The Development of Intensive Care Nursing as a Specialty at Wellington Hospital Intensive Care Unit, Wellington, New Zealand, 1964-1989

<p>Intensive care nursing developed as a specialty with the advent of intensive care units (ICUs) following the poliomyelitis outbreaks of the 1950s. In New Zealand (NZ) the first ICU was opened in the early 1960s in Auckland. Many ICUs were quickly established in other NZ hospitals around this time with Wellington Hospitals ICU opening in 1964. This work explores the first 25 years of the development of the Wellington ICU and the specialisation of ICU nursing. Oral history interviews with past and present staff who worked and taught in the ICU during this time and Hospital archives and primary documentation sources provided much of the background information about this development. One find during the cataloguing of materials and administrative records prior to the move to the newly built Wellington Regional Hospital was the patient admission records documenting each year of the unit‟s operation since it opened. The information gathered from these records provided data on patient demographics, giving age, admission diagnosis, discharge destination, mortality information and admission source for each patient admitted. Education of the nurses, many of whom were embracing the knowledge and technology required to look after ICU patients for the first time was paramount to the care of the critically ill patient. With the advent of an ICU six-month nursing course in 1968 many of the educational needs of the nurses were met. Working relationships with the medical staff were very different from those that many nurses had been used to when working in the wards with the Doctor - Nurse relationship becoming less formal and more collaborative. This thesis illustrates the hard work and determination of those early nurses to provide excellent and appropriate care and translate knowledge into practice in order to look after these critically ill patients.</p>

The Development of Intensive Care Nursing as a Specialty at Wellington Hospital Intensive Care Unit, Wellington, New Zealand, 1964-1989

<p>Intensive care nursing developed as a specialty with the advent of intensive care units (ICUs) following the poliomyelitis outbreaks of the 1950s. In New Zealand (NZ) the first ICU was opened in the early 1960s in Auckland. Many ICUs were quickly established in other NZ hospitals around this time with Wellington Hospitals ICU opening in 1964. This work explores the first 25 years of the development of the Wellington ICU and the specialisation of ICU nursing. Oral history interviews with past and present staff who worked and taught in the ICU during this time and Hospital archives and primary documentation sources provided much of the background information about this development. One find during the cataloguing of materials and administrative records prior to the move to the newly built Wellington Regional Hospital was the patient admission records documenting each year of the unit‟s operation since it opened. The information gathered from these records provided data on patient demographics, giving age, admission diagnosis, discharge destination, mortality information and admission source for each patient admitted. Education of the nurses, many of whom were embracing the knowledge and technology required to look after ICU patients for the first time was paramount to the care of the critically ill patient. With the advent of an ICU six-month nursing course in 1968 many of the educational needs of the nurses were met. Working relationships with the medical staff were very different from those that many nurses had been used to when working in the wards with the Doctor - Nurse relationship becoming less formal and more collaborative. This thesis illustrates the hard work and determination of those early nurses to provide excellent and appropriate care and translate knowledge into practice in order to look after these critically ill patients.</p>

883 A Closed-Loop Audit to Improve Admissions Documentation in A Busy ENT Department

Aim Accurate and thorough admissions documentation is crucial for patient safety and effective care. We amended the admissions pro-forma used on a busy adult ENT ward to improve adherence to a modified version of Royal College of Surgeons of England guidelines. Method Baseline documentation of the 25 parameters of interest was assessed using electronic medical records for all emergency and pre-operative admissions over a 4-week period (n = 75). A new pro-forma was introduced, and the documentation over the following 4 weeks (n = 75) was assessed in the same way. Statistical analysis was done using Excel and RStudio (z-test for two proportions, p-value ≤ 0.05). Results The two groups were similar in age, gender, length of stay, and presenting complaint. The new pro-forma was completed for more admissions than the prior version (91% vs 77%) and resulted in documentation improvements in 19 out of 25 parameters. 9 of these were statistically significant, including initial vital signs and differential diagnosis. Parameters that improved, but not significantly, include admission source, medication history, and cognitive assessment. Across the 8 weeks, using a pro-forma (n = 126) significantly improved documentation of 11 parameters compared to freehand clerking (n = 24). Conclusions Adequate documentation at admission can help with immediate patient care, and act as a point of reference during extended stays. We were able to increase use of a pro-forma and produce meaningful documentation improvements quickly. Further work is required to assess why certain parameters are infrequently completed, and how future pro-forma iterations can become more user-friendly.

Creating and Validating a Predictive Model for Suitability of Hospital at Home for Patients With Solid-Tumor Malignancies

PURPOSE: Hospital at home (HaH) is a means of providing inpatient-level care at home. Selection of admissions potentially suitable for HaH in oncology is not well studied. We sought to create a predictive model for identifying admissions of patients with cancer, specifically solid-tumor malignancies, potentially suitable for HaH. METHODS: In this observational study, we analyzed admissions of patients with solid-tumor malignancies and unplanned admissions (January 1, 2015, to June 12, 2019) at an academic, urban cancer hospital. Potential suitability for HaH was the primary outcome. Admissions were considered potentially suitable if they did not involve escalation of care, rapid response evaluation, in-hospital death, telemetry, surgical procedure, consultation to a procedural service, advanced imaging, transfusion, restraints, and nasogastric tube placement. Admission source, patient demographics, vital signs, laboratory test results, comorbidities, admission and active cancer diagnoses, and recent hospital utilization were included as candidate variables in a multivariable logistic regression model. RESULTS: Of 3,322 admissions, 905 (27.2%) patients were potentially suitable for HaH. After variable selection in the derivation cohort (n = 1,097), thirteen factors predicted potential suitability: admission source; temperature and respiratory rate at presentation; hemoglobin; breast cancer, GI cancer, or malignancy of secondary or ill-defined origin; admission for genitourinary, musculoskeletal, or neurologic symptoms, intestinal obstruction or ileus, or evaluation of secondary malignancy; and emergency department visit in prior 90 days. Model c-statistics were 0.71 (95% CI, 0.68 to 0.75) and 0.63 (0.59 to 0.67) in the derivation and validation (n = 1,095) cohorts. CONCLUSION: Hospital admissions of patients potentially suitable for HaH may be identifiable using data available at admission.

Risk modifiers of acute respiratory distress syndrome in patients with non-pulmonary sepsis: a retrospective analysis of the FORECAST study

Background Predisposing conditions and risk modifiers instead of causes and risk factors have recently been used as alternatives to identify patients at a risk of acute respiratory distress syndrome (ARDS). However, data regarding risk modifiers among patients with non-pulmonary sepsis is rare. Methods We conducted a secondary analysis of the multicenter, prospective, Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome, Sepsis and Trauma (FORECAST) cohort study that was conducted in 59 intensive care units (ICUs) in Japan during January 2016–March 2017. Adult patients with severe sepsis caused by non-pulmonary infection were included, and the primary outcome was having ARDS, defined as meeting the Berlin definition on the first or fourth day of screening. Multivariate logistic regression modeling was used to identify risk modifiers associated with ARDS, and odds ratios (ORs) and their 95% confidence intervals were reported. The following explanatory variables were then assessed: age, sex, admission source, body mass index, smoking status, congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, steroid use, statin use, infection site, septic shock, and acute physiology and chronic health evaluation (APACHE) II score. Results After applying inclusion and exclusion criteria, 594 patients with non-pulmonary sepsis were enrolled, among whom 85 (14.3%) had ARDS. Septic shock was diagnosed in 80% of patients with ARDS and 66% of those without ARDS (p = 0.01). APACHE II scores were higher in patients with ARDS [26 (22–33)] than in those without ARDS [21 (16–28), p < 0.01]. In the multivariate logistic regression model, the following were independently associated with ARDS: ICU admission source [OR, 1.89 (1.06–3.40) for emergency department compared with hospital wards], smoking status [OR, 0.18 (0.06–0.59) for current smoking compared with never smoked], infection site [OR, 2.39 (1.04–5.40) for soft tissue infection compared with abdominal infection], and APACHE II score [OR, 1.08 (1.05–1.12) for higher compared with lower score]. Conclusions Soft tissue infection, ICU admission from an emergency department, and a higher APACHE II score appear to be the risk modifiers of ARDS in patients with non-pulmonary sepsis.

Developing a standardised approach to the aggregation of inpatient episodes into person-based spells in all specialties and psychiatric specialties

Background Electronic health record (EHR) data are available for research in all UK nations and cross-nation comparative studies are becoming more common. All UK inpatient EHRs are based around episodes, but episode-based analysis may not sufficiently capture the patient journey. There is no UK-wide method for aggregating episodes into standardised person-based spells. This study identifies two data quality issues affecting the creation of person-based spells, and tests four methods to create these spells, for implementation across all UK nations. Methods Welsh inpatient EHRs from 2013 to 2017 were analysed. Phase one described two data quality issues; transfers of care and episode sequencing. Phase two compared four methods for creating person spells. Measures were mean length of stay (LOS, expressed in days) and number of episodes per person spell for each method. Results 3.5% of total admissions were transfers-in and 3.1% of total discharges were transfers-out. 68.7% of total transfers-in and 48.7% of psychiatric transfers-in had an identifiable preceding transfer-out, and 78.2% of total transfers-out and 59.0% of psychiatric transfers-out had an identifiable subsequent transfer-in. 0.2% of total episodes and 4.0% of psychiatric episodes overlapped with at least one other episode of any specialty. Method one (no evidence of transfer required; overlapping episodes grouped together) resulted in the longest mean LOS (4.0 days for all specialties; 48.5 days for psychiatric specialties) and the fewest single episode person spells (82.4% of all specialties; 69.7% for psychiatric specialties). Method three (evidence of transfer required; overlapping episodes separated) resulted in the shortest mean LOS (3.7 days for all specialties; 45.8 days for psychiatric specialties) and the most single episode person spells; (86.9% for all specialties; 86.3% for psychiatric specialties). Conclusions Transfers-in appear better recorded than transfers-out. Transfer coding is incomplete, particularly for psychiatric specialties. The proportion of episodes that overlap is small but psychiatric episodes are disproportionately affected. The most successful method for grouping episodes into person spells aggregated overlapping episodes and required no evidence of transfer from admission source/method or discharge destination codes. The least successful method treated overlapping episodes as distinct and required transfer coding. The impact of all four methods was greater for psychiatric specialties.

Factors Associated With Clinical Deterioration Among Patients Hospitalized on the Wards at a Tertiary Cancer Hospital

PURPOSE: Patients hospitalized outside the intensive care unit (ICU) frequently experience clinical deterioration. Little has been done to describe the landscape of clinical deterioration among inpatients with cancer. We aimed to describe the frequency of clinical deterioration among patients with cancer hospitalized on the wards at a major academic hospital and to identify independent risk factors for clinical deterioration among these patients. METHODS: This was a retrospective cohort study at a 1,300-bed urban academic hospital with a 138-bed inpatient cancer center. We included consecutive admissions to the oncology wards between January 1, 2014, and June 30, 2017. We defined clinical deterioration as the composite of ward death and transfer to the ICU. RESULTS: We evaluated 21,219 admissions from 9,058 patients. The composite outcome occurred during 1,945 admissions (9.2%): 1,365 (6.4%) had at least one ICU transfer, and 580 (2.7%) involved ward death. Logistic regression identified several independent risk factors for clinical deterioration, including the following: age (odds ratio [OR], 1.33 per decade; 95% CI, 1.07 to 1.67), male sex (OR, 1.15; 95% CI, 1.05 to 1.33), comorbidities, illness severity (OR, 1.11; 95% CI, 1.10 to 1.13), emergency admission (OR, 1.45; 95% CI, 1.26 to 1.67), hospitalization on particular wards (OR, 1.525; 95% CI, 1.326 to 1.67), bacteremia (OR, 1.24; 95% CI, 1.01 to 1.52), fungemia (OR, 3.76; 95% CI, 1.90 to 7.41), tumor lysis syndrome (OR, 3.01; 95% CI, 2.41 to 3.76), and receipt of antimicrobials (OR, 2.04; 95% CI, 1.72 to 2.42) and transfusions (OR, 1.65; 95% CI, 1.42 to 1.92). CONCLUSION: Clinical deterioration was common; it occurred in more than 9% of admissions. Factors independently associated with deterioration included comorbidities, admission source, infections, and blood product transfusion.

Effect of Pharmacy-Driven Bedside Discharge Medication Delivery Program on Day 30 Hospital Readmission

Background: Previous studies demonstrated that transitions of care bundles, which include bedside discharge medication delivery (BDMD), may be helpful in decreasing hospital readmissions. Objective: To evaluate the effects of BDMD alone on day 30 readmission rates. Methods: Retrospective, cohort study comparing those who received pharmacy-driven BDMD to usual discharge. Primary outcome was day 30 readmission rates. Multivariable logistic regression was used to account for baseline differences between groups. Results: A total of 30916 patients met inclusion and exclusion criteria. Of those, 2253 (7%) received BDMD and 28663 (93%) received usual care. Significant differences in age, distance from hospital, race, marital status, insurance type, previous hospitalizations, admission source, baseline comorbidities, and medication counts were observed between groups. Patients who received BDMD were less likely to have day 30 readmissions (10.6% vs 12.8%, P = .002). However, after adjusting for baseline characteristics, BDMD was not an independent predictor of day 30 readmission (adjusted odds ratio = 0.91, 95% confidence interval = 0.79-1.04, P = .17). BDMD was associated with decreased day 14 readmissions in an unadjusted analysis. Conclusions: BDMD was not independently associated with a reduction in day 30 readmissions. Future studies should focus on targeting patients who are most likely to benefit from this service.

Heterogeneity in Medicare Home Health Patients by Admission Source

Unlike other post-acute care settings, a large and growing share of Medicare Fee-For-Service patients are admitted to home health without a prior hospitalization or facility-based post-acute stay. Differences in home health patients by admission source have implications for standardizing measurement, and potentially payment, across post-acute care settings. We examined home health patients’ demographic, health, and utilization patterns when stratified by their admission source. We found that community-admitted patients were more likely to be dually eligible, have multiple home health episodes, have Alzheimer disease, and have suffered from depression. Noncommunity admission sources were associated with higher 30-day post home health admission hospitalization rates. These differences should be accounted for in properly incentivizing agencies to care for all types of patients appropriate for home health.

2082 Profile of pediatric potentially avoidable transfers

OBJECTIVES/SPECIFIC AIMS: While hospital-hospital transfers of pediatric patients is often necessary, some pediatric transfers are potentially avoidable. Pediatric potentially avoidable transfers (PAT) represent a process with high costs and safety risks but few, if any, benefits. To better understand this issue, we described pediatric inter-facility transfers with early discharges. METHODS/STUDY POPULATION: We conducted a descriptive study using electronic medical record data at a single-center over a 12-month period to examine characteristics of pediatric patients with a transfer admission source and early discharge. Among patients with early discharges, we performed descriptive statistics for PAT defined as patient transfers with a discharge home within 24 hours without receiving any specialized tests, interventions, consultations, or diagnoses. RESULTS/ANTICIPATED RESULTS: Of the 2414 pediatric transfers 31.2% were discharged home within 24 hours. Among transferred patients with early discharges, 348 patients (14.4% of total patient transfers) received no specialized tests, interventions, consultations, or diagnoses. Direct admissions were categorized as PAT 2.2-fold more frequently than transfers arriving to the emergency department. Among transferred direct admissions, PAT proportions to the neonatal intensive care unit (ICU), pediatric ICU, and non-ICU were 5.8%, 17.4%, and 27.3%, respectively. Respiratory infections, asthma, and fractures were the most common PAT diagnoses. DISCUSSION/SIGNIFICANCE OF IMPACT: Early discharges and PAT are relatively common among transferred pediatric patients. Further studies are needed to identify the etiologies and clinical impacts of PAT, with a focus on direct admissions given the high frequency of PAT among direct admissions to both the pediatric ICU and non-ICU.