Search Results (30)

Objectives: Stroke is a leading cause of disability worldwide, requiring timely intervention with intravenous thrombolysis (IVT) or endovascular thrombectomy (EVT). This study evaluates real-world stroke management in a regional stroke unit, focusing on IVT administration and EVT transfer logistics. Design: A sub-analysis was performed using prospectively collected data from an observational study. Setting: This study took place at a regional, non-university stroke unit in Germany, serving approximately 253,000 inhabitants. Participants: A total of 2436 patients were admitted for suspected stroke between May 2019 and June 2021. Outcome Measures: Outcome measures included IVT administration rates, reasons for IVT non-administration, and EVT transfer logistics for acute ischemic stroke (AIS) patients. Results: Of 952 stroke cases, 14.8% received IVT, with a mean door-to-needle time (DNT) of 41 ± 36 min. The most common reasons for IVT non-administration were unclear or elapsed symptom onset (51.8%), anticoagulation (7.9%), resolving symptoms (18.4%), and intracranial hemorrhage (7.1%). EVT transfers occurred in 6.7% of AIS patients, with a mean door-in-door-out (DIDO) time of 81 ± 36 min. Conclusions: This study highlights the low IVT rate, primarily due to delayed hospital presentation, and the limited number of EVT transfers. The prolonged DIDO times emphasize the urgent need for streamlined transfer protocols to optimize stroke care delivery. Full article

Background/Objectives: Effective management of acute pancreatitis (AP) hinges on prompt volume resuscitation and is adversely affected by delays in diagnosis. Given diverse clinical settings (tertiary care vs. community hospitals), further investigation is needed to understand the impact of the initial setting to which patients presented on clinical outcomes and quality of care. This study aimed to compare outcomes and quality indicators between AP patients who first presented to the emergency department (ED) of a tertiary care center and AP patients transferred from community hospitals. Methods: This study included AP patients managed at our tertiary care hospital between 2008 and 2018. We compared demographics and outcomes, including length of stay (LOS), intensive care unit (ICU) admission, rates of local and systemic complications, re-admission rates, and one-year mortality in transferred patients and those admitted from the ED. Quality indicators of interest included duration of volume resuscitation, time until advancement to enteral feeding, pain requiring opioid medication [measured in morphine milliequivalent (MME) dosing], and surgical referrals for cholecystectomy. Categorical variables were analyzed by chi-square or Fisher’s exact test; continuous variables were compared using Kruskal–Wallis tests. Regression was performed to assess the impact of transfer status on our outcomes of interest. Results: Our cohort of 882 AP patients comprised 648 patients admitted from the ED and 234 patients transferred from a community hospital. Transferred patients were older (54.6 vs. 51.0 years old, p < 0.01) and had less frequent alcohol use (28% vs. 39%, p < 0.01). Transferred patients had a significantly greater frequency of gallstone AP (40% vs. 23%), but a lower frequency of alcohol AP (16% vs. 22%) and idiopathic AP (29% vs. 41%) (p < 0.001). Regarding clinical outcomes, transferred patients had significantly higher rates of severe AP (revised Atlanta classification) (10% vs. 2% severe, p < 0.001) and ICU admission (8% vs. 2%, p < 0.001) and longer median LOS (5 vs. 4 days, p < 0.001). Regarding quality indicators, there was no significant difference in the number of days of intravenous fluid administration, or days until advancement to enteral feeding, pain requiring opioid pain medication, or rates of surgical referral for cholecystectomy. Conclusions: Though the quality of care was similar in both groups, transferred patients had more severe AP with higher rates of systemic complications and ICU admissions and longer LOS, with no difference in quality indicators between groups. Full article

Inter-hospital transfers remain a significant part of emergency care service missions, even though efforts have been made to change this. We examined the use of prehospital emergency care units in inter-hospital patient transfers in one wellbeing services county in Finland. We evaluated the potential strain they place on regional prehospital emergency care readiness, and examined how these transfers arise between different regions, populations, and healthcare centers. This was a register-based pilot study using prehospital emergency care inter-hospital transfer mission statistics within the wellbeing services county of Pirkanmaa, Finland during 2020 and 2021. The data were extracted from the emergency care service’s field management program. A descriptive analysis of the data was performed, in which interdependencies between several variables were examined. During the two years, there were 5812 prehospital emergency care inter-hospital transfer missions dispatched to prehospital emergency care units. The number of prehospital emergency care inter-hospital transfer missions was especially notable in rural regions, where there were also fewer units available. Based on the results, the criteria for prehospital emergency care use in inter-hospital transfers require clarification, since there is an observable strain caused by these transfers on regional emergency care readiness. The results of this pilot study encourage further studies on the use of prehospital emergency care units in inter-hospital patient transfers. Full article

(1) Background: The COVID-19 pandemic presented significant challenges in managing acute respiratory distress syndrome (ARDS), with extracorporeal membrane oxygenation (ECMO) being a critical but resource-intensive intervention. (2) Methods: This retrospective study analyzed veno-venous (VV) ECMO therapy in ARDS patients before and during the pandemic at a high-volume ECMO center in Germany. The study used a reduced ECMO team (one medical and one nursing specialist) to optimize patient care with limited resources, aiming to offer insights for future pandemic management. Data from 181 adult patients (age ≥ 18) with severe ARDS were analyzed: 57 pre-pandemic and 124 during the pandemic. (3) Results: Despite increased isolation measures during the pandemic (25% pre-COVID-19 vs. 79% during COVID-19, p < 0.0001), there was no significant change in transportation mode (ground vs. air) or ECMO implantation times at local hospitals. Similarly, time and distance for primary ECMO transport remained unchanged between the two periods. Complication rates related to ECMO circuit placement and prolonged transport were also insignificant across groups. However, ECMO therapy duration (median 12 days pre-COVID-19 vs. 19 days during COVID-19, p < 0.0001) and hospital stays (median 3 days pre-COVID-19 vs. 7 days during COVID-19, p < 0.01) were longer during the pandemic. Mortality rates were also higher during the pandemic (49% pre-COVID-19 vs. 65% during COVID-19, p < 0.05). (4) Conclusions: In conclusion, a reduced ECMO team proved to be an effective resource-saving strategy that maintained high-quality care with low complication rates, despite the additional challenges posed by pandemic-related isolation measures. Full article

Background: Despite advancements in emergency medical systems, inter-hospital transfer (IHT) remains a critical component. Several studies have analyzed the impact of IHT on patient outcomes. Some studies have reported positive effects, indicating that transfers can improve patient prognosis. However, other studies have suggested that transfers may worsen outcomes. We investigated whether IHT is associated with in-hospital mortality. Methods: This retrospective observational study utilized data on patient outcomes from the National Emergency Department Information System (NEDIS) from 2016 to 2018, focusing on patients admitted to hospitals after visiting the emergency department (ED). The primary outcome was the in-hospital mortality rate. Results: This study included 2,955,476 adult patients admitted to emergency medical centers, with 832,598 (28.2%) undergoing IHT. The in-hospital mortality rate was significantly higher in the transfer group (6.9%) than in the non-transfer group (4.8%). Multiple logistic regression analysis revealed that IHT was an independent predictor of in-hospital mortality (adjusted odds ratio [aOR] 1.114, 95% confidence interval [CI] 1.101–1.128) after adjusting for variables. Sub-analysis indicated that higher severity scores, shorter symptom onset-to-arrival duration, and diagnoses of infectious or respiratory diseases were significantly associated with increased in-hospital mortality among transferred patients. Conclusions: This study identifies IHT as a significant factor associated with increased in-hospital mortality. Additionally, it suggested the need for policies to mitigate the risks associated with IHT, particularly in critically ill patients, those with the acute phase response, and those with infectious, genitourinary, and respiratory diseases. Full article

Background: Safe inter-hospital transport of critically ill patients is a complex procedure where nurses are integral to maintaining patient safety. A structured checklist is pivotal to ensuring the transfer process mitigates potential complications. Objective: The objective of this scoping review was to devise and implement a detailed checklist to enhance patient safety during the transfer of critically ill patients. Methods: A comprehensive literature review was conducted by Joanna Briggs Institute’s guidelines across several databases including MEDLINE, CINAHL Complete, LILACS, and Scopus. The search considered works published in Portuguese, English, or Spanish from 2008 onwards. A total of eight studies met our inclusion criteria and were selected for detailed analysis. Results: Our analysis delineated the critical clinical information necessary to compose an effective transfer checklist. This checklist was developed through iterative refinement, informed by the literature and appraised during a focus group meeting with experts. Subsequent to its development, the checklist was implemented in the emergency department of a Central Portuguese hospital. Conclusions: This scoping review emphasizes the significance of evidence-based protocols and clear communication in safeguarding patient welfare during critical transfers. The developed checklist is a tool that standardizes care processes, supports clinical decision-making, and is instrumental in minimizing adverse events during inter-hospital transfers. Full article

The patient voice is missing from the evidence regarding the dietary management of diverticular disease. This study aimed to determine the patient experiences of imposed dietary restrictions during the medical treatment of acute, uncomplicated diverticulitis. An Interpretive Phenomenological Analysis methodology guided participant selection, data collection, and the data analysis of a qualitative interview study. Four interviews were conducted with adults admitted to hospital with acute, uncomplicated diverticulitis. Six themes were interpreted. Five themes were found to inter-relate as a cycle, which was embedded within a driving theme of ‘corrupted diet-disease knowledge of patients, family, and healthcare providers’. The cycle commenced with a theme of ‘fear of food’, which was followed by the theme of an ‘internal locus of control with rigid constraint’. ‘Loss of culture and social stigma’ ensued, which led to ‘vulnerability amid self-perceived failure’, and finally ‘overshadowed psychological pain’. The cycle recommenced with a renewed fear of food. The thematic phenomenon of the ‘Fear of Food in Gastrointestinal Disease Framework’ was developed. Adults with diverticular disease and at least one hospitalisation for acute, uncomplicated diverticulitis were interpreted to experience a cyclical thematic phenomenon represented by the ‘Fear of Food in Gastrointestinal Disease Framework’. Further qualitative research is required to evaluate the transferability of the framework to other conditions. Full article

Background: Germany’s high density of under-equipped hospitals and anticipated surge in orthopedic and trauma surgery-related diseases by 2030, combined with personnel shortages, are expected to increase patient transfers between hospitals, an issue that urgently needs standardized protocols. Despite some existing cooperative agreements, such as between joint-replacement centers or within the Trauma Network DGU^®, these measures do not adequately address the full range of patient-transfer cases, including those due to a lack of specialization or staff shortages, resulting in delayed treatment and potential health risks. This study aims to dissect the intricacies of interhospital transfers in orthopedics and trauma surgery across Germany, focusing on understanding the underlying reasons for transfers, comparing the operational structures of small and large hospitals, and laying the groundwork for future standardized protocols to enhance patient care. Material and Methods: A cross-sectional study was conducted in the form of an online survey via SoSci Survey, which was directed at orthopedic surgeons and trauma surgeons working in hospitals in Germany. The 22-question survey gathered information on participants’ clinic roles, departmental details, transfer processes, frequent diagnoses, perceptions of transfer quality, and improvement areas. The survey was sent to orthopedic and trauma surgeons in Germany by the specialist society. The data were analyzed using descriptive and inferential statistics to ensure a comprehensive insight into interhospital transfer practices. Results: The study involved 152 participants from various hospital ranks and located in different hospital sizes and types across rural and urban areas. A significant difference was observed between the care structures of basic/regular care and central/maximum care hospitals, especially regarding the available facilities and specialties. These findings suggest improvements such as better patient documentation, increased digital communication, optimized patient distribution, and standardization of transfer requests, among others. Conclusions: This study highlights the urgent need for improved protocols and resource allocation to eliminate inequalities in transfers between hospitals in orthopedics and trauma surgery in Germany. Full article

Breastfeeding is particularly important for vulnerable preterm infants as it provides protection from infections and reduces newborn mortality. However, preterm infants are often too immature to breastfeed after birth and may have medical conditions that require admission to the neonatal nursery. The published literature on the development of preterm feeding skills has focused mostly on bottle feeding. In order to better support breastfeeding after preterm birth, there is a need for evidence on the development of breastfeeding skills in preterm infants. The aim of this study was to examine breastfeeding skill development in a group of infants born at 25–33 weeks’ gestation. Infants were assessed during weekly monitored breastfeeds from 33 weeks corrected gestational age (CGA) using the Preterm Infant Breastfeeding Behaviour Scale (PIBBS), and milk transfer was measured. Mothers rated PIBBS items—rooting, areolar grasp, latch to the breast, sucking, longest sucking burst and swallowing—and clinical staff performed test weights. Pearson correlation was used to assess changes in PIBBS scores items over time and associations between total PIBBS score and milk transfer volume. Total PIBBS scores at 33, 34 and 35 weeks’ CGA were compared between groups of infants born at <30/40 and 30–33/40 weeks using Student’s t-test. Our cohort consisted of 60 preterm mother–infant dyads recruited from the neonatal nurseries at King Edward Memorial Hospital between February 2015 and February 2016. A positive trend was found between increasing CGA and higher ratings for six PIBBS items: rooting (R² = 0.08, F (1, 164) = 13.9, p < 0.001), areolar grasp (R² = 0.11, F (1, 164) = 21.0, p < 0.001), latching (R² = 0.14, F (1, 164) = 27.5, p < 0.001), sucking (R² = 0.14, F (1, 164) = 27.1, p < 0.001), longest sucking burst (R² = 0.17, F (1, 164) = 32.3, p < 0.001) and swallowing (R² = 0.14, F (1, 163) = 26.1, p < 0.001). A higher total PIBBS score was associated with a higher milk transfer volume (mL) (R² = 0.214, F (1, 164) = 44.8, p < 0.001). When compared to infants born at 30–33 weeks’ gestation, infants born at 25–29⁺⁶ weeks’ gestation had similar PIBBS scores at 33 weeks’ CGA (9.2 ± 3.6 vs. 9.5 ± 4.1, p = 0.83) and lower scores at 34 weeks’ CGA (9.2 ± 3.4 vs. 11.7 ± 4.3, p = 0.036) and 35 weeks’ CGA (12.3 ± 3.1 vs. 14.9 ± 3.5, p = 0.031). The development of preterm breastfeeding skills advances from 33 weeks CGA with wide inter-individual variation and slower progression observed in those born < 30 weeks’ gestation. Therefore, an individualised approach to anticipatory guidance regarding breastfeeding progression during the neonatal nursery stay is needed. Findings from this study can contribute to the formation of breastfeeding information resources for clinical staff and parents of preterm infants. Full article

Background and objectives: Although the intravenous tissue plasminogen activator (rt-PA) has been shown to be effective in the treatment of acute ischemic stroke (AIS), only a small proportion of stroke patients receive this drug. The low administration rate is mainly due to the delayed presentation of patients to the emergency department (ED) or the lack of a stroke team/unit in most of the hospitals. Thus, the aim of this study is to analyze ED time targets and the rate of rt-PA intravenous administration after the initial admission of patients with AIS in an ED from a traditional healthcare center (without a neurologist or stroke team/unit). Methods: To analyze which factors influence the administration of rt-PA, we split the general sample (n = 202) into two groups: group No rt-PA (n = 137) and group rt-PA (n = 65). This is based on the performing or no intravenous thrombolysis. Results: Analyzing ED time targets for all samples, we found that the median onset-to-ED door time was 180 min (IQR, 120–217.5 min), door-to-physician time was 4 min (IQR, 3–7 min), door-to-CT time was 52 min (IQR, 48–55 min), and door-in-door-out time was 61 min (IQR, 59–65 min). ED time targets such as door-to-physician time (p = 0.245), door-to-CT time (p = 0.219), door-in-door-out time (p = 0.24), NIHSS at admission to the Neurology department (p = 0.405), or NIHSS after 24 h (p = 0.9) did not have a statistically significant effect on the administration or no rt-PA treatment in patients included in our study. Only the highest door-to-CT time was statistically significantly correlated with the death outcome. Conclusion: In our study, the iv rt-PA administration rate was 32.18%. A statistically significant correlation between the highest door-to-CT time and death outcome was found. Full article

Trauma is a significant public health issue worldwide, particularly affecting economically active age groups. Quality management of trauma care at the national level is crucial to improve outcomes of major trauma. In Korea, a biennial nationwide survey on preventable trauma death rate is conducted. Based on the survey results, we analyzed opportunities for improving the trauma treatment process. Expert panels reviewed records of 8282 and 8482 trauma-related deaths in 2017 and 2019, respectively, identifying 258 and 160 cases in each year as preventable deaths. Opportunities for improvement were categorized into prehospital, interhospital, and hospital stages. Hemorrhage was the primary cause of death, followed by sepsis/multiorgan failure and central nervous system injury. Delayed hemostatic procedures and transfusions were common areas for improvement in hospital stage. Interhospital transfers experienced significant delays in arrival time. This study emphasizes the need to enhance trauma care by refining treatment techniques, centralizing patients in specialized facilities, and implementing comprehensive reviews and performance improvements throughout the patient transfer system. The findings offer valuable insights for addressing trauma care improvement from both clinical and systemic perspectives. Full article

Background and Objectives: There is scarce data about the epidemiology, clinical features, investigations, diagnosis, treatment, and outcome in patients attending Singapore emergency departments (EDs) with nontraumatic headache. We sought to describe these characteristics of adult patients presenting to the ED with a primary complaint of headache. Materials and Methods: We performed a cross-sectional study on adult patients with nontraumatic headache over 4 consecutive weeks from 18 March 2019 to 14 April 2019 across four EDs in Singapore. Exclusion criteria were history of head trauma within 48 h of presentation, missing records, interhospital transfers, representation with the same headache as a recent previous visit and headache as an associated symptom. Results: During the study period, 579 patients (representing 1.8% of the total ED census) comprising 55.3% males and with a median age of 36 years presented to the four Singapore EDs with a primary complaint of nontraumatic headache. Paracetamol (41.5%), non-steroidal anti-inflammatory drugs (34.4%) and tramadol (31.5%) were the three commonest analgesics used either singly or in combination. Prochlorperazine (22.9%) and metoclopramide (17.4%) were frequent anti-emetic adjuncts. One-third of patients had computed tomography of the brain performed, which found abnormalities among 20.9% of them. ED diagnoses of primary headache conditions were made in 73.6% of patients. Conclusions: Primary headaches constituted most ED headache diagnoses. ED imaging of selected patients yielded a relatively high pick-up rate for significant intracranial abnormalities. Opioid use for symptomatic relief of headaches in the ED was found to be high, underscoring the need for improvement in headache analgesia relief practices in the ED. Full article

Effective inter-hospital coordination is crucial in improving the stroke treatment process and outcomes. The introduction of endovascular thrombectomy (EVT) further emphasized the importance of coordination. Although previous studies considered various clinical data besides stroke in terms of the network structure between hospitals, a majority of these studies performed only quantitative analyses instead of topological analyses. This study proposes a new framework (PatientFlow) for constructing a network based on stroke patient transfer data and performing exploratory analysis. The proposed framework can visualize the network structure among hospitals at the national level and analyze the detailed structure through dynamic queries. The hub-and-spoke structure for each cluster derived through community detection can be compared visually and analyzed quantitatively using network measures. Further, the relationship between regions can be analyzed by aggregating the transfer of patients by province. PatientFlow allows medical researchers to perform an exploratory analysis to understand the network at the national, provincial, and community levels with multiple coordinated views. Full article

Background: The first wave of the COVID-19 epidemic led to a rapid and unexpected saturation of the French ICU, forcing the health care system to adapt. Among other emergency measures, inter-hospital transfers were carried out. Objective: To assess the psychological experience of patients and their relatives regarding inter-hospital transfers. Methods: Semi-structured interviews were conducted with transferred patients and their relatives. A phenomenological study design was used to examine subjective experiences and their meanings for the participants. Results: The analysis found nine axes pertaining to the experiences of IHT (inter-hospital transfers), grouped in three super-ordinate themes: Information about inter-hospital transfers, differences in patients’ and relatives’ experiences, and host hospital experience. It appears that patients felt little impacted by the transfers, unlike relatives who experienced intense anxiety when the transfer was announced. Good communications between patients and their relatives resulted in a good level of satisfaction regarding their host hospitals. COVID-19 and its somatic consequences seem to have had more psychological impact on the participants than the transfers by themselves. Conclusion: Our results suggest that there are limited current psychological consequences of the IHT implemented during the first wave of COVID-19, although the involvement of patients and their relatives in the organization of the IHT at the time of transfer could further limit them. Full article

The COVID-19 pandemic management has led to a significant change in orthopedic surgical activity. During the pandemic, femur fractures in patients over 65 years of age have maintained a constant incidence. Our study will focus on this fragile population, analyzing the incidence of SARS-CoV-2 infection during hospital stays and the clinical and radiographic orthopedic outcomes. We also evaluated the va\riation of COVID-19 infection after health professionals’ vaccinations, and the influence of inter-hospital transfers caused by logistical and organizational aspects of the pandemic. Material and Methods: This is a descriptive and prospective study from 13 October 2020 to 15 March 2021. Participants were patients over 65 years of age with diagnoses of proximal femoral fractures with r surgical treatments indicated. We compared the SARS-CoV-2 infected patients during the stay with non-infected cases. A second evaluation was carried out dividing the patients into those who underwent inter-hospital transfers and a group without transfers. We subdivided the study period into two, according to the percentage of healthcare workers vaccinated against SARS-CoV-2. The reported clinical variables included the Parker and Palmer Score, the Nottingham Hip Fracture Score, the Harris Hip Score, mortality, the Rush Score, and evaluation of reduction in radio-lucent lines in prosthetic implants. Results: Ninety-three patients were studied. The whole positive COVID cohort (11.83%) was hospitalized during the period when less than 80% of health workers were vaccinated (p = 0.02). The COVID cohort and the patients transferred before surgery had longer stays in the Emergency Room (p = 0.019; p = 0.00007) and longer lengths of stay compared to the other patients (p = 0.00001; p = 0.001). Mortality was higher both in the infected group and in the patients who underwent a transfer before the surgical procedure (18.18% vs. 1.22 %; p = 0.003. 25% vs. 6.85%; p = 0.02). In terms of orthopedic outcomes measured through the third month of follow-up, we found worse score results in functional and radiographic outcomes in the COVID positive cohort and in the transferred patients’ cohort. Conclusions: The impact of the COVID-19 pandemic on patients treated for proximal femur fracture was statistically significant. Patients with Coronavirus during hospitalization obtained poor short-term radiographic and functional results and increased peri-operative mortality. The incidence of intra-hospital infection was high during the period in which health professionals were not yet covered by the anti-COVID vaccination cycle. Patients who were transferred between two hospitals due to pandemic-related management issues also achieved reduced outcomes compared to non-transferred cases, with increased mortality. Full article