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Wir freuen uns, Ihnen in unserer Rubrik LeseEcke des Departements für Pflegewissenschaft und Gerontologie diesmal folgende Literaturübersicht anbieten zu können:
Impact of the COVID-19 Pandemic on Therapy and Outcome of Acute Exacerbations of Chronic Obstructive Lung Disease at the Emergency Department
Autor*innen: Verena Fuhrmann, Bettina Wandl, Anton N. Laggner, Dominik Roth
Quelle: https://doi.org/10.3390/healthcare12060637
Abstract
This study compared the treatment outcomes of acute exacerbation of COPD (AECOPD) at an academic tertiary care emergency department before and during the COVID-19 pandemic. Analyzing data from 976 patients, our study showed a significant surge in overall respiratory therapy interventions amidst the noticeable decline in the total number of AECOPD cases during the pandemic. The marked increase in the utilization of non-invasive ventilation (NIV) was particularly important, soaring from 12% to 18% during the pandemic. Interestingly, this heightened reliance on NIV stood in contrast to the stability observed in other therapeutic modalities, including oxygen insufflation alone, high-flow nasal cannulas, and invasive ventilation. This distinctive treatment pattern underscores the adaptability of healthcare providers in the face of novel challenges, with a discernible emphasis on the strategic utilization of NIV. The shift in patient acuity during the pandemic became evident as the data showed a cohort of individuals presenting with AECOPD who were more severely ill. This was reflected in the increased use of NIV and, notably, a statistically significant rise in one-year mortality rates—from 32% before the pandemic to 38% during the pandemic (p = 0.046). These findings underscore the intricate balance healthcare providers must strike in navigating the complexities of patient care during a public health crisis. A closer examination of the longitudinal trajectory revealed a subtle decrease in re-admission rates from 65% to 60%. The increased reliance on NIV, a key finding of this investigation, reflects a strategic response to the unique demands of the pandemic, potentially influenced by both medical considerations and non-medical factors, such as the prevalent “fear of aerosols” and the imperative to navigate transmission risks within the healthcare setting. These insights contribute to understanding the evolving dynamics of AECOPD management during public health crises.
Methods
We conducted a retrospective chart review investigating the temporal dynamics of the COVID-19 pandemic’s impact on healthcare delivery. The study period encompassed the initial wave of the pandemic, spanning from 15 March 2020 to 14 March 2021, and was compared with the corresponding time frame exactly one year prior, extending from 15 March 2019 to 14 March 2020. To ensure a thorough understanding of the long-term implications, all patients were followed up for a duration of one year. In adherence to robust research methodologies, our study findings are presented in accordance with the REporting of studies Conducted using Observational Routinely collected health Data (RECORD) Statement, an extension that augments the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement [13]. The study was approved by our local institutional review board. The study setting was a 2300-bed tertiary care university hospital, which is the largest of seven public hospitals in a city with 1.9 million inhabitants. The Department of Emergency Medicine is a pivotal component of this healthcare center and shoulders the responsibility for the treatment of all medical emergencies in adult patients. The department is divided into three parts, including an intensive care unit consisting of seven positions, a seven-bed intermediate care unit, and an outpatient clinic, each tailored to meet the diverse medical needs of the patient population. Patient triage, a critical facet in the emergency care continuum, is expertly handled by qualified nurses who employ the internationally recognized Emergency Severity Index (ESI). This stratification system categorizes patients into five groups, ranging from 1 (life-threatening) to 5 (no medical resources needed) [14]. Collaborative care is a cornerstone of the department’s operational philosophy and sees physicians working in tandem with consultant physicians from various specialties such as ENT, surgery, orthopedics, and others, ensuring a thorough approach to patient well-being. In the context of the Austrian healthcare landscape, characterized by a universal healthcare system, our study benefits from insights derived within a framework that ensures healthcare coverage for all, including hospitalization, outpatient care, and ambulance services. Noteworthy is the absence of regulations dictating the level of care, allowing patients the autonomy to choose their preferred level of care without the need to navigate through a general practitioner or any other intermediary healthcare provider.
Results
A total of 976 patients were treated for AECOPD over the whole study period. Total visits decreased by 32% from 580 before the pandemic to 396 during the pandemic. There were no relevant differences regarding gender (295 (51%) male patients before and 218 (55%) during the pandemic) or age (median age 70 years; inter-quartile range (IQR) 63–77 before and 72 years (IQR 65–79) after; overall, four patients were younger than 40 years, 19 were between 40–49, 123 were between 50–59, 295 were between 60–69, 369 were between 70–79, 139 were between 80–89, and 27 were 90 years or older), nor regarding previous LTOT therapy (see Table 1). Interestingly, despite the aforementioned regulations being in place, there was also no change in means of arrival (66% walk-ins before, 65% after).
Comparing treatment before and during the pandemic, there was a significant increase in the number of patients requiring some form of respiratory support. This spectrum of support encompasses a range from oxygen insufflation to invasive ventilation, revealing a statistically significant rise from 71% to 80% (p = 0.001). Additionally, a significant rise is observed in the subset of patients receiving non-invasive ventilation support, with the percentage increasing from 12% before the pandemic to 18% during the pandemic (p = 0.01). Notably, however, there were no substantial differences concerning oxygen insufflation alone (49% vs. 51%), HFNC utilization (3% vs. 3%), or the application of invasive ventilation (7% vs. 8%). A detailed graphical representation can be found in Figure 2. Regarding patients diagnosed with COVID-19, six (60%) needed oxygen insufflation (WHO ordinal scale category 4), one patient (10%) received NIV and HFNC therapy (WHO category 5), respectively, and none needed invasive ventilation. Within the emergency department (ED), a marked change is observed in the proportion of patients admitted to the department’s own Intensive Care Unit (ICU), surging significantly from 39% before the pandemic to 64% during the pandemic (p < 0.001). This shift underscores the evolving dynamics and heightened acuity of cases necessitating specialized critical care within the ED during the pandemic era. Regarding further treatment after a stay at the ED, there was no change in boarding time (median 280 min, IQR 146–557 vs. 283 min, 181–515), the percentage of those who could be discharged (3.6 vs. 3.8%), those who had to be admitted to a regular ward (90 vs. 89%), or those who had to be treated at an ICU (7 vs. 8%). The length of stay experienced only a marginal increase, with a mere seven-minute difference, as the mean time at the ED extended from 6 h 33 min before the pandemic to 6 h 40 min during the pandemic (Figure 3). The mean boarding time of COVID-19 patients was 164 min.
Conclusion
In the complex field of healthcare dynamics during the COVID-19 pandemic, a noticeable and statistically significant decline was observed in the overall number of patients seeking treatment for AECOPD. Our findings highlight some of the changes that occurred in patient flow into the ED. Within a diminished patient cohort, a compelling shift in clinical acuity emerged, with patients manifesting a more severe illness profile. This heightened severity manifested in the augmented utilization of NIV and a notably discernible increase in one-year mortality rates. These nuanced shifts underscore the multifaceted challenges faced by both patients and healthcare providers within the evolving landscape of the pandemic. It becomes evident that the healthcare providers’ decisions were likely shaped by a complex interplay of diverse medical and non-medical factors. The observed increase in the employment of NIV as a therapeutic modality during the pandemic, coupled with the elevated one-year mortality rates, suggests a distinctive pattern that necessitates a more comprehensive exploration. While the observed trends are suggestive, drawing conclusive links between specific factors and treatment choices requires a more detailed examination.
Construct validity of the Braden scale in acute- and long-term care settings in Austria: A structural equation modeling analysis
Autor*innen: Petra Schumacher, Eduardto José Ferreira Santos, Bettina Wandl, Gerhard Müller
Quelle: https://doi.org/10.5430/jnep.v14n8p44
Objective
The Braden scale is frequently used to assess pressure ulcer risk in health care settings. Selected psychometric properties have been tested using various methods of classical test theory in international studies. However, limited information on construct validity is available. Aim was to determine if the Braden subscale items correlate with the construct pressure ulcer risk and whether the construct validity concerning the factor structure of the Braden scale is adequate in acute and long-term settings.
Methods
A quantitative design with secondary analysis of data from one acute (n = 328) and eight long-term care facilities (n = 311) in Austria was used to test construct validity. Data analysis included principal axis factor analysis with Promax rotation and assessment of internal consistency, followed by structural equation modeling.
Results
For the acute care setting, a structure equation model with two latent factors and for the long-term care setting with one latent factor was tested according to principal axis factoring results. The Braden subscale items correlated with the construct pressure ulcer risk. Almost all examined model fit indices were within recommended reference values. Thus, the construct validity of the Braden scale was adequate in both settings.
Conclusions
The factor structure in the acute care setting did not match that in the investigated long-term care setting. Further research regarding the construct validity of the Braden scale is therefore necessary.