Vascular responses of the extremities to transdermal application of vasoactive agents in Caucasian and African descent individuals

This is an accepted manuscript of an article published by Springer in European Journal of Applied Physiology on 04/04/2015, available online: https://doi.org/10.1007/s00421-015-3164-2 The accepted version of the publication may differ from the final published version.© 2015, Springer-Verlag Berlin Heidelberg. Purpose: Individuals of African descent (AFD) are more susceptible to non-freezing cold injury than Caucasians (CAU) which may be due, in part, to differences in the control of skin blood flow. We investigated the skin blood flow responses to transdermal application of vasoactive agents. Methods: Twenty-four young males (12 CAU and 12 AFD) undertook three tests in which iontophoresis was used to apply acetylcholine (ACh 1 w/v %), sodium nitroprusside (SNP 0.01 w/v %) and noradrenaline (NA 0.5 mM) to the skin. The skin sites tested were: volar forearm, non-glabrous finger and toe, and glabrous finger (pad) and toe (pad). Results: In response to SNP on the forearm, AFD had less vasodilatation for a given current application than CAU (P = 0.027–0.004). ACh evoked less vasodilatation in AFD for a given application current in the non-glabrous finger and toe compared with CAU (P = 0.043–0.014) with a lower maximum vasodilatation in the non-glabrous finger (median [interquartile], AFD n = 11, 41[234] %, CAU n = 12, 351[451] %, P = 0.011) and non-glabrous toe (median [interquartile], AFD n = 9, 116[318] %, CAU n = 12, 484[720] %, P = 0.018). ACh and SNP did not elicit vasodilatation in the glabrous skin sites of either group. There were no ethnic differences in response to NA. Conclusion: AFD have an attenuated endothelium-dependent vasodilatation in non-glabrous sites of the fingers and toes compared with CAU. This may contribute to lower skin temperature following cold exposure and the increased risk of cold injuries experienced by AFD.Published versio

The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study

Background: Worldwide, hospitals face pressure to reduce costs. Some respond by working with a reduced number of nurses or less qualified nursing staff. Objective: This study aims at examining the relationship between mortality and patient exposure to shifts with low or high nurse staffing. Methods: This longitudinal study used routine shift-, unit-, and patient-level data for three years (2015–2017) from one Swiss university hospital. Data from 55 units, 79,893 adult inpatients and 3646 nurses (2670 registered nurses, 438 licensed practical nurses, and 538 unlicensed and administrative personnel) were analyzed. After developing a staffing model to identify high- and low-staffed shifts, we fitted logistic regression models to explore associations between nurse staffing and mortality. Results: Exposure to shifts with high levels of registered nurses had lower odds of mortality by 8.7% [odds ratio 0.91 95% CI 0.89–0.93]. Conversely, low staffing was associated with higher odds of mortality by 10% [odds ratio 1.10 95% CI 1.07–1.13]. The associations between mortality and staffing by other groups was less clear. For example, both high and low staffing of unlicensed and administrative personnel were associated with higher mortality, respectively 1.03 [95% CI 1.01–1.04] and 1.04 [95% CI 1.03–1.06]. Discussion and implications: This patient-level longitudinal study suggests a relationship between registered nurses staffing levels and mortality. Higher levels of registered nurses positively impact patient outcome (i.e. lower odds of mortality) and lower levels negatively (i.e. higher odds of mortality). Contributions of the three other groups to patient safety is unclear from these results. Therefore, substitution of either group for registered nurses is not recommended. © 2021 The Author

Longitudinal Study of the Variation in Patient Turnover and Patient-to-Nurse Ratio: Descriptive Analysis of a Swiss University Hospital

Background: Variations in patient demand increase the challenge of balancing high-quality nursing skill mixes against budgetary constraints. Developing staffing guidelines that allow high-quality care at minimal cost requires first exploring the dynamic changes in nursing workload over the course of a day. Objective: Accordingly, this longitudinal study analyzed nursing care supply and demand in 30-minute increments over a period of 3 years. We assessed 5 care factors: patient count (care demand), nurse count (care supply), the patient-to-nurse ratio for each nurse group, extreme supply-demand mismatches, and patient turnover (ie, number of admissions, discharges, and transfers). Methods: Our retrospective analysis of data from the Inselspital University Hospital Bern, Switzerland included all inpatients and nurses working in their units from January 1, 2015 to December 31, 2017. Two data sources were used. The nurse staffing system (tacs) provided information about nurses and all the care they provided to patients, their working time, and admission, discharge, and transfer dates and times. The medical discharge data included patient demographics, further admission and discharge details, and diagnoses. Based on several identifiers, these two data sources were linked. Results: Our final dataset included more than 58 million data points for 128,484 patients and 4633 nurses across 70 units. Compared with patient turnover, fluctuations in the number of nurses were less pronounced. The differences mainly coincided with shifts (night, morning, evening). While the percentage of shifts with extreme staffing fluctuations ranged from fewer than 3% (mornings) to 30% (evenings and nights), the percentage within "normal" ranges ranged from fewer than 50% to more than 80%. Patient turnover occurred throughout the measurement period but was lowest at night. Conclusions: Based on measurements of patient-to-nurse ratio and patient turnover at 30-minute intervals, our findings indicate that the patient count, which varies considerably throughout the day, is the key driver of changes in the patient-to-nurse ratio. This demand-side variability challenges the supply-side mandate to provide safe and reliable care. Detecting and describing patterns in variability such as these are key to appropriate staffing planning. This descriptive analysis was a first step towards identifying time-related variables to be considered for a predictive nurse staffing model. © 2020 Journal of Medical Internet Research. All rights reserved

Changepoint analysis of gestational age and birth weight: proposing a refinement of Diagnosis Related Groups

Background: Although the complexity and length of treatment is connected to the newborn’s maturity and birth weight, most case-mix grouping schemes classify newborns by birth weight alone. The objective of this study was to determine whether the definition of thresholds based on a changepoint analysis of variability of birth weight and gestational age contributes to a more homogenous classification. Methods: This retrospective observational study was conducted at a Tertiary Care Center with Level III Neonatal Intensive Care and included neonate cases from 2016 through 2018. The institutional database of routinely collected health data was used. The design of this cohort study was explorative. The cases were categorized according to WHO gestational age classes and SwissDRG birth weight classes. A changepoint analysis was conducted. Cut-off values were determined. Results: When grouping the cases according to the calculated changepoints, the variability within the groups with regard to case related costs could be reduced. A refined grouping was achieved especially with cases of >2500 g birth weight. An adjusted Grouping Grid for practical purposes was developed. Conclusions: A novel method of classification of newborn cases by changepoint analysis was developed, providing the possibility to assign costs or outcome indicators to grouping mechanisms by gestational age and birth weight combined. © 2019, International Pediatric Research Foundation, Inc

A Bayesian spatial-temporal model for prevalence estimation of a VRE outbreak in a tertiary care hospital.

BACKGROUND There was a nosocomial outbreak of vancomycin-resistant enterococci (VRE) in our hospital from 1.1.2018 to 31.7.2020. The goals of the study were to describe weekly prevalence, and to identify possible effects of the introduction of selected infection control measures. METHODS We performed a room centric analysis of 12 floors (243 rooms) of the main hospital building, including data on 37,558 patients over 22,072 person weeks for the first two years of the outbreak (2018-19). Poisson Bayesian hierarchical models were fitted to estimate prevalence per room and week, including both spatial and temporal random effects terms. RESULTS Exploratory data analysis revealed significant variability in prevalence between departments and floors, along with sporadic spatial and temporal clustering during colonization "flare-ups". The oncology department experienced slightly higher prevalence over the 104 week study period (adjusted prevalence ratio (aPR) 4.8 [2.6, 8.9], p<0.001, compared to general medicine), as did both the cardiac surgery (aPR 3.8 [2.0, 7.3], p<0.001) and abdominal surgery departments (aPR 3.7 [1.8, 7.6], p<0.001). Estimated peak prevalence was reached in July 2018, at which point a number of new infection control measures (including the daily disinfection of rooms and room cleaning with UV light upon patient discharge) were introduced that resulted in a decreasing prevalence (aPR=0.89 per week, 95% CI [0.87, 0.91], p<0.001). CONCLUSION Relatively straightforward, but personnel-intensive cleaning with disinfectants and UV light provided tangible benefits in getting the outbreak under control. Despite additional complexity, Bayesian Hierarchical Models provide a more flexible platform for studying transmission dynamics

KODIERUNG DER MANGELERNÄHRUNG IN DER CH: WIRKSAM UND EFFIZIENT

Introduction: Die krankheitsassoziierte Mangelernährung (KAM) ist in Schweizer Spitälern ein häufiges Problem (20 – 50% der Hospitalisierten[i]) mit weitreichenden medizinischen und ökonomischen Folgen. Im SwissDRG-System erbringt die Kodierung der KAM nur bei gewissen Fällen einen Mehrerlös; bei der Mehrheit gibt es trotz ernährungstherapeutischem Aufwand keinen. Objectives: Die vorliegende 4-Jahres-Analyse soll zeigen, ob der Mehrerlös durch die Kodierung der KAM resp. einer E4_ Diagnose kostendeckend ist. Dazu wird dargelegt, bei welchen Patientengruppen besonders oft eine KAM-Diagnose vorliegt. Methods: In dieser retrospektiven Datenerhebung wurden alle stationären Patienten im Inselspital Bern mit einer E4_ Diagnose (E40 – E46) in den Jahren 2013 bis 2016 analysiert. Betrachtet wurden die Hauptdiagnose, die Hospitalisationsdauer, die Art der KAM-Therapie, der Mehrerlös und die Kosten. Der Aufwand für die Ernährungsberatung, Pflege und Ernährungstherapie (Zwischenmahlzeiten, orale Nahrungssupplemente (ONS), Sondenkost, parenterale Nährlösungen, Material etc.) wurde hochgerechnet. Die Patienten wurden aufgrund ihrer Haupt-Diagnose in 12 Gruppen eingeteilt, die auf der ICD-10 Klassifikation der WHO beruhen. Neugeborene und Kinder wurden separat eingeteilt. Results: Von den stationären Patienten (n = 169.515) in den 4 Jahren wurden insgesamt 5.442 Fälle (3,2%) mit KAM kodiert. Davon waren 462 Fälle (8,5%) erlösrelevant. Von den 5.442 Patienten erhielten 3.211 (59%) ONS, 1.578 (29%) enterale Ernährung und 653 (12%) parenterale Ernährung. Die Kodierung der KAM ergab einen Mehrerlös von EUR 3.283.700 und einen Aufwand von EUR 2.634.600. Die erlösrelevanten Fälle wurden mehrheitlich mit leichter und mittelschwerer KAM kodiert. Die durchschnittliche Hospitalisationsdauer betrug 20,4 (± 19,8) Tage, diejenige der DRG-relevanten nur 11,8 (± 7,3) Tage. Am häufigsten mit KAM kodiert wurden onkologische Patienten (n = 1708, 31,4%), gefolgt von Patienten mit Krankheiten des Verdauungssystems (n = 671, 12,3%) und des Kreislaufsystems (n = 609, 11,2%). Der Anteil der Kinder betrug 4,9% (n = 267). Conclusion: Diese Analyse zeigt, dass der Mehrerlös durch die Kodierung der KAM im SwissDRG-System den finanziellen Aufwand für die ernährungstherapeutischen Behandlungen deckt. Die konsequente Erfassung, Behandlung und Kodierung der KAM führt zu einer hohen Behandlungsqualität und ist zudem kosteneffizient