Managing violence against healthcare personnel in the emergency settings of Pakistan: a mixed methods study

ObjectivesThe primary objective of this study was to evaluate the effectiveness of a half-day training on de-escalation of violence against healthcare personnel regarding prevention and management of violence incidents versus a similar tertiary-level hospital with no such training. Secondary objectives were to compare the overall satisfaction, burnout, fear of violence and confidence in coping with patients’ aggression of the healthcare personnel in the two hospitals.DesignMixed method design, with a comparative cross-sectional (quantitative) and focus group discussions (qualitative) components.SettingEmergency departments of the two tertiary care hospitals in district Peshawar over 6 months starting from May 2018.ParticipantsHealthcare personnel in the emergency departments of the two hospitals (trained vs untrained).Outcome measuresViolence exposure (experienced/witnessed) assessed through a previously validated tool in the past 5 months. Burnout, confidence in coping with patient aggression and overall job satisfaction were also assessed through validated tools. The qualitative component explored the perceptions of healthcare personnel regarding the management of violence and the importance of training on de-escalation of violence through focus group discussions in the two hospitals.ResultsThe demographic characteristics of the healthcare personnel within the two hospitals were quite similar. The de-escalation training did not lead to a reduction in the incidences of violence; however, confidence in coping with patient aggression and the overall satisfaction were significantly improved in the intervention hospital. The de-escalation training was lauded by the respondents as led to an improvement in communication skills, and the healthcare personnel suggested for scale-up to all the cadres and hospitals.ConclusionThe study found significant improvements in the confidence of healthcare personnel in coping with patient aggression, along with better job satisfaction and less burnout in the intervention hospital following the de-escalation training.

Baby-Friendly Hospital Initiative for Neonatal Wards: impact on breastfeeding practices among preterm infants

ABSTRACT Objective: to assess breastfeeding support practices for preterm infants at two Baby-Friendly hospitals in southeastern Brazil, comparing the effect of implementing the guidelines for Baby-Friendly Hospital Initiative for Neonatal wards. Methods: a quasi-experimental study, pre- and post-intervention with control. Implementation of this initiative in the intervention hospital using Knowledge Translation. Data collection on compliance with the adapted Ten Steps, Three Guiding Principles and the Code before and after the intervention was carried out via interviews with mothers of preterm babies and professionals, unit observation and documentary analysis in the intervention and control hospitals. Intra-intergroup comparison was performed. Results: increases in global compliance with the Three Principles, Ten Steps, the Code, partial compliance with each Principle and in most Steps was greater in the intervention hospital. Conclusion: this initiative improved practices related to breastfeeding in the intervention hospital, demonstrating the potential to improve care and breastfeeding in neonatal wards.

Lipid Profile Results after Cardiovascular Prevention Programme: Euroaction Model in Spain

Background: Cardiovascular prevention and rehabilitation programmes (CVPRP) are an established model of care designed to improve risk factor management. They have been successfully implemented in a variety of settings, in patients with coronary heart disease (CHD). Objective: To assess the long term impact of a nurse-coordinated, multidisciplinary, CVPRP in patients with CHD in the reduction of lipid profile and medication prescription in clinical practice. Methods: The study used an analytical, experimental, population based, prospective and longitudinal design. In Spain, the study was conducted in the Valencian Community, including two randomized hospitals. Coronary patients were prospectively and consecutively identified in both hospitals. The intervention hospital carried out an 8-week CVPRP. Results: The proportion of patients achieving improved standards of preventive care increased in the intervention hospital compared with the usual care hospital, mainly regarding LDL-C concentrations. Furthermore, an increased prescription of statins was found in the intervention group. However, there were no statistically significant differences in triglycerides and glucose levels. Conclusion: The EUROACTION nurse-led CVPRP enabled coronary patients to control lipid profile to the European targets. A large proportion of patients were prescribed statin therapy as cardioprotective medication with favorable changes in medication for coronary patients. To improve the potential for cardiovascular prevention, we need local preventive cardiology programmes adapted to the health policy of individual countries.

A Community‐Engaged Stroke Preparedness Intervention in Chicago

Background We evaluated a community‐engaged stroke preparedness intervention that aimed to increase early hospital arrival and emergency medical services (EMS) utilization among patients with stroke in the South Side of Chicago, Illinois. Methods and Results We compared change in early hospital arrival (<3 hours from symptom onset) and EMS utilization before and after our intervention among patients with confirmed ischemic stroke at an intervention hospital on the South Side of Chicago with concurrent data from 6 hospitals in nonintervention communities on the North Side of Chicago and 17 hospitals in St Louis, Missouri. We assessed EMS utilization for suspected stroke secondarily, using geospatial information systems analysis of Chicago ambulance transports before and after our intervention. Among 21 497 patients with confirmed ischemic stroke across all sites, early arrival rates at the intervention hospital increased by 0.5% per month (95% CI, −0.2% to 1.2%) after intervention compared with the preintervention period but were not different from North Side Chicago hospitals (difference of −0.3% per month [95% CI, −0.12% to 0.06%]) or St Louis hospitals (difference of 0.7% per month [95% CI, −0.1% to 1.4%]). EMS utilization at the intervention hospital decreased by 0.8% per month (95% CI, −1.7% to 0.2%) but was not different from North Side Chicago hospitals (difference of 0.004% per month [95% CI, −1.1% to 1.1%]) or St Louis hospitals (difference of −0.7% per month [95% CI, −1.7% to 0.3%]). EMS utilization for suspected stroke increased in the areas surrounding the intervention hospital (odds ratio [OR], 1.4; 95% CI, 1.2–1.6) and in the South Side (OR, 1.2; 95% CI, 1.1–1.3), but not in the North Side (OR, 1.0; 95% CI, 0.9–1.1). Conclusions Following a community stroke preparedness intervention, early hospital arrival and EMS utilization for confirmed ischemic stroke did not increase. However, ambulance transports for suspected stroke increased in the intervention community compared with other regions. Registration URL: https://www.clini​caltr​ials.gov ; Unique identifier: NCT02301299.

The Acute Kidney Outreach to Prevent Deterioration and Death trial: a large pilot study for a cluster-randomized trial

Background and Objectives The Acute Kidney Outreach to Reduce Deterioration and Death trial was a large pilot study for a cluster-randomized trial of acute kidney injury (AKI) outreach. Methods An observational control (before) phase was conducted in two teaching hospitals (9 miles apart) and their respective catchment areas. In the intervention (after) phase, a working-hours AKI outreach service operated for the intervention hospital/area for 20 weeks, with the other site acting as a control. All AKI alerts in both hospital and community patients were screened for inclusion. Major exclusion criteria were patients who were at the end of life, unlikely to benefit from outreach, lacking mental capacity or already referred to the renal team. The intervention arm included a model of escalation of renal care to AKI patients, depending on AKI stage. The 30-day primary outcome was a combination of death, or deterioration, as shown by any need for dialysis or progression in AKI stage. A total of 1762 adult patients were recruited; 744 at the intervention site during the after phase. Results A median of 3.0 non-medication recommendations and 0.5 medication-related recommendations per patient were made by the outreach team a median of 15.7 h after the AKI alert. Relatively low rates of the primary outcomes of death within 30 days (11–15%) or requirement for dialysis (0.4–3.7%) were seen across all four groups. In an exploratory analysis, at the intervention hospital during the after phase, there was an odds ratio for the combined primary outcome of 0.73 (95% confidence interval 0.42–1.26; P = 0.26). Conclusions An AKI outreach service can provide standardized specialist care to those with AKI across a healthcare economy. Trials assessing AKI outreach may benefit from focusing on those patients with ‘mid-range’ prognosis, where nephrological intervention could have the most impact.

Reducing intrapartum fetal deaths through low-dose high frequency clinical mentorship in a rural hospital in Western Kenya: a quasi-experimental study

Background Intrapartum fetal mortality can be prevented by quality emergency obstetrics and newborn care (EmONC) during pregnancy and childbirth. This study evaluated the effectiveness of a low-dose high-frequency onsite clinical mentorship in EmONC on the overall reduction in intrapartum fetal deaths in a busy hospital providing midwife-led maternity services in rural Kenya. Methods A quasi-experimental (nonequivalent control group pretest – posttest) design in a midwife-led maternity care hospitals. Clinical mentorship and structured supportive supervision on EmONC signal functions was conducted during intervention. Maternity data at two similar time points: Oct 2015 to July 2016 (pre) and August 2016 to May 2017 (post) reviewed. Indicators of interest at Kirkpatrick’s levels 3 and 4 focusing on change in practice and health outcomes between the two time periods were evaluated and compared through a two-sample test of proportions. Proportions and p-values were reported to test the strength of the evidence after the intervention. Results Spontaneous vaginal delivery was the commonest route of delivery between the two periods in both hospitals. At the intervention hospital, assisted vaginal deliveries (vacuum extractions) increased 13 times (0.2 to 2.5%, P < 0.0001), proportion of babies born with low APGAR scores requiring newborn resuscitation doubled (1.7 to 3.7%, P = 0.0021), proportion of fresh stillbirths decreased 5 times (0.5 to 0.1%, P = 0.0491) and referred cases for comprehensive emergency obstetric care doubled (3.0 to 6.5%, P < 0.0001) with no changes observed in the control hospital. The proportion of live births reduced (98 to 97%, P = 0.0547) at the control hospital. Proportion of macerated stillbirths tripled at the control hospital (0.4 to 1.4%, P = 0.0039) with no change at the intervention hospital. Conclusion Targeted mentorship improves the competencies of nurse/midwives to identify, manage and/or refer pregnancy and childbirth cases and/or complications contributing to a reduction in intrapartum fetal deaths. Scale up of this training approach will improve maternal and newborn health outcomes.

Factors Associated With Worsened Neurological Outcomes in Traumatic Subarachnoid Hemorrhage

INTRODUCTION Patients are often admitted for observation due to isolated traumatic subarachnoid hemorrhage (tSAH). However, factors that are associated with worsening neurological outcomes are unclear. METHODS Patients who presented with tSAH from January 2017 to May 2017 to our ED were identified. Initial patient characteristics on presentation associated with a neurological decline, neurosurgical intervention, hospital readmission, or death were identified via univariate and multivariate regression. Of note, we did not include patient characteristics that are not available on initial evaluation. We then tested this model by identifying those without risk factors and reported their outcome. RESULTS A diagnosis of intracranial hemorrhage was identified in 401 consecutive patients over 5 mo, of which 165 (41.1%) had tSAH. On univariate analysis, patient characteristics associated with a neurological decline, neurosurgical intervention, hospital readmission, or death included depressed skull fractures (P = .02), GCS < 13 (P < .001), cranial nerve palsies (P = .01), any disorientation to self, place, or time (P < .001), concomitant epidural (P = .027) or acute subdurals (P < .001), the presence of midline shift (P < .001), and INR > 1.5 (P = .03). On multivariate analysis, disorientation [odds ratio (OR): 3.53 (1.24-10.0), P = .018] and the presence of midline shift [OR: 6.8 (1.87-24.66), P = .003] were associated with worsened neurological outcomes. Out of the 165 patients, 104 patients had one or more risk factors, and 44 experienced worsened neurological outcomes; 61 patients did not have any of the above risk factors, and 0/61 (0%) experienced a neurologic decline, intervention, hospital readmission, or death. This corresponds to a test sensitivity of 100%, specificity of 50.4%, and a negative predictive value of 100%. CONCLUSION Patients with tSAH who are fully oriented and who do not have a midline shift on initial head computed tomography (CT) are less likely to have a neurological decline, require neurosurgical intervention and hospital readmission, or have mortality. Although the presence of risk factors alone does not necessitate worsened outcomes, patients without any risk factors are unlikely to have a neurological decline.

Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before–after study

ObjectivesWe aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators.DesignAdjusted before–after analysis.SettingA large hospital in the Champagne-Ardenne region, France.ParticipantsPatients admitted to the ED between 13 January 2015 and 13 January 2017.InterventionImplementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016).Primary and secondary outcome measuresProportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions.ResultsThe ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before–after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before–after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%.ConclusionsThe implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.

Increasing smear positive-pulmonary tuberculosis cases by strengthening district TB coordinating team in low case-detection provinces, Thailand

Background: Tuberculosis (TB) is a communicable infectious diseases and remains a major global health problem as the cause of death from an infectious disease worldwide. This study was increased TB cases notification by strengthening the system of district TB coordinating team. Materials and methods: The research was mixed method, Quasi - Experimental study with two –group control and intervention pre–post analysis. The two low TB-case notification provinces in public health region 7 were purposive selected and two districts from each province was random selected to be the area of the study. Selapoom district, Roiet province and Banpai district, Khonkaen province were the study sites for intervention and control group respectively. The sample size included all of TB suspected cases in both group. Data collected from the suspected TB cases form case record form in each district hospital in 9 month period of base line before and after intervention period in both group. The satisfaction questionnaire collected from participants in district TB coordinating team. The curriculum for TB knowledge applied from the standard of National TB program (NTP ) for teaching in the intervention workshop .Focus group discussion was done about system implementation. Data analysis by descriptive statistic, chi square test, focus group analysis was used in qualitative study. Results: The district TB coordinating team was set up in the intervention hospital included of 14 health personnel from hospital, district health office and health center. The work flow and monitoring system was implemented by the district team in intervention group in 9 months period. There were 838 and 324 suspected TB cases in baseline 9 months before the study and 769 and 379 of suspected TB cases in post 9 months after intervention period among control and intervention hospital respectively. The most age group of TB suspected cases were more than 60 year and the most occupation were agriculturists in both group. In both group found that the factors of gender, chest radiography, sputum microscopy, chest radiography with sputum microscopy, chest radiography with completed microscopic examinations, were associated statistically significant at the 0.05 level. For the relative risk of TB notification cases in control hospital ( RR=0.74 ,95%CI 0.54-1.03, p-value 0.07) and intervention hospital (RR=1.61 ,95%CI 1.04-2.51, p-value 0.03) defined that in the hospital with non-intervention provided had a 25% reduction of TB notification cases and in the hospital with intervention provided had a 61% increase of TB notification cases.. Focus group analysis concluded that district TB coordinating team was benefit in district level and helping team to monitoring of TB control program. The coordinating system especially having TB coordinator was the most satisfaction from the participants. Conclusion: Strengthening district TB coordinating team and the coordinating network in hospital , district health office and health center help to increase TB case notification and percent of suspected tuberculosis cases to complete the investigation in district level.

The Impact of Opening a Medical Step-Down Unit on Medically Critically Ill Patient Outcomes and Throughput: A Difference-in-Differences Analysis

Objective: To understand the impact of adding a medical step-down unit (SDU) on patient outcomes and throughput in a medical intensive care unit (ICU). Design: Retrospective cohort study. Setting: Two academic tertiary care hospitals within the same health-care system. Patients: Adults admitted to the medical ICU at either the control or intervention hospital from October 2013 to March 2014 (preintervention) and October 2014 to March 2015 (postintervention). Interventions: Opening a 4-bed medical SDU at the intervention hospital on April 1, 2014. Measurements and Main Results: Using standard summary statistics, we compared patients across hospitals. Using a difference-in-differences approach, we quantified the association of opening an SDU and outcomes (hospital mortality, hospital and ICU length of stay [LOS], and time to transfer to the ICU) after adjustment for secular trends in patient case-mix and patient-level covariates which might impact outcome. We analyzed 500 (245 pre- and 255 postintervention) patients in the intervention hospital and 678 (323 pre- and 355 postintervention) in the control hospital. Patients at the control hospital were younger (60.5-60.6 vs 64.0-65.4 years, P < .001) with a higher severity of acute illness at the time of evaluation for ICU admission (Sequential Organ Failure Assessment score: 4.9-4.0 vs 3.9-3.9, P < .001). Using the difference-in-differences methodology, we identified no association of hospital mortality (odds ratio [95% confidence interval]: 0.81 [0.42 to 1.55], P = .52) or hospital LOS (% change [95% confidence interval]: −8.7% [−28.6% to 11.2%], P = .39) with admission to the intervention hospital after SDU opening. The ICU LOS overall was not associated with admission to the intervention hospital in the postintervention period (−23.7% [−47.9% to 0.5%], P = .06); ICU LOS among survivors was significantly reduced (−27.5% [−50.5% to −4.6%], P = .019). Time to transfer to ICU was also significantly reduced (−26.7% [−44.7% to −8.8%], P = .004). Conclusions: Opening our medical SDU improved medical ICU throughput but did not affect more patient-centered outcomes of hospital mortality and LOS.