In a new study, deaths in U.S. emergency departments were estimated to account for 11.3% of total deaths from 2010 to 2019.
Death during or shortly after an emergency department visit is relatively common, and EDs should be prepared to provide better end-of-life care, according to a new research article.
From a patient experience point of view, it is unlikely that most EDs are a good setting for an unanticipated death. Earlier research on patients with cancer who die in an ICU shows there is a lower quality experience such as physical distress than patients who die at home.
The new research article, which was published by JAMA Network Open, features information drawn from the Optum clinical electronic health record data set from 2010 to 2020. Data was also used from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and U.S. Census.
The study features several key data points:
Among more than 104 million patients with more than 96 million ED visits, 205,372 ED deaths were found in the Optum data set, with a median age of 72
Deaths in EDs were estimated to account for 11.3% of total deaths from 2010 to 2019
A third of people who died nationally visited an ED within one month of their death
The proportion of deaths occurring in the ED decreased 0.27% annually but the proportion of people who died within one month of an ED visit increased by 1.2% annually
Compared to all ED visits, patients with ED visits resulting in death were older, male, and had higher Charlson Comorbidity Index scores
Among patients older than 80 who had ED visits, nearly 1 in 12 died within one month
"This retrospective cohort study found deaths during or shortly after ED care were common, especially among patients who are older and with chronic comorbidities. EDs must identify patients for whom end-of-life care is necessary or preferred and be equipped to deliver this care excellently," the study's co-authors wrote.
Interpreting the data
The data suggest approaches to end-of-life care in the ED setting, the study's co-authors wrote. "We found that more than 1 in 3 U.S. residents come to the ED within 1 month of their death, a proportion that has increased 42% over a decade. Moreover, nearly 300,000 U.S. residents die in the ED annually. Taken together, these findings highlight a pressing need to develop systems and resources to support end-of-life care in the ED. Unsurprisingly, we find that patients with death proximate to their final ED encounter are older and have significantly more comorbidities compared with the overall ED population. … These patients may exhibit identifiable trajectories of dying that offer an opportunity to avoid unwanted aggressive care or hospitalization at end of life."
The quality of end-of-life care in the ED is generally suboptimal, the study's co-authors wrote. "There is general consensus that delivering high-quality end-of-life care in the ED is an unmet need. Compared with dying at home or in a hospice facility, quality of dying in the hospital is worse and may lead to protracted grief and psychological distress for families. Time constraints, patient volume, and environmental factors may contribute to suboptimal patient care and family experience."
The study's co-authors offer suggestions for improving end-of-life care in EDs. "Development and implementation of policies, structural changes, and allocation of additional resources can improve delivery of care to these patients. ED programs should clearly include grief and bereavement resources. Practitioners and staff in the ED should have core primary palliative care skills, including symptom management for actively dying patients, the ability to give serious news, and focus on talking to patients and families about goals of care."
EDs should be prepared to connect patients near the end of life with palliative care and hospice care, the study's co-authors wrote. "ED practitioners and systems of care should consider developing relations with community palliative care and hospice programs to follow up with the large number of patients who, although they will survive their acute encounter, have impending or ongoing palliative care needs."
Some medical device supply chain challenges at hospitals are foundational such as determining what they own and establishing a comprehensive inventory.
Medical devices are one of the most challenging facets of supply chain management at health systems and hospitals.
Medical devices include a range of equipment from monitors, to IV pumps, to million-dollar magnetic resonance imaging machines. Hospitals not only need to acquire medical devices but also need to keep track of them and maintain them in good working condition.
This equipment is high in the supply chain hierarchy, says David Klumpe, PharmD, president of clinical asset management solutions at Indianapolis-based TRIMEDX. "Medical devices are an important part of the hospital supply chain. On the capital side, medical equipment represents 20% to 25% of what the hospital is spending every year on capital equipment. It is a major driver of organizational spending for capital on an ongoing basis."
He says there are four primary supply chain challenges related to medical devices:
"The first challenge is gaining visibility to what you own. We find that many of our clients do not fully understand everything that they own. When we help them complete an inventory, there is a pretty big difference between what they think that they own and what they actually own—they can be off as much as 30%," he says.
"The second challenge is measuring device utilization. Hospitals own thousands of devices and they need to know how many they are using on a regular basis. Nearly every hospital struggles with this challenge because it is very difficult for hospitals without technology to monitor device utilization. A typical hospital is only using 40% to 50% of the equipment that they own on any given day. So, asset utilization can be far less than what they might expect," Klumpe says.
"The third challenge is that many hospitals lack comparative benchmarks—how much equipment does a hospital own compared to similar hospitals. For example, how many ventilators does a hospital own and how many IV pumps does a hospital own? Many hospitals do not have comparative benchmarks to gauge the level of investment they have made in their equipment," he says.
"Lastly, like a lot of things in a hospital, there are many stakeholders for medical devices—many people involved in decisions about clinical equipment. There is the administrative point of view, the frontline caregiver point of view, the finance point of view, the regulatory point of view, and the infection control point of view. So, because there are many stakeholders involved, there can be complex decisions that need to be made with input from many individuals," Klumpe says.
There are strategies to rise to these challenges, he says. "The first strategy is to create and maintain an accurate single source of truth. A hospital should have a comprehensive inventory of all the equipment that it owns in one location, where they know everything about that equipment. There should not only be an inventory of equipment but also how much of it is utilized, and an accounting of how old it is and whether parts are available."
The second strategy is to establish effective governance over medical devices, Klumpe says. "There is governance over pharmaceuticals and supplies, and there should be the same level of governance over the ongoing investment in clinical assets. You should get all of the stakeholders around the table, get alignment around goals, and establish accountability for who can make decisions and how decisions are going to be made."
The third strategy involves technology, he says. "If you are going to try to do this work with manual processes, it is going to be very difficult. So, you need to seek solutions that can automate the collection and maintenance of the data. You need to automate the understanding of utilization. You need to automate infusion of benchmarks into conversations about medical devices."
Managing medical devices
Hospitals need to establish the useful life of medical devices to help maintain the equipment in good condition, Klumpe says. "Many hospitals rely on the equipment manufacturers to make recommendations about replacement intervals, but there are many pieces of equipment that have useful life far beyond what the manufacturer may suggest through a robust clinical engineering program. Often, hospitals find a partner who can help bring insight to useful life beyond what the manufacturer might suggest is the useful life, which is a way for hospitals to stretch their capital."
There are two primary strategies to extend the useful life of medical devices, he says.
"One approach is to have a quality clinical engineering program. You should have a team of highly trained, disciplined clinical engineers who are able to do repairs on the equipment in a timely way. These engineers can keep the equipment functioning past what the manufactures have suggested as the useful life of the device," Klumpe says.
The other approach, which goes hand-in-hand with a quality clinical engineering program, is an advanced supply chain, he says.
"There are parts available for clinical devices after the manufacturers have stopped manufacturing parts. There are several firms that provide 'aftermarket' parts. You need to understand that market and be thoughtful about who you are going to buy aftermarket parts from. An advanced supply chain will conduct rigorous supplier management and make sure parts are coming from qualified suppliers. This supplier management ensures that the device is safe and continues to function as it needs to for the care of the patient."
"This system has failed many patients awaiting organ transplants due to the lack of oversight and accountability," says one health system executive.
Leaders at AdventHealth are calling for improvements in the U.S. organ transplant system—the Organ Procurement and Transplantation Network (OPTN), the federal government agency that oversees organ transplants in the country, and the United Network for Organ Sharing (UNOS), the nonprofit organization that manages the organ transplant system under a contract with the OPTN.
The organ transplant system needs to be reformed, Barry Friedman, BSN, executive director of the AdventHealth Transplant Institute, recently testified before the U.S. Senate Finance Committee. "Families in need of life-saving organs have no other choice but to trust the organ transplant system that is in place. This system has failed many patients awaiting organ transplants due to the lack of oversight and accountability. Approximately 23% of kidneys procured from deceased donors are not used and discarded, resulting in preventable deaths. It is our responsibility to address this issue."
Transportation of organs also needs to be improved, he said. "Organ transportation is a process left to federally designated organ procurement organizations (OPOs). Currently, they develop their own relationships with curriers, [and] rely on airlines, charter flights, ground transportation, and federal agencies to facilitate transportation. In many cases, organs must connect from one flight to another, leaving airline personnel responsible for transfers. While anyone can track their Amazon or FedEx package, there is currently no consistent way of tracking life-saving organs. … Currently, there is no requirement for OPOs to use tracking systems. Data availability and transparency are key to improving organ procurement, and UNOS has not proven capable in providing this function."
Also, OPTN technology needs to be updated, Friedman said. "OPTN technology has significant interoperability challenges and lags behind other technology platforms. This contributes to a fractured flow of information between OPOs, donor hospitals, and transplant programs."
UNOS should be taking advantage of electronic medical records at health systems and hospitals, Bobby Nibhanupudy, MD, a transplant surgeon at AdventHealth, told HealthLeaders.
"We need to have more integration of EMRs with the database at UNOS, so we can transfer information more easily. Right now, a lot of information is entered on donors in the hospital EMRs and the database at UNOS. There is also information in EMRs and the UNOS database on outcomes. But a lot of that data is given secondhand through forms that are entered physically. UNOS needs to catch up to the capabilities of EMRs and their interfaces. They just do not have a large enough information technology department, which is probably a financial issue, but it needs to be more robust than it is now," he said.
In addition, UNOS is not effectively screening organ donors so that they can be quickly directed to transplant programs, Friedman said. "UNOS asks centers to voluntarily opt out of certain organs via a filtering process. As a result, OPOs waste valuable time making organ offers to centers that will never accept them. Time wasted equates to prolonged cold ischemic time, and organs not placed resulting in lost organ transplant opportunities. This creates a vicious cycle that disadvantages patients on the wait list."
The shortcomings of UNOS are that the complexities of the organ transplantation system have outgrown some of the abilities of the organization, Nibhanupudy said.
"UNOS has been great responding to the transplant community for many years. But over the past five years, UNOS has become more of an executive board-driven entity rather than listening to the transplant community. This has led to a couple of problems. In information technology, the needs of the transplant community have outgrown the abilities of UNOS. That has hindered the ability of UNOS to respond quickly to what the transplant community needs. Secondly, the executive board driven–approach has led to one-blanket-fits-all allocation changes; and no matter how noble the intent was, it has led to decreased transplants in the state of Florida, organs are not being utilized, and there have been increases in costs for the transportation of organs," he said.
Perspective at UNOS
Before his departure from UNOS at the end of September, former CEO Brian Shepard, told HealthLeaders that the organ transplant system is functioning effectively. "The United States has the largest and most productive organ transplant system in the world. Nobody touches our numbers—we have set records for nine consecutive years. We had 40,000 transplants for the first time last year, which is a number that no other country has come close to meeting. Some of that performance is our size—we are a big country—but if you adjust for population, we are still the largest organ transplant system in the world."
UNOS is committed to having effective technology capabilities, he said. "We have constantly updated our technology, and technology accounts for nearly half of UNOS' budget. We spend almost $30 million a year upgrading, improving, and advancing technology. We are always adding new features to help transplant hospitals do their job better such as providing predictive analytics. We provide screening tools that help them target the right organ to the right candidate faster. So, improving the system is an ongoing and continuous process."
Although UNOS is not in charge of organ transportation, the organization does provide a tracker that OPOs can use, Shepard said.
"We do provide a GPS tracker that folks can choose to use. But there are other commercial trackers that people can use—not everybody uses our tracker. We have a couple of committees—our policies always arise from experts in the field—that are looking at questions such as mandating that everyone uses a tracker or mandating that everyone uses the same tracker so it can be monitored through the same interface. These committees are also considering whether it is OK not to use a tracker when the surgeon is traveling with the organ. So, we have committees looking at how we can make the tracking of organs better."
There is not a conflict of interest in having the OPTN and UNOS share board members, he said. "We look for specific issues to see if there is a certain policy we can adopt or a certain information technology programming plan. I don't see a conflict of interest. We are a mission-based nonprofit whose goal is to increase the number of transplants performed in the United States."
Migraine can be safely diagnosed in the primary care setting and advanced medications are available.
There is a shortage of neurologists nationwide, and primary care physicians can help fill the gap in migraine care, a headache expert says.
Migraine is one of the most common disabling medical conditions, according to the American Migraine Foundation. In the United States, 1 in 4 households has a family member who suffers from migraine, and migraine affects 1 out of 7 people globally, the foundation says.
Recent advancements in migraine care and research make treating migraine in the primary care setting easier, says Loretta Mueller, OD, a headache specialist and family physician at Cooper University Health Care, which is based in Camden, New Jersey. "There has been a boom of new therapies in recent years and a lot more research going on. It is a good time to be treating headache and researching headache. The newer medications that are out generally are tolerated better than the older medications, and many of them work much quicker than the older medications."
Primary care physicians have several medication options for migraine that have become available over the past four years, she says. "The newer ones that have come out since 2018 include injected monoclonal antibodies that target the calcitonin gene-related peptide, which is migraine specific. We also have new oral medications called gepants that also target the calcitonin gene-related peptide. Two of the oral treatments are for as-needed use once a headache starts—rimegepant, which is Nurtec ODT, and ubrogepant, which is Ubrelvy. We also have a new medication that is only for headache prevention—atogepant, which is Qulipta. Nurtec ODT can also be used for prevention, when taken every other day."
Detecting migraine in the primary care setting
Diagnosing migraine is appropriate for the primary care setting, Mueller says. "It is not a procedural field, so every primary care physician who has an interest in headache should be able to treat migraine. It is just a matter of having the time to sit down and provide the care as well as having the education about what to look for. The reality is that most of what you are going to see in a primary care practice is migraine. So, if primary care physicians were taught to start with the diagnosis of migraine and work backwards from there, we would have a lot more patients who could be easily treated for migraine."
To diagnose migraine, primary care physicians should review the patient's medical history and schedule a visit to focus on the patient's headaches, she says.
"The medical history is key as well as dedicating an office visit specifically for headaches rather than just having a by-the-way complaint when a patient is in the office for high blood pressure or another condition. The primary care physician should focus only on headache during a visit. I see nothing but headache patients on a hospital's neurology floor, and it takes me an hour with a new patient, but we do have migraine identifiers such as ID Migraine, which is only three questions: Have you not been able to function at least one day out of the past three months because of your headaches? Do you ever get nauseous with your headaches? Do you ever get light sensitivity with your headache? If two out of those three are positive, there is about a 93% chance that the condition is migraine. If all three are positive, there is a 98% chance that the condition is migraine."
Primary care physicians can use tools to rule out more serious causes of headache such as SNOOP, Mueller says.
'S' is for systemic symptoms such as cancer.
'N' is for neurologic abnormalities.
The first 'O' is onset of rapid escalation of pain within seconds or the so-called thunderclap headache that can be a marker for aneurysm or brain bleed.
The second 'O' is for onset of new headache over the age of 50.
'P' is for prior headache history, where a change in headache history such as increased severity or frequency could be signs of a serious condition.
Treating migraine in the primary care setting
The treatment of migraine requires a holistic approach to care, Mueller says. "It comes down to a clinical judgment call. There is no single algorithm as is the case for other conditions such as a diagnosis of Lyme disease calling for a specific antibiotic. There is some art in the treatment of migraine because many of these patients have other comorbidities such as depression and anxiety. You look at the whole picture."
Migraine treatment can be complicated, she says. "There are many treatment options. For example, how many medications do you go through or how many classes of medications do you go through with the patient in shared decision-making. A lot of migraine care requires shared decision-making. Some patients definitely have a preference as to what they are looking for or side effects that they do not want. Some migraine medications have weight gain associated with them."
Compared to other hospitalized patients, patients with diabetes have longer lengths of stay and higher readmission rates.
Hospitals could save millions of dollars with better glycemic control of patients with diabetes.
In 2017, per capita healthcare expenditures for hospital care were estimated at $4,966 for patients with diabetes and $1,202 for patients without diabetes, according to the American Diabetes Association. Riverside Healthcare found that better management of hypoglycemic patients at their facility led to an estimated savings of $544,756 annually, and that by reducing length of stay in critical care units due to the implementation of a computer-guided insulin protocol they achieved a $2.1 million in savings in a year.
"There are high healthcare costs with the poor management of blood sugar. Costs associated with diabetes in hospitals include length of stay—these patients tend to stay in the hospital longer than other patients. They need more treatments—insulin management is a major cost for these patients. They need more interventions. They also have more readmissions than other patients," says Betsy Kubacka, MSN, an endocrinology advanced practice registered nurse at The Hospital of Central Connecticut in New Britain, Connecticut.
There are two primary elements of caring for patients with diabetes in the hospital setting, she says. "When a diabetic patient is admitted to the hospital, they are primarily treated with insulin, which is the safest modality and has the least amount of side effects. We can get blood sugar control of the patient and maintain it throughout the hospitalization. When they are under control, patients can recover quicker and have less of a risk for infection. For most patients, we want to keep their blood sugar between 100 and 180 milligrams per deciliter throughout the hospitalization. We also want to ensure that our diabetic patients have adequate diabetes education to manage their diabetes when they are back home. We provide chronic disease management education."
Diabetes management is a challenge in the inpatient setting, Kubacka says. "Resources such as endocrinology are often limited at hospitals, so it is often a challenge getting our patients under control within the hospital setting. With insulin, you must give the right amount. If we don't give the right amount, you either have blood sugar that is too high or too low, both of which can lead to adverse outcomes."
In the hospital setting, there are adverse outcomes for patients with diabetes who have low blood sugar and high blood sugar, she says. "The adverse outcomes of low blood sugar include hypoglycemia, which can make the patient feel shaky and dizzy. In severe cases where the patient's blood sugar goes below 40, they can have altered mental status or hypoglycemic coma. Those patients have a longer length of stay at the hospital. Low blood sugar is the biggest concern for hospital staff. The adverse outcomes of high blood sugar—above 180 during hospitalization—include bacterial infections. Among COVID-19 patients, those who had uncontrolled high blood sugar while hospitalized have had higher mortality rates."
Managing hospitalized diabetic patients
Expert resources for patients with diabetes are often lacking in many hospitals across the country, and technology can fill the gap, Kubacka says. "We have a shortage of endocrinologists. We have a shortage of nurses who specialize in diabetes to help support team members in managing diabetic patients in hospitals. With a shortage of expert resources, we must look at things like technology to improve glycemic care. That is something that we implemented within Hartford HealthCare to assist our staff in calculating insulin doses by using Food and Drug Administration-cleared computerized algorithms."
The Hospital of Central Connecticut has launched three primary initiatives to improve glycemic care, she says.
"There has been a lot of work in order set design. Within the electronic health record, we provide guidance to our physicians, nurse practitioners, and physician assistants in how to prescribe insulin. So, although endocrinology may not be their specialty, information on how to prescribe for a patient is at their fingertips."
"We have ensured through our nutrition services that diabetic patients are getting the correct diet. We ensure that we have a process, so the nurse knows when a meal is delivered, and the nurse can check the patient's blood sugar before the meal and administer insulin in a timely manner. We have put processes in place and support the staff as best as we can."
"We have an endocrine council that meets monthly, and I serve on that council. We look at any adverse event that occurs in the hospital and do root cause analysis on those events to see if there is anything within our processes that we can do differently to prevent adverse outcomes in the future."
Researchers found that completion of the primary series of COVID vaccination before acute COVID-19 illness was associated with a lower risk of long COVID.
A new research article gauges the prevalence of long COVID symptoms among U.S. adults and examines the effectiveness of vaccination for averting long COVID.
The World Health Organization has definedlong COVID as a syndrome that occurs three months after a COVID-19 infection, with symptoms that last for at least two months. Long COVID symptoms include cough, shortness of breath, anxiety, depression, cardiac issues, and fatigue.
The new research article, which was published by JAMA Network Open, features survey data collected from more than 16,000 adults who experienced a test-confirmed COVID-19 illness. The study includes several key data points:
Among the 16,091 survey respondents, 2,359 people (14.7%) reported long COVID symptoms. When this data was reweighted for national sociodemographic distributions, these long COVID patients represented 13.9% of patients who had tested positive for COVID-19.
Completion of the primary series of COVID vaccination before acute COVID-19 illness was associated with a lower risk of long COVID (odds ratio 0.72).
Older age per decade above 40 years was associated with higher risk of persistence of long COVID (adjusted odds ratio 1.15).
Female gender was associated with higher risk of persistence of long COVID (adjusted odds ratio 1.91).
People with a graduate education versus high school or less were associated with a lower risk of persistence of long COVID (adjusted odds ratio 0.67).
People who lived in urban versus rural areas were associated with a lower risk of persistence of long COVID (adjusted odds ratio 0.74).
Among long COVID patients, fatigue was the most common symptom (52.2% of patients), followed by loss of smell (43.7%), brain fog (40.4%), and shortness of breath (39.7%).
"This study suggests that long COVID is prevalent and associated with female gender and older age, while risk may be diminished by completion of primary vaccination series prior to infection," the study's co-authors wrote.
The data estimates the prevalence of long COVID among adults who test positive for COVID-19, they wrote. "In this cross-sectional study of a cohort of 16,091 adults surveyed between February 2021 and July 2022 in all 50 states in the U.S. and the District of Columbia, we estimated that 14.7% of those who reported a positive COVID-19 test result more than 2 months previously continued to describe symptoms that they associated with acute infection, or 13.9% after reweighting to reflect the U.S. adult population."
To help address healthcare workforce shortages in western Kentucky, Owensboro Health has led an effort to open a staff development innovation center in Owensboro, Kentucky.
Many healthcare executives say workforce shortages are their top challenge as the country emerges from the crisis phase of the coronavirus pandemic. Health systems, hospitals, and physician practices nationwide are struggling with workforce shortages in clinical and nonclinical roles.
Mark Marsh, president and CEO of Owensboro Health, says workforce shortages have affected the entire organization. "Throughout the country, workforce shortages are impacting our ability to provide care. It is affecting clinical roles such as nursing, respiratory therapy, and physical therapy, but we are seeing shortages throughout our organization including the support staff, dietary staff, and housekeeping. With COVID, we had a lot of retirements. We are seeing shortages on the inpatient and the outpatient sides."
Owensboro Health has launched the Commonwealth West Healthcare Workforce Innovation Center (CWHWIC), which was formed in collaboration with nine regional colleges and universities. The Kentucky General Assembly approved $38 million to establish the innovation center and develop a curriculum.
Owensboro Health got involved to spearhead the CWHWIC to meet a critical need, Marsh says. "We knew we were facing workforce hardships, including burnout from COVID. I am on a collaborative with the other nine big health systems in Kentucky, including Norton Healthcare. We were all facing workforce hardships. With traveling nurses, we have just been swapping nurses. So, we have been trying to put a plug in the problem, but even with the travelers, it has not been enough."
Working in collaboration with the colleges and universities is a critical component of the CWHWIC, he says. "We are blessed—we have nine colleges and universities in the western part of the state. When I first got here—I have been at Owensboro Health for about 16 months—I pulled those nine colleges and universities together and said, 'Here is what we are confronting.' I said, 'How can we put our collective resources together to address workforce shortages?' I came to the conclusion that we are going to be a lot better off trying to solve for this problem ourselves rather than rely on state or national resources. CWHWIC is an attempt to grow our own staff."
Owensboro Health worked with state legislators to establish the CWHWIC, Marsh says. "That was the exciting part. … Lawmakers love collaborative efforts. They saw nine public and private institutions come together with a solution. Lawmakers had been hearing about workforce shortages from the health systems in Kentucky. It made it easy for me to work with some of our local politicians. One was state Rep. Suzanne Miles. We had the chance to put our story together, and we went to the capital to meet with politicians. What was initially designed just to present the concept and how the innovation center would help moved so quickly that it went up for a vote in the appropriations committee."
Owensboro Health has invested heavily in the CWHWIC, says Bart Darrell, vice president of the innovation center. "Owensboro Health did not just go to the legislature and make a request for money. It has made a significant investment in everything from personnel to auxiliary services and the human resources piece. Owensboro Health is all in. This would not have moved forward if the state legislature and the governor did not believe that Owensboro Health was going all in. There is a significant $10 million–$12 million investment from Owensboro Health, which makes a great point to everybody that this is not just an idea. This has been researched and we have the right people involved."
How the CWHWIC will work
Owensboro Health has made a facility available to house the innovation center, Marsh says. "We have a facility that serves as our business office in the heart of Owensboro. It is about 48,000 square feet. We needed space to create the simulation labs and the innovation center. We were able to have some people work from home, and we have some other facilities throughout the area where we can relocate some of our personnel. It gave us the freedom to go ahead and convert and retrofit our business office into this new innovation center. That was a great speed to market for us and we are investing those resources."
The contribution of space for the innovation center was crucial for the initiative, Darrell says. "If Owensboro Health was not willing to contribute this building, you could not build a similar facility with the money that is coming from the legislature. Without that facility, this initiative would not be happening. It is going to be a state-of-the-art facility. It will have the cutting edge in technology as it relates to simulation."
Simulation labs are the key component of the CWHWIC, he says. "Anything that we do here is going to be done with excellence. So, we are making sure that we are being smart on how we start down the road. We anticipate offering simulation lab training in nursing, respiratory therapy, radiology, and lab techs initially."
The simulation labs will provide essential training at the innovation center, Marsh says. "We are putting together 13 simulation labs—those simulation labs are going to provide real-life scenarios where participants can see what an operating room nurse is or an ER nurse is. We are trying to role-play and provide real-life scenarios, so when participants get into the workplace setting, it will reduce the orientation and allow them an easier transition. It will give innovation center participants a better understanding of what their jobs entail."
Collaboration with the colleges and universities is also crucial, Darrell says. "Another piece is when we collaborate with the colleges and universities. Each one of them has their own niche or specialty. We know where we are going for the first three to five years, but we are also ready for whatever the healthcare environment presents to us and whatever technological advances arise. We believe we will be well-positioned to take advantage of change."
Researchers examined 1,193 major surgeries involving 992 community-living older adults from 2011 to 2017.
Among nearly 1,000 Medicare beneficiaries over age 65, the overall 1-year mortality rate after major surgery was 13.4%, according to a new research article.
Earlier research has found that the 5-year cumulative risk of major surgery for older U.S. adults is 13.8%, which amounts to nearly 5 million people. Given this relatively high number, major surgery for older adults is a consequential public health concern in the United States.
The new research article, which was published by JAMA Surgery, features data collected from 1,193 major surgeries involving 992 community-living older adults from 2011 to 2017. The data was drawn from Centers for Medicare & Medicaid Services fee-for-service Medicare claims and the National Health and Aging Trends Study. The definition of major surgery included any procedure performed in an operating room with general anesthesia.
The study includes several key data points:
The 1-year mortality rate was highest for patients over the age of 90
The 1-year mortality rate for elective surgeries was 7.4%, and the mortality rate for nonelective (unplanned) surgeries was 22.3%
Older adults who had elective surgery tended to have a more favorable risk profile than older adults who had nonelective surgery, including younger age, higher educational attainment, and lower incidence of frailty as well as possible or probable dementia
The 1-year mortality rate for older adults who were not frail was 6.0% and 27.8% for older adults who were frail
The 1-year mortality rate for older adults without dementia was 11.6% and 32.7% for older adults with probable dementia
The median time to death was 96 days for all major surgeries, 169 days for elective surgeries, and 62 days for nonelective surgeries
"In this study, the population-based estimate of 1-year mortality after major surgery among community-living older adults in the U.S. was 13.4% but was 3-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery," the research article's co-authors wrote.
Interpreting the data
The data shows there are significant differences in 1-year mortality after major surgery for older adults across subcategories, the study's co-authors wrote.
"We found that nearly 1 of every 7 community-living older U.S. adults died in the year after major surgery, including more than 1 of 4 who were frail and nearly 1 of 3 who had probable dementia. Mortality was 3-fold higher for nonelective than elective surgery and was especially elevated for persons who were 90 years or older. Our findings suggest substantial differences in 1-year mortality after major surgery across distinct subgroups of older persons and highlight the potential prognostic value of geriatric conditions such as frailty and dementia," they wrote.
The data suggests there are ways to improve outcomes for older adults who undergo major surgery, the study's co-authors wrote. "Our findings are notable because they define the scope and scale of mortality after major geriatric surgery in the U.S. and because they suggest a mix of surgical quality and safety among older persons. With improved preoperative optimization and recognition as well as enhanced perioperative management strategies, it is possible that mortality after major surgery could be reduced among older persons, especially those in high-risk subgroups."
Researchers examined data from 9.5 million deliveries in hospitals between 2007 and 2018.
Compared to White women, Black women had a 53% increased risk of dying in the hospital during childbirth, according to new research set to be presented at the ANESTHESIOLOGY 2022 conference.
Earlier research has found racial healthcare disparities in maternal mortality. For example, a 2019 study by researchers at the Centers for Disease Control and Prevention found that pregnancy-related deaths per 100,000 live births for Black, American Indian, and Alaska Native women older than 30 were four to five times as high as they were for White women.
The new research is based on data collected from 9.5 million deliveries in hospitals between 2007 and 2018. The data was drawn from inpatient databases in California, Florida, Kentucky, Maryland, New York, and Washington.
The finding that Black mothers had a 53% increased risk of dying in hospitals compared to White women was regardless of income level, type of insurance, or other social determinants of health. The research includes another key finding. Of the 49,472 mothers who died in the hospital or experienced harm to the heart, eyes, kidney, or other organ, there were 0.8% of all Black women, 0.5% of all Hispanic women, and 0.4% of all White women.
"This study is the most up-to-date and extensive study—factoring in various states, insurance types, hospital types, and income levels—to determine that the much higher maternal mortality rate among Black women often cannot be attributed to differences in health, income or access to care alone," Robert White, MD, MS, lead author of the study and assistant professor of anesthesiology at Weill Cornell Medicine in New York, said in a prepared statement.
White called for interventions to address the healthcare disparity. "Clearly there's a need for legislation to improve access to healthcare throughout pregnancy and improve funding among safety-net hospitals. But it's also essential that hospitals train their employees to provide culturally appropriate care, offer translation services, and conduct implicit bias association testing."
Anesthesiologists are well-positioned to impact maternal mortality, White said. "Physician anesthesiologists are leaders in quality, safety, and perioperative medicine and are working very hard to help decrease racial differences through science and implementation of protocols that treat everyone the same—with a focus on those who are worse off to achieve health equity. We not only provide pain management during childbirth, but our training in critical and emergency care help us to proactively handle complications, prevent death, and ensure the health and safety of the mother and baby."
Healthcare organizations must create an environment where it is unambiguous that racist behavior will not be tolerated, ECRI's top leader says.
A new report published by ECRI includes data on racist incidents at health systems and hospitals.
The majority of the racist incidents involved patients and family members making inappropriate comments related to race or ethnicity. These comments can have a negative impact on the mental health of healthcare providers—leading them to consider leaving their jobs at a time when workforce shortages are a significant problem at healthcare organizations.
The new report features data collected between July 1, 2019, and June 30, 2020. The data on racist incidents was drawn from more than 500 patient safety incident reports collected from health systems and hospitals nationwide.
The patient safety incident reports were broken into seven categories:
Patients or family members making inappropriate comments about race or ethnicity (56%)
Patients saying that others are racist or engaged in racist behavior (22%)
Patients or family members saying that they received substandard care because of the patient or family's race or ethnicity (9%)
Staff members making inappropriate comments about race or ethnicity (7%)
Staff members saying management or a supervisor discriminated against them (4%)
Patients requesting a healthcare provider based on race or ethnicity (1%)
Patients or family members complaining that interpretation or translation services were not provided (less than 1%)
Addressing racist incidents at healthcare organizations
Racist incidents are not just a matter of bad behavior, Marcus Schabacker, MD, PhD, president and CEO of ECRI, told HealthLeaders.
"These incidents have negative consequences for patient safety directly and indirectly. If a staff member is exposed to racist comments, then they are going to be impacted in their emotional well-being. If they are not emotionally well—if they are frustrated or angry—they may not be able to provide the best care and they might not be as attentive to potential health issues of the patient as they could be. That is a direct impact on patient safety. If a staff member has racially motivated issues, they might not provide appropriate care to a patient," he said.
There are two primary ways healthcare organizations can detect racist incidents in the workplace, Schabacker said. "First of all, the leadership, administration, and management team must provide an environment in which employees and patients feel comfortable that they can report these issues, that they are going to be taken seriously, and that there are mechanisms in place for incidents to be reported. Secondly, it is helpful to have a dedicated member of the senior management team who is the advocate for reporting and is trained in dealing with these issues both on the staff side and the patient side."
Although healthcare organizations cannot single-handedly change racist societal constructs, they can create an environment where it is unambiguous that racist behavior will not be tolerated, he said. "Leadership at the top must be clear that racism is an unacceptable behavior, then they must train their staff on being able to deal with racism in the appropriate manner. There also must be training for conscious and unconscious biases among staff. Unconscious bias is a big source of racially tainted comments. Leadership can't do much about unconscious bias among patients, but they can certainly address it among staff."
Healthcare organizations can address racist comments by patients, Schabacker said. "Among patients, they may not be aware that they are making racially tainted comments, but someone in an appropriate way can address the patient and say, 'I'm not sure you meant to say that, but it was very offensive, and we ask you not to do that anymore.' That signals to the staff that they are taken seriously, which can prevent their frustration or even leaving their job."
Staff members should be able to turn to specific people in the organization when a patient or family member makes racist comments, he said.
"As difficult as it is, they should not engage with the patient. The organization should have people to notify under these circumstances, so the staff member can say, 'I was exposed to this behavior. I feel uncomfortable addressing that person. Can you speak to them?' There needs to be a safety net for staff. They need to know that they will be taken seriously. They need to know they have somebody to go to. There must be a mechanism in place to support them. The leadership and the administration must take action."
To address racist behavior by staff members, healthcare organizations should have a clear culture and rules for what is acceptable and what is not acceptable, Schabacker said.
"You need to provide training to everybody—particularly around unconscious bias. When incidents occur, they should be tackled up front. It should not be allowed to fester. A typical reaction is to say, 'They really didn't mean that.' But if there is a racist comment, it needs to be dealt with and it needs to be addressed. There should be a clear code of conduct and a rulebook that says if there is racist behavior, here is what this organization is going to do. If something happens, there is a warning, there is training, then if something happens again, there is an escalation and there are disciplinary consequences."