Out-of-Hospital Emergencies in Children Under Palliative Home Care

Introduction: Specialized palliative home care (SPHC) enables children and adolescents with life-limiting illnesses and complex needs to receive care at home. In addition to controlling symptoms and stabilizing the psychosocial situation, crisis anticipation is a component of SPHC. Since the establishment of the reporting SPHC team, parents have called for additional help from emergency medical services (EMS) in emergency situations with unexpected frequency. Children with life limiting diseases could undergo invasive procedures and unhelpful treatments with uncertain consequences. The questions arose as to which factors led to the involvement of the EMS in a palliative situation, what therapy was performed and what outcome could be reached.Methods: Records of the pediatric SPHC patients and EMS call-outs in these children of the reporting SPHC-team in the central region of Hesse, Germany (population: 1.1 million) were retrospectively analyzed from 01.11.2014 to 01.05.2021. The causes of the call-outs, the existence of an emergency agreement, the National Advisory Committee for Aeronautics (NACA) score, EMS therapy and outcome were examined. Patient data included age, palliative-justifying diagnosis, duration and intensity of care, place of death and median overall survival (MOS) and palliative SHPC treatment.Results: In total, 172 patients were analyzed during the study period. There were 27 EMS calls for a total of 20 patients/families (= EMS group). Palliative illness or a complication was the most frequent cause of call-outs. The patients in the EMS group were significantly less likely to have a DNR order, required more home visits and telephone calls and were under SPHC care for longer. There was a significantly higher proportion of crisis interventions at home visits. The children in the EMS group died less often from the underlying disease. Of the remaining 152 patients (= non-EMS group), a significantly higher proportion had a European home country.Conclusions: Despite the introduction of the SPHC, parents still call the EMS. Good cooperation and joint training should be sought to prepare all those involved for future call-outs.

Responsible innovation in health and health system sustainability: Insights from health innovators’ views and practices

Although healthcare managers make increasingly difficult decisions about health innovations, the way they may interact with innovators to foster health system sustainability remains underexplored. Drawing on the Responsible Innovation in Health (RIH) framework, this paper analyses interviews ( n=37) with Canadian and Brazilian innovators to identify: how they operationalize inclusive design processes; what influences the responsiveness of their innovation to system-level challenges; and how they consider the level and intensity of care required by their innovation. Our qualitative findings indicate that innovators seek to: 1) engage stakeholders at an early ideation stage through context-specific methods combining both formal and informal strategies; 2) address specific system-level benefits but often struggle with the positioning of their solution within the health system; and 3) mitigate staff shortages in specialized care, increase general practitioners’ capacity or patients and informal caregivers’ autonomy. These findings provide empirical insights on how healthcare managers can promote and organize collaborative processes that harness innovation towards more sustainable health systems. By adopting a RIH-oriented managerial role, they can set in place more inclusive design processes, articulate key system-level challenges, and help innovators adjust the level and intensity of care required by their innovation.

220 Electrocardiographic findings and mortality in COVID-19 patients hospitalized in different clinical settings

Aims 12-lead electrocardiogram (ECG) still represents the first line approach for cardiovascular assessment even in patients with COVID-19. We therefore sought to describe and compare ECG findings in three different hospital settings: intensive care unit (ICU) (invasive ventilatory support), respiratory care unit (RCU) (non-invasive ventilatory support) and Covid-19 dedicated internal medicine unit (IMU) (oxygen supplement with or without high flow). Methods and results We retrospectively analysed the 12-lead ECGs of 1124 consecutive patients hospitalized for respiratory distress and COVID-19 in a single III level hospital. Age, gender, main clinical data and in-hospital survival were recorded. 548 patients were hospitalized in IMU, 361 in RCU, 215 in ICU. Arrhythmias in general were less frequently found in RCU (16% vs. 26%, P < 0.001). Deaths occurred more frequently in ICU patients (43% vs. 20–21%, P < 0.001). After pooling predictors of mortality (age, intensity of care setting, heart rate, ST-elevation, QTc prolongation, Q-waves, right bundle branch block, and atrial fibrillation), the risk of in-hospital death can be estimated by using a derived score. Three zones of mortality risk can be thus identified: <5%, score <5 points; 5–50% score 5–10, and >50%, score >10 points. The accuracy of the score assessed at ROC curve analysis was 0.791. Conclusions ECG differences at admission con be found in COVID-19 patients according to different clinical settings and intensity of care. A simplified score derived from few clinical and ECG variables may predict in-hospital mortality with a good accuracy.

Caregiving Intensity and Psychosocial Impact of COVID-19 in Dementia and Non-Dementia Caregivers

COVID-19 has adversely impacted the well-being of informal caregivers (CG) due to infection risk, changes to the home environment, and changes to resource availability. CG of persons living with dementia (PLWD) may be especially vulnerable due to the intensity of care provided. We compared CG activities and well-being among CG who did and did not care for PLWD during COVID-19. We conducted an anonymous online survey from April 2020-present. Respondents self-identified as 18+ years and CG to a child or adult with mental health or medical conditions. CG answered questions regarding hours of care provision and caregiving activities, and completed measures of CG burden (Zarit Burden Inventory-4), loneliness (UCLA Loneliness Scale), depressive symptoms (Patient Health Questionnaire), and anxiety (Generalized Anxiety Disorder-2). Of the 258 respondents within the United States, 86 cared for PLWD (33%; 88% female; 56±12 years) while 172 did not (66%; 87% female; 49±14 years). Compared to non-dementia CGs, more CGs of PLWD provided 40+ hours of caregiving/week (36% vs. 49%, p<.05), performed more caregiving activities (8.5 vs. 10.5, p<.01), and assisted with more activities of daily living (55% vs. 73%, p<.01). Compared to non-dementia CG, more dementia CG reported CG burden (53% vs. 67%; p<.05) and loneliness (7.3 vs. 9.1, p<.05). No differences in depressive symptoms or anxiety were found. Results suggest that existing needs of CG of PLWD may be exacerbated by the stressors and concerns of the pandemic, necessitating higher levels of support.

Facility Characteristics Associated With Intensity of Care of Nursing Home Residents With Advanced Dementia

Profound variations in care intensity of nursing home (NH) residents with advanced dementia exist for NHs within and across hospital referral regions (HRRs). Little is known about how these levels of influence relate. Nationwide 2016-2017 Minimum DataSet was used to categorize NHs and HRRs into 4 levels of care intensity based on hospital transfer and tube-feeding rates among residents with advanced dementia: low intensity NH in low intensity HRR; high intensity NH in low intensity HRR; low intensity NH in high intensity HRR; and high intensity NH in high intensity HRR. We used multinomial logistic regression to identify NH characteristics associated with belonging to each of 4-levels of intensity as compared to low intensity NH in low intensity HRRs (reference). We found high intensity NHs in high intensity HRRs were more likely to be in an urbanized area, not have an dementia unit, have an NP/PA on staff, have a higher proportion of residents who were male, age <65, of Black race, and had pressure ulcers, and relatively fewer days on hospice. Whereas in low intensity HRRs, higher proportion of Black residents was the only characteristic associated with being a high intensity NH. These findings suggest potentially modifiable factors within high intensity HRRs that could be targeted to reduce burdensome care, including having a dementia unit, palliative care training for NP/PAs, or increased use of hospice care. This study underscores the critical need to better understand the role race plays in the intensity of care of NH residents with dementia.

Parents’ preferences for follow-up care in a type 1 diabetes paediatric population: a survey-based study in Quebec, Canada

ObjectivesExamine variations in parent’s preferences for their child’s type 1 diabetes (T1D) follow-up care and the determinants of the preferred intensity of care. Clinical guidelines recommend multidisciplinary management of T1D, with follow-up visits with an endocrinologist at least every 3 months in the paediatric population. However, there could be heterogeneity in parents’ needs, and preferences in terms of care management may deviate from clinical guidelines.SettingNot applicable.ParticipantsParents who have a child living with T1D and who reside in Quebec, Canada.InterventionIn collaboration with a patient-partner (a parent of a child with T1D), we developed a survey to collect data from parents of children living with T1D. Our primary outcome of interest was the preferred time in months between two appointments. We ran a probit model to analyse longer time (over 3 months between appointments), compared with the standard of care (3 months or less).ResultsResults suggest that about one-third (33%) of parents want to deviate from the guideline. Parents who want to increase the time between appointments are more experienced in the management of the disease and have higher costs than those who wish to follow the 3-month guideline. The number of years since the diagnosis is positively associated with a preference for a longer time between appointments, while the perceived useful of information provided during the consultation, and a parent having made a change in their professional life were negatively associated with a desire to space out appointments. The child’s gender is not a significant factor in parents’ preferences.ConclusionsAdapting visit protocols could make the health system more efficient to respond to T1D patients and their parent’s needs.

The COVID-19 Assessment for Survival at Admission (CASA) Index: A 12 Months Observational Study

Objective: Coronavirus disease 2019 (COVID-19) is a disease with a high rate of progression to critical illness. However, the stratification of patients at risk of mortality is not well defined. In this study, we aimed to define a mortality risk index to allocate patients to the appropriate intensity of care.Methods: This is a 12 months observational longitudinal study designed to develop and validate a pragmatic mortality risk score to stratify COVID-19 patients aged ≥18 years and admitted to hospital between March 2020 and March 2021. Main outcome was in-hospital mortality.Results: 244 patients were included in the study (mortality rate 29.9%). The Covid-19 Assessment for Survival at Admission (CASA) index included seven variables readily available at admission: respiratory rate, troponin, albumin, CKD-EPI, white blood cell count, D-dimer, Pa02/Fi02. The CASA index showed high discrimination for mortality with an AUC of 0.91 (sensitivity 98.6%; specificity 69%) and a better performance compared to SOFA (AUC = 0.76), age (AUC = 0.76) and 4C mortality (AUC = 0.82). The cut-off identified (11.994) for CASA index showed a negative predictive value of 99.16% and a positive predictive value of 57.58%.Conclusions: A quick and readily available index has been identified to help clinicians stratify COVID-19 patients according to the appropriate intensity of care and minimize hospital admission to patients at high risk of mortality.

دلالة تربوية في مجـــيء الاسم ظاهرًا وضميرًا في أحاديث الأربعين النووية

This research aims to study the educational significance of the advent of an explicit noun and implicit noun in the Hadiths of al-Arba'in al-Nawawi which represents a problem among readers to understand deeply the meaning of Hadith. This research described an explicit noun and implicit noun and analyzed it from syntactic and educational semantic sides. The study has reached some results: An explicit noun indicated concern and care, signify specialization and honor. An implicit noun came to show concealment, to attract attention and proximity, to specialize and intensity of care and attention. للاسم في اللغة العربية ثلاثة صور من حيث الخصوص، إما أن يأتي اسمًا ظاهرًا، وإما أن يأتي مضمرًا وإما أن يأتي مبهمًا. يهدف هذا البحث إلى إبراز دلالة تربوية في مجيء الاسم اسما ظاهرا ومضمرًا في أحاديث الأربعين النووية التي تمثل مشكلةً لدى كثير من القراء لفهمها فهمًا دقيقًا ولأجل مساعدة المجتمع الماليزي في فهم النصوص النبوية من خلال الدعاة والمهتمين بشرح أحاديث الأربعين النووية في المساجد والمدارس. وقد قام البحث على المنهج الوصفي التحليلي حيث قام بوصف المفعول به وتحليله تحليلاً نحويا دلاليًا تربويا اعتمادًا على آراء العلماء في النحو والدلالة والحديث. وقد توصلت الدراسة إلى بعض النتائج المهمة وهي: أن قد ورد الاسم اسما ظاهرا للدلالة على الاهتمام والعناية، وعلى التخصيص، وعلى التعظيم والتشريف. وجاء الاسم ضميرًا للدلالة على الإخفاء، وجذب الانتباه والقربة، والتخصيص وشدة الاعتناء والاهتمام. وأملي أن يكون جهدي المتواضع هذا قد قدّم ما يؤهله للانضمام إلى مسيرة ‏البحث الأكاديمي ويستفيد الباحثون من الدعاة والمهتمين بشرح الأحاديث النبوية الشريفة ويراعون الدلالات الخاصة بكلام النبي صلى الله عليه وسلم عندما يخاطبون قلوب المجتمع الماليزي للإرتقاء به والحفاط عليه. الكلمات الافتتاحية : دلالة تربوية ، الاسم الظاهر، الضمير، أحاديث الأربعين النووية.