancy was conducted at the University of Pennsylvania Health System. Data was collected on patients prescribed a PARPi between December 2014 and October 2019. The primary endpoint was the status of PARPi therapy at the end of the study period. Key secondary endpoints included toxicity management strategies, time to discontinuation due to toxicity, progression free survival (PFS), and overall survival (OS). Results: Of the 85 patients included, 45 (53%) received olaparib, 24 (28%) niraparib, and 16 (19%) rucaparib. Twenty-nine patients (34%) continued on therapy, 15 (18%) discontinued due to toxicity, and 41 (48%) discontinued due to progression. Fifty-one percent of patients required a dose reduction due to toxicities. The median time to discontinuation due to toxicity was 69 days (9-353). Median PFS was 181 days (9-365) and median OS was 338 days (9-365). Conclusion: PARPi therapy is associated with numerous toxicities that are best managed through a multi-modal approach. Importantly, about half the patients in the current study required a dose reduction. Overall, this observational study outlines the incidence of PARPi toxicities and reviews potential management strategies, further guiding practitioners in an area with limited real-world experience. [ABSTRACT FROM AUTHOR]

Background: During rapidly evolving outbreaks, health services and essential medical care are interrupted as facilities have become overwhelmed responding to COVID-19. In the Eastern Mediterranean Region (EMR), more than half of countries are affected by emergencies, hospitals face complex challenges as they respond to humanitarian crises, maintain essential services, and fight the pandemic. While hospitals in the EMR have adapted to combat COVID-19, evidence-based and context-specific recommendations are needed to guide policymakers and hospital managers on best practices to strengthen hospitals' readiness, limit the impact of the pandemic, and create lasting hospital sector improvements towards recovery and resilience. Aim: Guided by the WHO/EMR's "Hospital readiness checklist for COVID-19", this study presents the experiences of EMR hospitals in combatting COVID-19 across the 22 EMR countries, including their challenges and interventions across the checklist domains, to inform improvements to pandemic preparedness, response, policy, and practice. Methods: To collect in-depth and comprehensive information on hospital experiences, qualitative and descriptive quantitative data was collected between May-October 2020. To increase breadth of responses, this comprehensive qualitative study triangulated findings from a regional literature review with the findings of an open-ended online survey (n = 139), and virtual in-depth key informant interviews with 46 policymakers and hospital managers from 18 out of 22 EMR countries. Purposeful sampling supported by snowballing was used and continued until reaching data saturation, measures were taken to increase the trustworthiness of the results. Led by the checklist domains, qualitative data was thematically analyzed using MAXQDA. Findings: Hospitals faced continuously changing challenges and needed to adapt to maintain operations and provide essential services. This thematic analysis revealed major themes for the challenges and interventions utilized by hospitals for each of hospital readiness domains: Preparedness, Leadership, Operational support, logistics, supply management, Communications and Information, Human Resources, Continuity of Essential Services and Surge Capacity, Rapid Identification and Diagnosis, Isolation and Case Management, and Infection, Prevention and Control. Conclusion: Hospitals are the backbone of COVID-19 response, and their resilience is essential for achieving universal health coverage. Multi-pronged (across each of the hospitals readiness domains) and multi-level policies are required to strengthen hospitals resilience and prepare health systems for future outbreaks and shocks. [ABSTRACT FROM AUTHOR]

The resumption of work and production is one of the key issues during the novel coronavirus (COVID‐19) post‐epidemic phase. We used location‐based service data of mobile devices to assess the work resumption of 22,098 hospitals in mainland China. The multiscale influences of the determinants on work resumption in hospitals, including medical‐service capacity, human movement, and epidemic severity, were examined using the multiscale geographically weighted regression technique. This study provides a novel insight into the assessment of work resumption in hospitals and its determinants, and is flexible to be extended to evaluate the work resumption of other industries. The findings can introduce helpful information for other countries to implement the strategies of work recovery during the post‐epidemic phase. [ABSTRACT FROM AUTHOR]

• A strong multidisciplinary organizational structure is necessary to drive consensus in selection and successfully implement point of care glucose meters across a large multi-hospital system. • Beyond the standard analytical laboratory evaluation, meter performance should be evaluated at the point of use, employing consensus error grids and defined acceptability criteria. • Structured end-user evaluation is as an essential element of the meter selection process which commonly includes the evaluation of cost, connectivity, indications for use, and ease of implementation. To select and standardize point-of-care (POC) glucose meters across a multi-hospital system. We formed a multidisciplinary POC glucose standardization working group including key stakeholders from each site. A set of selection criteria: usability, clinical and laboratory performance, indications for use, interface connectivity, ease of implementation and ongoing operational costs were used to develop a scoring schema to facilitate a consensus-driven selection process. Method comparison and consensus error grid evaluation against the clinically validated reference methods demonstrated that the analytical performance for all candidate meters was comparable for both the laboratory and clinical evaluation. However, Meter 1 ranked highest in usability evaluations, implementation and streamlined interface connectivity. The meter selection process and implementation were staggered across sites due to complexity of transitioning to a new manufacturer's meter and limitations in vendor support for training and ongoing troubleshooting of interface connectivity. Standardization of POC glucose meters in a large multi-hospital system is a complex undertaking requiring robust, multidisciplinary organizational structure both system-wide and locally, development of consensus-driven selection tools, usability evaluation by end-users, laboratory and clinical evaluation of the analytical performance, and a strong vendor-laboratory partnership during the implementation process. [ABSTRACT FROM AUTHOR]

Total quality management (TQM) is a dynamic philosophy that incorporates gradual and uninterrupted improvements. The total quality is accomplished if all the desired goals including quality of product, reputation in market, services, low cost of product, employee and customer satisfaction, optimum utilization of resources, work environment, and so on are attained. As far as the Pakistani perspective is concerned, TQM as a strategic tool is not appropriately used to optimize its performance. Public healthcare in Pakistan is one of the most ignored sectors with regard to its service quality implementation and delivery. The public sector hospitals are one of the major primary healthcare providers, but the facilities they provide do not meet the desired requirement. This study addresses six TQM attributes to analyze the TQM performance of various public sector teaching hospitals in the province Punjab of Pakistan. The data was obtained from medical experts. The TQM performance to study the behavior of TQM implementation in hospitals is evaluated using TQM digraphs. The hospitals are ranked according to the TQM performance index, which is obtained from TQM digraphs. The technique to find the most effective attribute for a hospital is also proposed. The TQM digraph approach not only focuses on the significance of attributes independently but also incorporates the relative importance of one attribute over another. Also, this approach is very flexible that can incorporate new attributes and market variation so that continuous improvement may be possible. Moreover, the results obtained in this approach are not limited to beneficial for benchmarking of teaching hospitals in Punjab on the TQM basis, but these can also help indicate the particular attribute that is more needed to be improved for a particular hospital to increase its TQM performance. [ABSTRACT FROM AUTHOR]

Background: Palliative radiotherapy for gastric cancer bleeding has been reported to be a safe and effective treatment, but predictive factors for achievement of hemostasis and overall survival have not been established. Methods: In this retrospective study, 120 courses of palliative radiotherapy for gastric cancer bleeding in 117 patients in 4 institutes in Japan were reviewed with approval of the ethical committee in each institute. The rate of achieving hemostasis was evaluated by 50% or more reduction of red blood cell transfusion before and after the start of radiotherapy, elevation of blood hemoglobin concentration in a period of 4 weeks from the start of radiotherapy or improvement of subjective or objective clinical symptoms in a period of 4 weeks from the start of radiotherapy. Predictive factors for overall survival and achieving hemostasis were investigated with the Cox hazards model. Results: The median overall survival period was 3.7 months. Multivariate analysis showed that absence of metastatic disease, higher biological effective dose, higher serum albumin level, lower blood urea nitrogen level and lower neutrophil-to-lymphocyte ratio (NLR) were associated with longer overall survival. Elevation of hemoglobin concentration in a period of 4 weeks from the start of radiotherapy (mean concentration: 8.2 g/dL vs. 8.9 g/dL, p = 0.006) and decrease in the amount of red cell transfusion from a 4-week period before to a 4-week period after the start of radiotherapy (mean amount: 716 mL vs. 230 mL, p < 0.0001) were observed. The overall rate of achievement of hemostasis was 59.6%. In multivariate analysis, higher biological effective dose was associated with achievement of hemostasis. Grade 2 or higher acute adverse effects related to radiotherapy were observed in 17.5% of cases in 120 treatment courses. Six cases (5.0%) had grade 3 or 4 adverse effects including gastric penetration in 1 patient and anorexia requiring total parental nutrition in 3 patients. No grade 5 adverse effects were observed. Conclusions: Palliative radiotherapy for gastric cancer bleeding seems to be an effective and safe treatment strategy. Higher treatment dose was associated with longer overall survival and a hemostatic effect. Some hematological parameters may predict overall survival, and they would be helpful for deciding the treatment strategy. [ABSTRACT FROM AUTHOR]

Little is known regarding pre-hospital and in-hospital delays in acute ischemic stroke (AIS) patients in Indonesia. This study evaluated the nature of these delays and identified factors causing pre-hospital delays among AIS patients in Indonesia. This was a prospective, multicenter, observational study conducted among adult AIS patients in three hospitals in the city of Surabaya between March 15 and August 15, 2019. Baseline characteristics and the pre- and post-arrival time intervals of the patients to the study sites were collected and analyzed. Multiple logistic regression analyzes with a stepwise forward model were performed to evaluate the factors contributing to pre-hospital delay. A total of 126 patients were recruited for this study. The mean age was 58.56 ± 10.71-years-old. The mean time of pre-hospital delay and mean time to the computed tomography scan were 1,004 ± 1,116.09 and 189 ± 166.44 min, respectively. Eighteen out of 126 patients (14.29%) presented to the hospitals within 4.5 h of the intravenous thrombolysis (IVT) time window. However, only three patients (2.38%) ultimately received IVT. Wake-up stroke (odds ratio [OR] = 17.865; p = 0.019), unaware of the gravity of the symptoms (OR = 11.025; p = 0.007), unaware of stroke symptoms (OR = 7.880; p = 0.003) and referral patient (OR = 7.819; p = 0.008) were significantly associated with pre-hospital delay. Pre-hospital delay of AIS was patients very common and may represent the most challenging problem to improve stroke care in Indonesia. Wake-up stroke, a lack of patient understanding in recognizing stroke symptoms, and an ineffective referral system were the most prominent risk factors for pre-hospital delay in Indonesian AIS patients. [ABSTRACT FROM AUTHOR]

Objective: Robust disease and syndromic surveillance tools are underdeveloped in the United States, as evidenced by limitations and heterogeneity in sociodemographic data collection throughout the COVID-19 pandemic. To monitor the COVID-19 pandemic in Minnesota, we developed a federated data network in March 2020 using electronic health record (EHR) data from 8 multispecialty health systems. Materials and Methods: In this serial cross-sectional study, we examined patients of all ages who received a COVID-19 polymerase chain reaction test, had symptoms of a viral illness, or received an influenza test from January 3, 2016, through November 7, 2020. We evaluated COVID-19 testing rates among patients with symptoms of viral illness and percentage positivity among all patients tested, in aggregate and by zip code. We stratified results by patient and area-level characteristics. Results: Cumulative COVID-19 positivity rates were similar for people aged 12-64 years (range, 15.1%-17.6%) but lower for adults aged ≥65 years (range, 9.3%-10.7%). We found notable racial and ethnic disparities in positivity rates early in the pandemic, whereas COVID-19 positivity was similarly elevated across most racial and ethnic groups by the end of 2020. Positivity rates remained substantially higher among Hispanic patients compared with other racial and ethnic groups throughout the study period. We found similar trends across area-level income and rurality, with disparities early in the pandemic converging over time. Practice Implications: We rapidly developed a distributed data network across Minnesota to monitor the COVID-19 pandemic. Our findings highlight the utility of using EHR data to monitor the current pandemic as well as future public health priorities. Building partnerships with public health agencies can help ensure data streams are flexible and tailored to meet the changing needs of decision makers. [ABSTRACT FROM AUTHOR]

The hospital is a critical infrastructure for treating the injured after the earthquake. The hospital is a complex system composed of structure, non-structural components, and medical equipment that are located on different floors, have different importance and seismic performance, and need different control objectives, enhancing any component could improve the hospital's functionality. It is imperative to economically and rationally choose enhancement measures to minimize initial functionality losses and improve hospital resilience. This study provides a hospital functional evaluation method that takes into account the physical dimension of the damage to the structure, non-structural components and medical equipment, as well as the organizational dimension of the treatment process of earthquake casualties. Bayesian networks and discrete event simulation methods are used to calculate the availability probability of medical rooms and the functional indicator of the number of earthquake casualties that can be treated. Then, a two-stage and multi-objective functionality improvement method was proposed to improve hospital functionality. The first stage is the design optimization of the isolation system with the objectives of minimizing the functionality loss and displacement of the isolation layer. The second stage optimizing the enhancement strategies for non-structural components and medical equipment aims at minimizing the functionality loss and enhancement budget. The proposed method uses a fast and elitist non-dominated sorting genetic algorithm (NSGA-II) approach to optimize the design of the isolation system and the enhancement of non-structural components and medical equipment. The method is applied to a hypothetical hospital to highlight the proposed method's capability of improving the hospital's functionality. • A physical-organization based hospital functionality evaluation method that can consider the interaction between components. • A framework was proposed to determine the optimal enhancement strategy for improving the functionality of hospitals. • Structures, non-structural components and medical equipment were divided into two stages of multi-objective optimization. • The design optimization with the objectives of minimizing the functionality loss and displacement of the isolation layer. • Enhancement of non-structural components and medical equipment aimed at minimizing functionality loss and enhancement budget. [ABSTRACT FROM AUTHOR]

The 21st Century Cures Act is a federal mandate which requires sharing clinical notes with patients. To be in compliance, there must be balance between parent/guardian access and adolescent privacy. Healthcare providers must ensure confidential sharing of medical information with adolescents while maintaining parent/guardian access to some health information. This is particularly important in the provision of reproductive health care, where patient privacy is paramount. We sought to identify an intervention to implement adolescent clinical note sharing, ensuring adolescent portal account registration accuracy and correct proxy access for parents/guardians in two adolescent gynecology practices within a multi-hospital healthcare system. A query was built assessing portal account registration accuracy. Within this system, 80.0% of 12- to 17-year-old patient portal accounts were classified as inaccurately registered (IR) or registration accuracy unknown (RAU). To increase accurately registered (AR) accounts the following interventions were pursued: 1) distribution of standardized portal enrollment training; 2) patient outreach email campaign to accurately re-register portal accounts; 3) restriction of access to accounts not accurately registered. Proxy portal configurations were also optimized. In one practice, there was additional staff training staff in correct portal registration. Interventions had the following effect: Distribution of standardized training materials decreased IR and increased AR accounts without significance. The email campaign (response rate: 26.8% system-wide) was most effective in decreasing IR and increasing AR accounts (p=0.009 and p=0.013). Remaining IR and RAU accounts, 54.6% of accounts system-wide, were subsequently restricted. Post restriction, IR accounts continued declining and AR accounts continued increasing, without significance. Proxy portal enhancements with interventions deployed increased proxy portal account adoption overall. Trends observed for adolescent gynecology patients were similar to system-wide trends. Our last intervention, targeted training of staff, is underway. A stepwise intervention approach can be effectively utilized to implement adolescent clinical note sharing for adolescent gynecology practices in a manner that achieves compliance with federal mandates, increases access to health records for adolescents and their parents/guardians while importantly, protecting adolescent privacy. [ABSTRACT FROM AUTHOR]

• Blockchain (BC) adoption is evaluated in supply chain and logistics context. • Game theoretic insights are provided for order and collaboration of BC investment. • Results show that follower-led efforts in BC adoption provide greater benefits. • Transportation and logistics costs affect the shortcomings of BC implementation. The presence of Blockchain Technology (BCT) and its potential supply chain (SC) and logistic benefits—such as improved resilience or lessened disruption—have motivated organizations to consider BCT investment. BCT is a relatively novel technology and requires multiple participants to meet its greatest potential. Its novelty is a barrier to its adoption and can be dependent on an innovator or leader to convince others to invest in or adopt BCT. Using an institutional entrepreneurship theoretical lens, we determine who should lead the investment (adoption) or whether a collaborative investment is best. Insights into this context can be garnered using a sequential game-theoretic model where lead investment roles switch amongst parties. Four scenarios are evaluated and consider full, partial, or no collaboration between SC entities. Within this framework, the two-stage process of adopting and implementing BCT is introduced to separate cost and demand channels. During the adoption stage, a reduction in marginal production cost via positive net benefits of BCT-based transportation and logistics is considered in the cost channel. In the implementation stage, the optimal level of BCT investment is determined, increasing shipping quality for consumers in transportation and logistics and reducing supply chain disruption simultaneously, which is considered in the demand channel. The results show that greater disruption likelihood will boost retail prices, intermediate prices, and profits of SC entities after BCT is adopted. We also find that traditional SCs with higher disruption levels result in lower BCT investment. When a leader in the sequential game (the manufacturer in our model) is the institutional entrepreneur, collaboration in BCT investment becomes more attractive. One important—and counterintuitive—result reveals that when full SC cooperation doesn't exist, the entire SC is better off when the follower (not the leader) in a sequential game leads BCT adoption. The unique role of reduction in transportation and logistics costs via the cost channel is to compensate for a lower BCT investment due to lack of competition or reinforce a higher BCT investment by counterbalancing opportunistic behaviors. [ABSTRACT FROM AUTHOR]