Search Results (151)

Although technological innovations are often intended to improve quality and efficiency, they can exacerbate systemic challenges when not aligned with the principles of value-based care. As a result, healthcare systems in many countries face persistent inefficiencies stemming from the overuse, underuse, misuse, and waste associated with the adoption of health technology. This narrative review examines the dual impact of healthcare technology and evaluates how contract mechanisms can serve as strategic tools for promoting cost-effective, outcome-oriented integration. Drawing from healthcare management, and supply chain literature, this paper analyzes various payment and contract models, including performance-based, bundled, cost-sharing, and revenue-sharing agreements, through the lens of stakeholder alignment. It explores how these mechanisms influence provider behavior, patient access, and system sustainability. The study contends that well-designed contract mechanisms can align stakeholder incentives, reduce inefficiencies, and support the delivery of high-value care across diverse healthcare settings. We provide concrete examples to illustrate how various contract mechanisms impact the integration of health technologies in practice. Full article

Background: Congenital insensitivity to pain with anhidrosis (CIPA) is a rare genetic disorder, often leading to injuries and serious infections. In 2018, we established a multidisciplinary clinic (MDC) to provide structured, proactive care. We assessed the MDC’s impact on hospitalizations, surgeries, and infection rates. Methods: A retrospective study of genetically confirmed CIPA patients, treated from 2014 to 2024. Data from electronic medical records were compared between the pre-MDC (2014–2017) and post-MDC (2018–2024) periods. The core MDC team includes an infectious disease specialist, orthopedic surgeon, and nurses. The patients are stratified according to their carriage of resistant organisms and are managed using strict infection control measures. Follow-ups are scheduled routinely or as needed. Treatment is guided by clinical findings and culture results. Results: A total of 59 patients were included in the study. The baseline age did not differ significantly between the two periods. Hospitalization rates declined by 30.7% (from 57.7 to 40.0 per 1000 days), and clinic visits decreased by 42.9% (25.5 to 14.6). Overall surgical rates remained stable (2.8 to 2.7), with a 61.9% decrease in eye surgeries and a 130.5% increase in elective tooth extractions. Infection rates increased by 52% (from 6.6 to 10.1 per 1000 days). Conclusions: The implementation of the MDC bundle led to reduced hospitalizations, clinic visits, and eye surgeries, alongside the increased use of elective tooth extractions and culture testing. Closer monitoring and early infection management contributed to fewer severe complications. These findings support the value of structured, proactive multidisciplinary care in improving outcomes for children with CIPA. Full article

Background/Objectives: This work aims to assess the evolution in the management of Staphylococcus aureus bacteremia (SAB) and the impact of the COVID-19 pandemic on it. SAB is associated with high morbidity and mortality, requiring structured management strategies. The COVID-19 pandemic led to major changes in hospital workflows, potentially affecting the quality of SAB care. Methods: We conducted a retrospective per-protocol analysis of SAB episodes at Costa del Sol University Hospital (Marbella, Spain) across three periods: pre-pandemic, pandemic, and post-pandemic. Patients with early mortality or early transfer were excluded. Clinical variables, adherence to recommended management bundles, and outcomes were compared. Demographic characteristics were similar across the analyzed periods. Results: The incidence of SAB increased over time, with a notable rise post-pandemic. Key management indicators such as the identification of infection source and appropriate antibiotic therapy showed adherence rates of above 90%, while echocardiography exhibited an adherence rate of above 75% throughout the study. Adherence to the full management bundle was suboptimal, with no significant differences between periods. However, an appropriate treatment duration significantly improved in the post-pandemic group (p = 0.038). Mortality at 14 and 30 days was highest during the pandemic period (10.3% and 17.6%, respectively), although differences were not statistically significant. Complications and mortality were more frequent in patients with complete adherence to the bundle (p = 0.031). Conclusions: Despite stable or improved adherence to certain SAB management measures during the pandemic, mortality and complication rates did not significantly decrease, likely reflecting increased patient severity or healthcare system overload. These findings highlight the need for sustained, multidisciplinary, bedside-based approaches to SAB care, even during public health emergencies. Further research is needed to explore modifiable factors and enhance adherence to evidence-based recommendations. Full article

Research on late preterm infants is limited compared with extremely low birth weight infants, despite their vulnerability to brain injury. Early intervention is crucial, as these infants often face higher risks of cerebral palsy and developmental delays. This review examines methods to predict neurological outcomes and evaluates standard care protocols for neurologically affected late preterm infants. It also explores the potential for developing a comprehensive care bundle that integrates family involvement and delineates the responsibilities for continuous developmental monitoring. A total of 21 studies, primarily cohort studies, were included. This review synthesizes recent research on neurological development in late preterm infants, highlighting key markers and methods to improve neurological monitoring and long-term outcomes. Late preterm infants are at an increased risk for neurodevelopmental impairments, such as cerebral palsy and cognitive delays, particularly when growth restrictions or low birth weight are present. Early interventions, including specialized neurological assessments and targeted rehabilitation, show potential for improving these outcomes. Late preterm infants face increased neurodevelopmental risks despite low perinatal mortality. Early identification, standardized assessments, and targeted follow-up are essential. Emerging interventions show promise, but further research and equitable care access are needed to improve long-term outcomes. Full article

Firework-related injuries remain a serious public health issue in Germany, especially during New Year’s Eve. While many injuries are minor, the misuse of illegal or homemade fireworks can cause severe trauma resembling military combat injuries and can heavily burden emergency services. Notably, injury rates declined during the COVID-19 firework bans, underscoring the impact of preventive measures. We report two cases of young males with severe injuries from illicit fireworks. The first is a case of a 16-year-old that detonated an illegal Polish firework ball bomb, sustaining 9% total body surface area (TBSA) burns (second- to third-degree), hand fractures, compartment syndrome of the hand, and soft-tissue trauma. He underwent multiple surgeries, including fasciotomy, osteosynthesis, and skin grafting. The other case presented is a 19-year-old man who was injured by a homemade device made of bundled firecrackers, suffering deep facial and bilateral hand burns. He required prolonged ventilation, surgical debridement, and treatment with Kerecis^® fish skin and Epicite^® dressings. Both required intensive ICU care, interdisciplinary management, and lengthy rehabilitation. Total hospital costs amounted to €58,459.52 and €94,230.23, respectively, as calculated according to the standardized German DRG. These cases illustrate the devastating impact of illegal fireworks. The devastating consequences of explosive trauma are often difficult to treat and may lead to long-term functional and psychological impairments. Prevention through public education, stricter regulations, and preparedness is essential. Pandemic-era injury reductions support sustained policy efforts. Full article

Pediatric Intensive Care Units (PICUs) provide specialized care for critically ill children. Developing and managing these units in South Asia remains challenging. Resource limitations and infrastructural disparities are leading to challenging conditions. Above all, nurses play a pivotal role in delivering quality critical care. Effective nursing practices can curb hospital-acquired infections (HAIs), ensure medication safety, and enable protocols such as the ICU Liberation Bundle. In South Asia, another challenge is the proper management of the nursing workforce. Nurse-to-patient ratios are highly disproportionate, contributing to nurse burnout. This review highlights the country-specific challenges and circumstances. There is no one-size-fits-all solution; effective strategies vary based on each country’s context. With context-specific solutions, nurses can bridge the gap between healthcare teams and families, ultimately improving patient outcomes. Full article

Device-associated infections (DAIs) are a significant public health concern because of their attributable mortality, along with the extra length of stay and cost. This two- year prospective surveillance study aimed to assess the incidence of DAIs and their clinical impact on four Greek adult medical-surgical Intensive Care Units (ICUs). Centers for Disease Control and Prevention (CDC) definitions were used to diagnose DAIs. Of the 500 patients hospitalized for 12,624 days, 254 (50.8%) experienced 346 episodes of DAIs. The incidence of DAIs was 27.4 episodes per 1000 bed-days. The incidence of ventilator-associated events (VAEs), central line-associated bloodstream infections (CLABSIs), and catheter-associated urinary tract infections (CAUTIs) was 20.5 episodes per 1000 ventilator-days, 8.6 episodes per 1000 central line-days, and 2.5 episodes per 1000 catheter-days, respectively. The most common pathogens isolated were Acinetobacter baumannii (35.7%) and Klebsiella pneumoniae (29.9%). All gram-negative pathogens were carbapenem-resistant. The ICU’s mortality was 44.9% for patients with DAIs and 24.8% for patients without a DAI (attributable mortality 20.1%, p < 0.001), while the mean ICU length of stay was 34.5 days for patients with DAIs and 15.6 days for patients without a DAI (attributable length of stay 18.9 days, p < 0.001). The high incidence of multidrug-resistant pathogens and the attributable length of stay and mortality of DAIs emphasize the need to establish an organized antimicrobial surveillance program and implement a care bundle for DAI prevention in ICUs with personnel educational training, monitoring, and feedback. Full article

Heart failure with reduced ejection fraction due to ischemic cardiomyopathy remains a significant clinical challenge. Electrical conduction delays exacerbate symptoms by causing uncoordinated contractions, reducing pumping efficiency, and increasing mortality. Right ventricular pacing further worsens dyssynchrony, while resynchronization therapy improves outcomes but has a high non-responder rate. Given these limitations, bundle branch pacing engages the heart’s conduction system, restoring synchronized contraction and enhancing cardiac function. This review examines the impact of left-bundle-branch-block-induced dyssynchrony, the role of advanced imaging in assessing ventricular function, and the clinical outcomes of bundle branch pacing in heart failure patients. Specifically, we explore the mechanical and hemodynamic effects of left bundle branch block, imaging techniques for dyssynchrony evaluation, and the comparative benefits of bundle branch pacing versus resynchronization therapy. Conduction delays impair function, increase myocardial stress, and worsen clinical outcomes. Advanced imaging plays a critical role in patient selection, identifying those most likely to benefit from conduction system pacing. By restoring electrical coordination, bundle branch pacing enhances ventricular function, reduces hospitalizations, and promotes reverse remodeling. It offers similar or superior benefits to conventional resynchronization therapy, regulates stress hormones, reduces oxidative damage, and improves calcium handling. Bundle branch pacing represents a significant advancement in heart failure management, but careful patient selection remains crucial. Future research should focus on optimizing implantation techniques and validating long-term benefits through large-scale clinical trials. Full article

The World Health Organization recommends Tranexamic acid (TXA) in the treatment of postpartum haemorrhage (PPH) as part of the PPH care bundle. We conducted integrative review of 36 studies from three databases namely PubMed, Google Scholar, and Dimensions. The integrative review followed PRISMA guidelines and evaluated clinical efficacy of TXA, prophylactic use, cost-effectiveness, alternative administration routes, and real-world implementation challenges and facilitators. The review found that early administration of TXA within three hours of PPH onset significantly reduces maternal mortality by 31%. Despite concerns about thrombosis, pooled data from large-scale cohorts demonstrate minimal thromboembolic risk which reinforces the safety profile of TXA. However, the WOMAN-2 trial revealed no significant benefit in women with moderate-to-severe anaemia which highlights the necessity for patient-specific TXA protocols. Economic evaluations reveal that integrating TXA into national guidelines requires a modest budget increase (approximately 2.3%) but promises substantial cost savings through reduced surgeries and hospital stays. While intravenous TXA remains recommended route by WHO, emerging evidence supports intramuscular and topical administration which is crucial in rural or primary-care settings lacking intravenous facilities. Yet, questions about bioavailability and rapid haemostatic efficacy persist, awaiting outcomes from ongoing trials such as I’M WOMAN, which is currently recruiting women aged 18 years from five countries with results anticipated by late 2025. Significant barriers to widespread adoption of TXA include limited healthcare provider training, lack of budgetary allocation by government and cultural misconceptions associating TXA with “dangerous clotting” in some settings. Successful initiatives, like China’s Strategies and Tools to Enhance Parturient Safety (STEPS) programme, illustrate how enhanced perinatal care bundles, interdisciplinary team training, and continuous monitoring using statistical process control (SPC) tools can overcome these obstacles. To accelerate progress towards reducing preventable maternal deaths globally, future research must address variable effectiveness when TXA is used as prophylaxis, clarify subpopulations most likely to benefit, and rigorously assess alternative routes of TXA administration. Full article

Background: Despite significant prevention efforts, the incidence of central line-associated bloodstream infection (CLABSI) in intensive care units (ICUs) is rising at an alarming rate. CLABSI contributes to increased morbidity, mortality, prolonged hospital stays and elevated healthcare costs. This study aimed to determine the incidence rate of CLABSI, compliance with the central venous catheter (CVC) care bundle and risk factors associated with CLABSI among ICU patients. Method: This prospective observational study was conducted in one university hospital and two public hospitals in Malaysia between October 2022 to January 2023. Adult ICU patients (aged > 18 years) with CVC and admitted to the ICU for more than 48 h were included in this study. Data collected included patient demographics, clinical diagnosis, CVC details, compliance with CVC care bundle and microbiological results. All data analyses were performed using SPSS version 23. Results: A total of 862 patients with 997 CVCs met the inclusion criteria, contributing to 4330 central line (CL) days and 18 CLABSI cases. The overall incidence rate of CLABSI was 4.16 per 1000 CL days. The average of overall compliance with CVC care bundle components was 65%. The predominant causative microorganisms isolated from CLABSI episodes were Gram-negative bacteria (78.3%), followed by Gram-positive bacteria (17.4%) and Candida spp. (2.0%). Multivariate analysis identified prolonged ICU stay (adjusted odds ratio (AOR): 1.994; 95% confidence interval (CI): 1.092–3.009), undergoing surgery (AOR: 2.02, 95% CI: 1.468–5.830) and having had multiple catheters (AOR: 3.167, 95% CI: 1.519–9.313) as significant risk factors for CLABSI. Conclusions: The findings underscore the importance of robust surveillance, embedded infection-control and -prevention initiatives, and strict adherence to the CVC care bundle to prevent CLABSI in ICUs. Targeted interventions addressing identified risk factors are crucial to improve patient outcomes and reduce healthcare costs. Full article

Background: Quality improvement (QI) interventions may reduce the incidence and severity of Intraventricular Hemorrhage (IVH) in the population of inborn micropremature infants (born at ≤26 weeks’ gestation) with the goal of improving outcomes in this high-risk population. Methods: A multidisciplinary team reviewed the current literature to develop a site-specific brain protective bundle. Baseline data were collected from June 2014 to February 2015, with interventions occurring from March 2015 to December 2015. The period of sustainability was assessed from January 2016 to December 2023. Control charts were used to analyze the effect of the interventions. Outcome measures included all grades of IVH, periventricular leukomalacia (PVL), necrotizing enterocolitis (NEC), and spontaneous intestinal perforations (SIP). Results: Brain care initiatives decrease the rate of severe IVH in the inborn micropremature infant population from a baseline of 21% to 6.45% with a sustained rate of 4.5% with no change to balancing measures. Conclusions: Brain-protective initiatives such as midline head positioning and minimal handling are associated with a significant and sustained reduction in severe IVH among inborn micropremature infants. Full article

Objectives and Methods: We developed a 10-item VAP care bundle to address the high incidence of VAP in Vietnamese intensive care units (ICUs), comprising (i) hand hygiene, (ii) head elevation (gatch up 30–45°), (iii) oral care, (iv) oversedation avoidance, (v) breathing circuit management, (vi) cuff pressure control, (vii) subglottic suctioning of secretions, (viii) daily assessment for weaning and a spontaneous breath trial (SBT), (ix) early ambulation and rehabilitation, and (x) prophylaxis of peptic ulcers and deep-vein thrombosis (DVT). The VAP incidence (27.0 per 1000 mechanical ventilation days) slightly and not significantly decreased in the six months after the implementation of the care bundle. Methods and Results: However, the VAP incidence (11.3 per 1000 mechanical ventilation days) significantly decreased when we updated the two-item protocol with interactive communication and education (p < 0.001). Conclusions: Although the effectiveness of the interventions via protocol updates with interactive education needs further study, this intervention can make a VAP care bundle work in a resource-constrained and multidrug-resistant environment. Full article

Background/Objectives: Necrotizing enterocolitis (NEC) is one of the most devastating gastrointestinal emergencies in preterm infants. This quality improvement (QI) project aimed to increase the utilization of accepted evidence-based practices in our neonatal intensive care unit (NICU) to ultimately decrease the incidence of NEC in our level III NICU. Methods: Our QI team implemented a bundle of nine of these evidenced-based practices for NEC prevention and disseminated information among the NICU team. Items in the bundle included delayed cord clamping, parental education on the importance of breast milk, obtaining early consent for donor breast milk, adherence to the unit’s feeding protocol, avoiding routine gastric residual checks, the discontinuation of antibiotics at 48 h once blood cultures were negative, restricting the use of antacids, nasogastric tube (NGT) replacement every 72 h and the removal of central lines once a feeding volume of 100 mL/kg/day was attained. The baseline incidence of clinically proven NEC was found to be 7% at the start of the intervention. We conducted two Plan-Do-Study-Act (PDSA) cycles over a 2-year period from 1 January 2021 to 31 December 2022. Results: There were 74 infants who met the inclusion criteria of being <1500 g and/or at <32 weeks of gestation. The adherence to our process measures improved over the course of our two PDSA cycles from 78% adherence to 91.6%, p < 0.05. The incidence of NEC decreased from 7% to 5.3% following the first PDSA cycle, a 24% reduction. Following the second PDSA cycle, the incidence decreased even further from 5.3% to 2.8%, a 60% reduction from baseline, although this was not statistically significant due to the small sample size. Conclusions: In this QI initiative, we achieved improved adherence to several evidence-based interventions over a two-year period with the aim of reducing the incidence of NEC at our institution. Full article

Major bleeding is a life-threatening condition with high morbidity and mortality. Trauma, gastrointestinal bleeding, haemoptysis, intracranial haemorrhage or other causes of bleeding represent major concerns in the Emergency Department (ED), especially when complicated by haemodynamic instability. Severity and source of bleeding, comorbidities, and prior use of anticoagulants are pivotal factors affecting both the clinical status and the patients’ differential response to haemorrhage. Thus, risk stratification is fundamental in the initial assessment of patients with bleeding. Aggressive resuscitation is the principal step for achieving haemodynamic stabilization of the patient, which will further allow appropriate interventions to be made for the definite control of bleeding. Overall management of major bleeding in the ED should follow a holistic individualized approach which includes haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding. The aim of the present practical guide is to provide an update on recent epidemiological data about the most common etiologies of bleeding and summarize the latest evidence regarding the bundles of care for the management of patients with major bleeding of traumatic or non-traumatic etiology in the ED. Full article

Background: Antimicrobial resistance (AMR) is recognized as one of the most important global public health threats. There is an urgent need to reduce the spread of these multidrug-resistant bacteria (MDR-B), particularly in extremely vulnerable patients. The aim of this study was to investigate whether targeted gene amplification performed directly on clinical samples can be used simultaneously with a bundle of enhanced infection control measures in a Pediatric Intensive Care Unit (PICU) endemic to MDR-B. Methods: This study had three phases: (1) the baseline phase was performed prior to intervention when first screening and sample collection were performed; (2) the intervention phase was performed when various enhanced infection control measures (EICM) were applied; and (3) the maintenance phase occurred when EICMs were combined with the implementation of targeted molecular surveillance. The presence of four carbapenemase genes, bla_KPC, bla_OXA-48-like, bla_VIM, and bla_NDM, as well as the β-lactamase genes bla_TEM and bla_SHV, was evaluated by PCR after DNA isolation directly from stool samples. The results were compared to culture-based phenotypic analysis. Results and Conclusions: The implementation of EICM appeared to reduce the resistance burden in this sample endemic to an MDR-B clinical setting. The direct implementation of a targeted and customized rapid molecular detection assay to clinical samples seems to be an effective clinical tool for the evaluation of EICM measures. Full article