University of Nebraska Medical Center
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Evaluating the Nebraska Medical Center\u27s Repatriation of Inter-Hospital Transfers
Get PDFBackground: Bed capacity challenges at large academic medical centers delay the transfer of rural patients, negatively impacting their safety and quality of care. Repatriating inter-hospital transfer (IHT) patients to referral facilities upon completing specialized care can improve tertiary hospital bed capacity and community hospital financial sustainability.
Objectives: This project aims to identify the barriers and facilitators to successful IHT repatriation and the process and outcome variables influenced by the Nebraska Medical Center’s reverse transfer program.
Study Design: A retrospective observational cohort study was conducted to identify barriers and facilitators of NM’s IHT repatriation program.
Methods: Descriptive and comparative analyses of quantitative data collected from two repatriation-eligible IHT patient cohorts, i.e., Group 1 patients were successfully transferred back to the referring hospital upon conclusion of specialized care at NM, and Group 2 patients were not successfully repatriated, highlighted key barriers and facilitators of successful repatriation.
Results: 51 patients were repatriated to their original facilities between June 2022 and December 2024, resulting in 609 bed days saved based on the additional length of stay at the referral facility after repatriation from Nebraska Medical Center and $886,386 in total estimated cost savings based on the number of bed days saved. The combination of an AI screening tool introduced in June 2024 and a nurse-driven deep dive evaluation of IHT repatriation candidacy resulted in the identification of 92 potential candidates between June and December 2024. Of these 92 potential reverse transfer candidates, 17 were successfully repatriated to their home facility (18.5% success rate), and 75 did not repatriate. The top two reasons for unsuccessful reverse transfer were (1) ineligibility because the patient’s expected discharge was in 48 hours or less and/or they no longer required an acute inpatient care level (N=34, 45.3%) and (2) referral facility denial (N=17, 22.7%). Reasons for referral facility denial of a reverse transfer request include: (1) the patient’s insurance provider (not accepting Medicare advantage patients); (2) inappropriate level of care, either too medically unstable (e.g., high oxygen needs) or medically stable and awaiting placement in a post-acute care facility; (3) lack of resources such as specific subspecialty services, nursing staff capacity, and one facility had a scheduled power outage; (4) Lack of available beds at the referral facility; and (5) Facility not accepting lateral transfers. Statistical analyses revealed that the key factors driving disparate reverse transfer outcomes are gender, rural-urban commuting area (RUCA) score, area deprivation index (ADI), referral facility distance, and bed capacity. Variables associated with a higher likelihood of successful reverse transfer are male gender, patients from less rural areas and higher socioeconomic neighborhoods, patients transferred from farther away, and referral facilities with higher bed capacity.
Conclusion: Systematically identifying facilitators and barriers of NM’s IHT repatriation process provided insights on ways to improve repatriation through investment in full-time employees whose sole job responsibilities support a 24-hour IHT repatriation program, earlier initiation of the IHT repatriation process before the patient has completed their specialized tertiary care, limited NRC staff prioritization of repatriation attempts with larger referral hospitals located farther away (e.g., those with a minimum of 200 beds and a distance of \u3e 100 miles away), ongoing IHT repatriation program evaluation to understand and mitigate the key drivers of disparate repatriation outcomes, and future qualitative data collection among NM and referral facility stakeholders participating in the IHT repatriation program to understand better and address the factors leading to reverse transfer failure and reverse transfer request denial. Employing these improvements can lead to enhanced repatriation outcomes, IHT patient flow, tertiary hospital bed capacity, stronger community and tertiary hospital partnerships, and increased rural hospital sustainability
Development of the Mechanoresponsive Pericellular Matrix of Chondrons
Get PDFPhysical properties of cartilage are conferred by the composition and ultrastructure of the extracellular matrix. This study focuses on the development of the pericellular matrix (PCM), a domain that directly contacts the chondrocyte and is a key regulator of biomechanical and biochemical signaling. Using three-dimensional cell culture, microfluidic cell compression platforms, and genetic mouse models, we demonstrated that collagen VI is initially assembled at the cell surface and then displaced to form a shell at the PCM-territorial matrix boundary. Cell surface-bound hyaluronan is crucial for the assembly process, and hyaluronan-aggrecan complexes drive displacement. Integrin adhesion is not required early but is crucial to determine the final placement of the collagen VI shell. Dynamic compression accelerated PCM maturation except in aggrecan mutants. Together, these findings provide key insights into the development of the mechanosensitive PCM and establish an in vitro platform to support studies of matrix biology in normal and disease models
Lung-delivered IL-10 Mitigates Lung Inflammation Induced by Repeated Endotoxin Exposures in Male Mice
Get PDFTherapies capable of resolving inflammatory lung disease resulting from high-consequence occupational/environmental hazards are lacking. This study seeks to determine the therapeutic potential of direct lung-delivered interleukin (IL)-10 following repeated lipopolysaccharide exposures. C57BL/6 mice were intratracheally instilled with LPS (10 μg) and treated with IL-10 (1 μg) or vehicle control for 3 days. Lung cell infiltrates were enumerated by flow cytometry. Lung sections were stained for myeloperoxidase (MPO), CCR2, vimentin, and post-translational protein citrullination (CIT) and malondialdehyde-acetaldehyde (MAA) modifications. Lung function testing and longitudinal in vivo micro-CT imaging were performed. Whole lungs were profiled using bulk RNA sequencing. IL-10 treatment reduced LPS-induced weight loss, pentraxin-2, and IL-6 serum levels. LPS-induced lung proinflammatory and wound repair mediators (i.e., TNF-α, IL-6, CXCL1, CCL2, MMP-8, MMP-9, TIMP-1, fibronectin) were decreased with IL-10. IL-10 reduced LPS-induced influx of lung neutrophils, CD8+ T cells, NK cells, recruited monocyte-macrophages, monocytes, and tissue expression of CCR2+ monocytes-macrophages, MPO+ neutrophils, vimentin, CIT, and MAA. IL-10 reduced LPS-induced airway hyperresponsiveness and improved lung compliance. Micro-CT imaging confirmed the reduction in LPS-induced lung density by IL-10. Lung-delivered IL-10 therapy administered after daily repeated endotoxin exposures strikingly reduces lung inflammatory and wound repair processes to decrease lung pathologic changes and mitigate airway dysfunction
Understanding Stakeholder Perspectives, Medical Student Metacognition and Reflections on Learning Order Entry in the Electronic Health Record
No full textBackground: Accurate and complete order entry is an essential skill expected of all medical graduates. However, medical students report limited confidence performing this task. This study employed a convergent mixed methods design to examine stakeholder perspectives, medical student performance, and metacognition during simulated electronic health record order entry, with the goal of identifying educational gaps and informing curriculum development.
Methods: The study was conducted in two phases. Phase 1 included qualitative analysis of semi-structured interviews of interprofessional stakeholders: nurses, pharmacists, interns, and supervising physicians using open inductive coding. Phase 2 included quantitative and qualitative analysis of fourth-year medical student performance and metacognition on two simulated admission order entry cases using a think-aloud protocol with screen capture followed by self-reflection and exit interviews.
Results: Eight themes emerged from qualitative analysis of 17 stakeholder interviews in Phase 1: Education and Training, Contextual Awareness, Collaboration in Care, Oversight and Accountability, Optimizing Order Systems, Special Populations and Vulnerable Moments, Informed Decision Making, and Precision in Practice. In Phase 2, 36 students completed the recorded order entry simulation. Student confidence significantly improved. Use of order sets was associated with significant differences in required order elements including vital signs, diet order, activity order, and venous thromboembolism prophylaxis. Qualitative analysis revealed six core themes: Oversight and Accountability, Cognitive Load and Uncertainty, Experiential Learning Through Iteration, External Resources and Decision Support, Informed Decision Making, and Navigational Challenges in the Electronic Health Record Interface. Qualitative analysis of participant self-reflections and exit interviews revealed four key themes: Evolving Confidence Through Practice, Uncertainty in Task Expectations, Desire for Feedback and Comparative Reference Points, and System Navigation and Interface Literacy.
Conclusions: This study revealed critical gaps in order entry education. Stakeholder perspectives emphasized complexity of order entry, contextual awareness, oversight, and system optimization. Simulation fostered experiential learning and increased confidence, though safe and complete performance remained inconsistent. These findings support longitudinal simulation, interdisciplinary collaboration, and instruction in metacognition. Enhancing students\u27 metacognitive skill development may reduce risk of patient harm and better prepare them for independent practice. These methods may also be applied to other entrustable professional activities requiring high cognitive integration and digital competence
Correlation of Serial Lung Ultrasound Scores and Sonographic Measurements of Diaphragmatic Excursion with Extubation Success in Intubated NICU Patients Receiving a Dexamethasone Taper
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Interventions to Improve or Maintain Activity of Daily Living Performance in Adults with Dementia: A Systematized Review
Get PDFImportance: Dementia is a progressive cognitive disorder that leads to the degradation of one’s abilities until they are dependent for all activities of daily living (ADLs) (Andersen et al., 2004). There’s an increasing importance to search for effective ways to preserve independence in ADLs and quality of life for adults with dementia (Weng et al., 2019).
Objective: To identify effective occupational therapy (OT) interventions for maintaining or improving ADL performance among adults with dementia.
Data Sources: PubMed, CINAHL, PsycINFO. This search was conducted by a medical librarian.
Design: Inclusion criteria encompassed interventions within the scope of OT, at least one outcome measure addressing ADL performance, and participants with dementia. Meta-analyses and systematic reviews were excluded.
Findings: 24 studies met inclusion criteria: Thirteen IB, ten IIB and one IIIB studies. Five themes emerged including cognitive stimulation/training, physical exercise, task-oriented, multi-prong methods, and other interventions. Five IB, and one IIB studies provide strong strength of evidence for physical exercise. Three IIB studies provide low strength of evidence for other interventions. Three IB, and three IIB studies provide moderate strength of evidence for cognitive stimulation/cognitive training. One IB and one IIB study provide moderate strength of evidence for task-oriented. Four IB, two IIB, and one IIIB studies provide moderate strength of evidence for multi-prong interventions.
Conclusion: Physical activity and task-based interventions should be used routinely to improve or maintain ADL performance in adults with dementia. Cognitive stimulation/training, multi-prong, and other interventions should be used on a case-by-case basis.
References:
Andersen, C.K., Wittrup-Jensen, K.U., Lolk, A., Andersen, K., & Kragh-Sørensen, P. (2004). Ability to perform activities of daily living is the main factor affecting quality of life in patients with dementia. Health and Quality Life Outcomes, 2(52), 1-7. https://doi.org/10.1186/1477-7525-2-52
Weng, C.F., Lin, K.P., Lu, F.P., Chen, J.H., Wen, C.J., Peng, J.H., Tseng, A.H., & Chan, D.C. (2019). Effects of depression, dementia and delirium on activities of daily living in elderly patients after discharge. BMC Geriatrics, 19(1), 261. https://doi.org/10.1186/s12877-019-1294-9https://digitalcommons.unmc.edu/cahp_ot_sysrev/1016/thumbnail.jp