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Holding the Wall in Modern American Healthcare - The Impact of Healthcare Overcrowding on Care Delivery
No full textCOVID-19 and influenza vaccine Hesitancy among adults hospitalized in the United States, 2019-2022
No full textBackground: Understanding similarities and differences between hesitancy for influenza and COVID-19 vaccines could facilitate strategies to improve public receptivity toward vaccination.
Methods: We compared hesitancy for COVID-19 vaccines during the first 13 months of availability (January 2021-January 2022) with hesitancy for influenza vaccines in the 15 months prior to COVID-19 vaccine availability (October 2019-December 2020) among adults hospitalized with acute respiratory illness at 21 hospitals in the United States. We interviewed patients regarding vaccination status, willingness to be vaccinated, and perceptions of vaccine safety and efficacy. We used multivariate logistic regression to identify factors associated with vaccine hesitancy.
Results: Among 12,292 patients enrolled during the COVID-19 vaccine period, 5485 (44.6 %) were unvaccinated. Patient characteristics associated with not receiving the COVID-19 vaccine included younger age, female sex, higher BMI, lack of health insurance, absence of chronic comorbid medical conditions, no or rare influenza vaccination in prior years, higher CDC social vulnerability index (SVI), a measure of external stresses that may negatively impact health, living in the Midwest or southern US, lack of college or higher education, and not wearing a mask. Among 983 patients enrolled during the influenza vaccination period, 381(37.8 %) were unvaccinated. Characteristics associated with not receiving the influenza vaccine included no or one chronic comorbid medical condition, no or rare influenza vaccination in prior years, being a current smoker, and higher SVI. Discussion with healthcare providers was a reason for vaccination for 27.7 % (167) for influenza and 8.3 % (564) for COVID-19 and to decline vaccination for 0.5 % Ten great public health achievements-United States (2011) (2) for influenza and 2.2 % (118) for COVID-19.
Conclusions: We found that higher SVI scores and lack of prior influenza vaccination were associated with hesitancy for both COVID-19 and influenza vaccines. There were regional variations in COVID-19 vaccine acceptance and discussions with HCPs significantly influenced acceptance for both vaccines.
Keywords: COVID-19; Influenza; SARS-CoV-2; Vaccine acceptance; Vaccine hesitancy
Geriatric nutrition in the surgical patient: an American Association for the Surgery of Trauma Critical Care and Geriatric Trauma Committees clinical consensus document
No full textPreventing tipping points in high comorbidity patients: A lifeline from health coaches - rationale, design and methods
No full textBackground: This paper describes an innovative cluster randomized controlled trial design to evaluate the comparative effectiveness of two approaches to preventing significant destabilization, leading to unplanned hospitalization and increased disability for patients with high comorbidity, that is, multiple chronic diseases defined by an enhanced Charlson Comorbidity Index ≥4.
Methods: A total of 1974 patients were randomized in four waves at each of the sixteen Federally Qualified Health Centers (FQHCs) in four health systems -two in New York and two in Chicago. The two interventions compared 1) Patient-Centered Medical Home (PCMH) as implemented by the FQHCs (usual care control); or 2) PCMH plus a coaching intervention delivered by Health Coaches (experimental) helping patients identify life goals to encourage self-management enhanced by a positive affect/self-affirmation strategy. The two primary patient-centered clinical outcomes are 1) Unplanned hospitalizations; and 2) Within-patient changes in quality of life and disability, as measured by the World Health Organization Disability Assessment Scale 2 (WHODAS 2.0). The hypotheses are: 1) intervention patients will have a 5 % relative reduction in unplanned hospitalizations as compared to control patients; and 2) reduced disability measured by WHODAS2.0; 3) destabilization or \u27tipping points\u27 leading to hospitalization will be more often triggered by psychosocial issues than by medical Issues.
Conclusion: This cluster RCT has the potential to transform the care for patients with high comorbidity by helping motivate patients to engage in self-management and to successfully navigate the barriers, challenges, and stresses leading to destabilization, hospitalization, and increased disability.
Clinicaltrials: gov registration number: NCT04176510.
Keywords: Chronic conditions; Cluster randomized controlled trial; Federally qualified health centers; Health coaches
Evaluation of Interruptions During IV Smart Pump Medication Administration in Intensive Care Units
No full textObjectives: The objective of this project was to contribute to the understanding of how interruptions impact intravenous (IV) medication processes and identify areas for improvement. The specific aims were to evaluate the type, frequency, and duration of interruptions, including IV smart pump (IVSP) alerts and alarms, that nurses experience during IVSP activities.
Design: Real-world observational, exploratory, noninterventional design.
Methods: Level 1 academic medical center in the Northeast region of the United States. Data on interruptions were documented using an electronic Case Report Form.
Results: One hundred IVSP medication administration activities were observed, of which 25% encountered at least one IVSP alert or alarm. The mean duration for each alert/alarm was 17.9 seconds and alerts/alarms occurred every 1.69 minutes during the medication administration activity. Alarms and alerts accounted for 24.5% of the total duration of each IVSP activity, indicating that nurses spent about 25% of their medication administration time responding to alerts/alarms. Regarding other types of interruptions, 44% of the 100 IVSP medication administration activities experienced at least one interruption, averaging 1.23 per activity. The main sources of interruptions were health care professionals (20.4%), medical devices (20.4%), and other nurses (16.7%). Phone calls created the longest interruptions, averaging 48.0 seconds, followed by self-initiated interruptions at 45.7 seconds.
Conclusion: Findings reveal that interruptions, including IVSP alerts and alarms, significantly impact IV medication administration, consuming nearly 25% of nurses\u27 activity time. Additional interruptions, often caused by health care professionals and phone calls, further disrupt workflows and extend task durations. Addressing these challenges through streamlined alert systems and improved communication protocols is essential to enhance efficiency and patient safety in clinical settings.
Keywords: IV medication processes; IV smart pump; alerts/alarms; interruptions; patient safety
Surgery for Periprocedural Failure of Transcatheter Aortic Valve Replacement in the United States
No full textOutcome data for non-invasive prenatal testing suggestive of an atypical sex chromosome abnormality of fetal/placental origin
No full textThis study was designed to identify outcome data for non-invasive prenatal testing (NIPT) results suggestive of an atypical sex chromosome abnormality of fetal/placental origin. A single-center descriptive case series was performed between January 1, 2022 and August 1, 2024, which identified 16 cases, 11 of which completed diagnostic testing. Of those 11 cases, only 2 were found to have detectable chromosomal abnormalities of the fetus (monosomy X and mosaic monosomy X). The majority of the 9 cases without detectable fetal chromosome abnormalities cannot be assessed for the presence of confined placental mosaicism due to the lack of CVS testing; however one confirmed case was identified. While this case series is limited in size, it highlights examples that can be used by clinicians in counseling patients about possible outcomes for these atypical NIPT results. These cases also showcase the importance of pre and post-test counseling, due to the complexity of results. Larger studies are needed to elucidate the mechanisms underlying these findings and to further guide patient counseling.
Keywords: non‐invasive prenatal testing; sex chromosome aneuploidies
Utilization and Outcomes of Structural Heart Disease Interventions in Patients With Prior Mediastinal Radiation
No full textBackground: Outcomes of structural heart disease (SHD) interventions may be affected by prior mediastinal radiation.
Objectives: The objective of the study was to evaluate the outcomes of SHD interventions among patients with vs without prior mediastinal radiation.
Methods: We analyzed the Nationwide Readmissions Database (2016-2022) to identify patients aged ≥18 years with prior mediastinal radiation who underwent SHD interventions. The primary outcome was in-hospital mortality. Secondary outcomes included procedural complications, resource utilization (length of stay, costs, discharge disposition), and 90-day readmissions. In-hospital outcomes were analyzed with logistic regression and readmissions with Cox proportional hazards models.
Results: Among 810,849 weighted hospitalizations for transcatheter aortic valve replacement, mitral transcatheter edge-to-edge repair, transcatheter mitral valve replacement, and left atrial appendage occlusion, 1.3% included patients with prior mediastinal radiation. Utilization rates (procedures/100,000 hospitalizations) were higher in patients with vs without prior mediastinal radiation for transcatheter aortic valve replacement (577 vs 254), mitral transcatheter edge-to-edge repair (70 vs 35), and transcatheter mitral valve replacement (11 vs 4) (all P \u3c 0.001). There were no significant differences in adjusted in-hospital mortality, complications, or resource utilization between patients with vs without prior mediastinal radiation following any of the 4 SHD interventions. Ninety-day readmissions were similar after transcatheter aortic and mitral valve interventions but higher after left atrial appendage occlusion (adjusted HR: 1.51; 95% CI: 1.21-1.89) in patients with vs without prior mediastinal radiation.
Conclusions: Transcatheter aortic and mitral valve interventions are performed more frequently in patients with vs without prior mediastinal radiation with similar in-hospital outcomes and readmissions. Readmissions after LAAO are higher in patients with vs without prior mediastinal radiation.
Keywords: LAAO; MTEER; TAVR; TMVR; cancer; radiation
Multicenter Study Evaluating Impact of Patient and Sonographer Demographics on Quality of Focused Cardiac Ultrasounds
No full textIntroduction: Demographic inequities in cardiovascular care have been well established, with evidence of effects from sex, age, and body mass index (BMI). For instance, women are less likely to receive guideline-based care for acute myocardial Infarction, bystander cardiopulmonary resuscitation, or recognition of cardiac arrest. We investigated the impact of patient sex, along with other patient demographics such as age and BMI, on the quality of focused cardiac ultrasounds (FOCUS). We hypothesized that females would have lower overall FOCUS quality and more frequently omitted apical four-chamber (A4C) views due to breast tissue. Secondary objectives included evaluating differences in image quality and omission rates by BMI, and by age and sonographer sex and training level.
Methods: In this multicenter, retrospective study we investigated 1,200 total adult patients (100 females and 100 males per site) at six participating sites. The FOCUS quality was determined by two blinded experts per site using a 1-5 ordinal scale per view (parasternal long, parasternal short, A4C, and subxiphoid). The primary outcome, overall quality, was the summed score of the four views, with a maximum score of 20. This scale was then collapsed into three categories for the individual FOCUS views: images inadequate to support diagnosis; images meeting the minimum to support diagnosis; and images supporting the diagnosis well. Secondary outcomes were A4C quality and omission rate. We evaluated associations between sex and FOCUS overall quality using unadjusted mixed-effects models followed by multivariable mixed-effects models adjusted for patient age, BMI, operator sex, and operator experience level.
Results: The A4C images of female patients were of significantly lower quality (P \u3c .001) and had been omitted more frequently (P \u3c .001); male patients had \u3e 60% higher odds of a diagnostic A4C view (95% CI 1.3 - 2.0). Overall FOCUS quality decreased as BMI deviated from normal and as age increased. There was no significant difference in overall FOCUS quality between female and male patients.
Conclusion: We did not find sex-based differences in overall FOCUS quality; however, we did find that females received lower quality apical four-chamber views and had this view omitted more frequently. Additionally, overall quality declined as BMI deviated from normal, and as age advanced. Future research should elucidate the clinical implications of these differences in quality and the explanation behind not obtaining high-quality views in older patients, in individuals whose BMI deviated from normal toward either underweight or overweight, or in female patients