Disinvestment in the presence of uncertainty: Description of a novel, multi-group, disinvestment trial design and protocol for an application to reduce or cease use of mobilisation alarms for preventing falls in hospitals

Disinvestment is the removal or reduction of previously provided practices or services, and has typically been undertaken where a practice or service has been clearly shown to be ineffective, inefficient and/or harmful. However, practices and services that have uncertain evidence of effectiveness, efficiency and safety can also be considered as candidates for disinvestment. Disinvestment from these practices and services is risky as they may yet prove to be beneficial if further evidence becomes available. A novel research approach has previously been described for this situation, allowing disinvestment to take place while simultaneously generating evidence previously missing from consideration. In this paper, we describe how this approach can be expanded to situations where three or more conditions are of relevance, and describe the protocol for a trial examining the reduction and elimination of use of mobilisation alarms on hospital wards to prevent patient falls. Our approach utilises a 3-group, concurrent, non-inferiority, stepped wedge, randomised design with an embedded parallel, cluster randomised design. Eighteen hospital wards with high rates of alarm use (≥3%) will be paired within their health service and randomly allocated to a calendar month when they will transition to a “Reduced” (<3%) or “Eliminated” (0%) mobilisation alarm condition. Dynamic randomisation will be used to determine which ward in each pair will be allocated to either the reduced or eliminated condition to promote equivalence between wards for the embedded parallel, cluster randomised component of the design. A project governance committee will set non-inferiority margins. The primary outcome will be rates of falls. Secondary clinical, process, safety, and economic outcomes will be collected and a concurrent economic evaluation undertaken.

Significance of the cronobiological factors in a spa treatment of gynaecological patients

In the article the outcomes of the research of efficiency of complex SPA treatment of the patients with chronic inflammatory diseases of organs of the small pelvis in various seasons of the year in conditions of humid subtropics are indicated. The dynamics ofa psycho-emotional condition, vegetative reactivity, condition of the protective-adapting mechanisms of the gomeostasis are investigated, depending on a kind of applied SPA treatment (hydrogen sulfide or iodine bromide)? In cool and warm periods of a year. The recommendations for differentiated rehabilitation treatment of patients with valiants of clinical process of chronic inflammatory diseases of organs of the small pelvis and complications, accompanying them, in conditions of humid subtropics are represented.

Neuro-ophthalmology: Visual Fields

Visual field testing is an important part of the assessment of the afferent visual system. This chapter reviews the clinical process of visual field evaluation and the localization of lesions that affect the visual system. The visual field can be thought of as an island with an outer edge beyond which one cannot see and with an elevated center. The normal extent of the peripheral field of vision from the center is 90° to 100° temporally, 75° inferiorly, and 60° nasally and superiorly. Visual fields are subjective and should be considered only 1 part of the examination of the visual pathways.

Mining Clinical Process from Hospital Information System: A Granular Computing Approach

Data mining methods in medicine is a very important tool for developing automated decision support systems. However, since information granularity of disease codes used in hospital information system is coarser than that of real clinical definitions of diseases and their treatment, automated data curation is needed to extract knowledge useful for clinical decision making. This paper proposes automated construction of clinical process plan from nursing order histories and discharge summaries stored in hospital information system with curation of disease codes as follows. First, the system applies EM clustering to estimate subgrouping of a given disease code from clinical cases. Second, it decomposes the original datasets into datasets of subgroups by using granular homogenization. Thirdly, clinical pathway generation method is applied to the datasets. Fourthly, classification models of subgroups are constructed by using the analysis of discharge summaries to capture the meaning of each subgroup. Finally, the clinical pathway of a given disease code is output as the combination of the classifiers of subgroups and the the pathways of the corresponding subgroups. The proposed method was evaluated on the datasets extracted hospital information system in Shimane University Hosptial. The obtained results show that more plausible clinical pathways were obtained, compared with previously introduced methods.

Predicting COVID-19 progression from diagnosis to recovery or death linking primary care and hospital records in Castilla y León (Spain)

This paper analyses COVID-19 patients’ dynamics during the first wave in the region of Castilla y León (Spain) with around 2.4 million inhabitants using multi-state competing risk survival models. From the date registered as the start of the clinical process, it is assumed that a patient can progress through three intermediate states until reaching an absorbing state of recovery or death. Demographic characteristics, epidemiological factors such as the time of infection and previous vaccinations, clinical history, complications during the course of the disease and drug therapy for hospitalised patients are considered as candidate predictors. Regarding risk factors associated with mortality and severity, consistent results with many other studies have been found, such as older age, being male, and chronic diseases. Specifically, the hospitalisation (death) rate for those over 69 is 27.2% (19.8%) versus 5.3% (0.7%) for those under 70, and for males is 14.5%(7%) versus 8.3%(4.6%)for females. Among patients with chronic diseases the highest rates of hospitalisation are 26.1% for diabetes and 26.3% for kidney disease, while the highest death rate is 21.9% for cerebrovascular disease. Moreover, specific predictors for different transitions are given, and estimates of the probability of recovery and death for each patient are provided by the model. Some interesting results obtained are that for patients infected at the end of the period the hazard of transition from hospitalisation to ICU is significatively lower (p < 0.001) and the hazard of transition from hospitalisation to recovery is higher (p < 0.001). For patients previously vaccinated against pneumococcus the hazard of transition to recovery is higher (p < 0.001). Finally, internal validation and calibration of the model are also performed.

On the Annotation of Health Care Pathways to Allow the Application of Care-Plans That Generate Data for Multiple Purposes

Objectives: Procedural interoperability in health care requires information support and monitoring of a common work practice. Our aim was to devise an information model for a complete annotation of actions in clinical pathways that allow use of multiple plans concomitantly as several partial processes underlie any composite clinical process.Materials and Methods: The development of the information model was based on the integration of a defined protocol for clinical interoperability in the care of patients with chronic obstructive pulmonary disease and an observational study protocol for cohort characterization at the group level. In the clinical process patient reported outcome measures were included.Results: The clinical protocol and the observation study protocol were developed on the clinical level and a single plan definition was developed by merging of the protocols. The information model and a common data model that had been developed for care pathways was successfully implemented and data for the medical records and the observational study could be extracted independently. The interprofessional process support improved the communication between the stakeholders (health care professionals, clinical scientists and providers).Discussion: We successfully merged the processes and had a functionally successful pilot demonstrating a seamless appearance for the health care professionals, while at the same time it was possible to generate data that could serve quality registries and clinical research. The adopted data model was initially tested and hereby published to the public domain.Conclusion: The use of a patient centered information model and data annotation focused on the care pathway simplifies the annotation of data for different purposes and supports sharing of knowledge along the patient care path.

Introducing Rapid Change Escalades to Adjust Organisational Issues in Clinical Practice

Background: Running clinical facilities implies facing many challenges, as neat time management and fluid care processes. A method that warrants small changes and an interconnected and collaborative proceeding is convenient for adjusting clinical processes and avoiding unwanted side effects. From an organizational perspective, a smooth clinical process translates also into a levelled occupation of team members as reflected by over-time and absenteeism. Methods: The policlinic nurse team introduced weekly mini-huddles of maximum 15 minutes to discuss work organizational issues, with structured access to collaborating professionals and their hierarchies. The team selected the topic of patients presenting without a planned appointment. Nurse’s over-time stock and absenteeism were assessed before and after the intervention. Results: The clinical process had six steps, of which the patient’s waiting room period was transformed into a nurse’s evaluation and triage period followed by a transmission note to the physician. The new process decreased the average stock of nurse’s team over-time from 65.5 to 46.8 hours (-29%), and the nurse’s absenteeism from 4.6 % to 1.97 % (-57%). Conclusion: By cautious and collaborative proceeding, and the choice of an earnest issue by front nurses, we levelled the nurse’s workload and pleased patients and professional teams.

Color-Coded Droplets and Microscopic Image Analysis for Multiplexed Antibiotic Susceptibility Testing

Since the discovery of antibiotics, the emergence of antibiotic resistance has become a global issue that is threatening society. In the era of antibiotic resistance, finding the proper antibiotics through antibiotic susceptibility testing (AST) is crucial in clinical settings. However, the current clinical process of AST based on the broth microdilution test has limitations on scalability to expand the number of antibiotics that are tested with various concentrations. Here, we used color-coded droplets to expand the multiplexing of AST regarding the kind and concentration of antibiotics. Color type and density differentiate the kind of antibiotics and concentration, respectively. Microscopic images of a large view field contain numbers of droplets with different testing conditions. Image processing analysis detects each droplet, decodes color codes, and measures the bacterial growth in the droplet. Testing E. coli ATCC 25922 with ampicillin, gentamicin, and tetracycline shows that the system can provide a robust and scalable platform for multiplexed AST. Furthermore, the system can be applied to various drug testing systems, which require several different testing conditions.

Pain and Associated Neuropsychiatric Symptoms in Patients Suffering from Dementia: Challenges at Different Levels and Proposal of a Conceptual Framework

Old age is critically associated with multi-morbidity, chronic pain, and high risk for dementia. Recognizing and treating pain is very much dependent on language comprehension and production. Both may be impaired in dementia. Moreover, neuropsychiatric symptoms may interact with pain perception. The main aims of the present article were 1) to identify key areas for future research to elucidate the relation between pain and associated neuropsychiatric symptoms in dementia, and 2) to provide a conceptual framework for ameliorating the clinical process of recognizing, assessing, and managing pain in non-communicating patients with advanced dementia.