Derivation and Validation of a Model to Predict 30-Day Readmission in Surgical Patients Discharged to Skilled Nursing Facility

ObjectivesTo identify factors associated with 30-day all-cause readmission rates in surgical patients discharged to skilled nursing facilities (SNFs), and derive and validate a risk score.DesignRetrospective cohort.Setting and participantsPatients admitted to 1 tertiary hospital's surgical services between January 1, 2011, and December 31, 2014 and subsequently discharged to 110 SNFs within a 25-mile radius of the hospital. The first 2 years were used for the derivation set and the last 2 for validation.MethodsData were collected on 30-day all cause readmissions, patient demographics, procedure and surgical service, comorbidities, laboratory tests, and prior health care utilization. Multivariate regression was used to identify risk factors for readmission.ResultsDuring the study period, 2405 surgical patients were discharged to 110 SNFs, and 519 (21.6%) of these patients experienced readmission within 30 days. In a multivariable regression model, hospital length of stay [odds ratio (OR) per day: 1.03, 95% confidence interval (CI) 1.02-1.04], number of hospitalizations in past year (OR 1.24 per hospitalization, 95% CI 1.18-1.31), nonelective surgery (OR 1.33, 95% CI 1.18-1.65), low-risk service (orthopedic/spine service) (OR 0.32, 95% CI 0.25-0.42), and intermediate-risk service (cardiothoracic surgery/urology/gynecology/ear, nose, throat) (OR 0.69, 95% CI 0.53-0.88) were associated with all-cause readmissions. The model had a C index of 0.71 in the validation set. Using the following risk score [0.8 × (hospital length of stay) + 7 × (number of hospitalizations in past year) +10 for nonelective surgery, +36 for high-risk surgery, and +20 for intermediate-risk surgery], a score of >40 identified patients at high risk of 30-day readmission (35.8% vs 12.6%, P < .001).Conclusions/ImplicationsAmong surgical patients discharged to an SNF, a simple risk score with 4 parameters can accurately predict the risk of 30-day readmission.     

京津冀地区自建设施供水单位水质卫生学调查

目的了解京津冀地区自建设施供水单位的水质现状,分析存在的风险指标。方法于2015年对108家自建设施供水单位的基本情况进行调查,并采集出厂水进行水质检测。结果京津冀地区自建设施供水单位多以深井水为水源,48%(52/108)的单位未采取水处理措施,26.8%(29/108)的单位采取了消毒措施,超过1/2的自建设施供水单位日供水能力在500 t以下。氟化物、硝酸盐氮合格率分别为67.6%(73/108)和86.1%(96/108)。结论本次调查的京津冀地区自建设施供水单位的供水规模大多较小,供水水质与水源地质因素和处理工艺落后有关。     

Nursing Home Social Services and Post-Acute Care: Does More Qualified Staff Improve Behavioral Symptoms and Reduce Antipsychotic Drug Use?

ObjectivesAn increasing number of post-acute care patients are admitted to skilled nursing facilities (SNFs) with behavioral symptoms such as wandering and rejecting care, which can interfere with care and place a patient at risk of social isolation or injury. This study examines whether increasing the qualifications of social service staff through using a greater proportion of qualified social workers (QSWs) instead of paraprofessionals improves patients' behavioral symptoms and reduces the use of antipsychotic medications.DesignSecondary data analysis of national data drawn from the Minimum Data Set, Medicare Beneficiary Summary File, and Certification and Survey Provider Enhanced Reporting surveys.Setting and participantsNewly admitted, Medicare fee-for-service patients aged ≥65 years who received post-acute care after a hospitalization from 2011-2015 (1,201,096 patient admissions in 5383 unique SNFs).MethodsA regression discontinuity approach is used to identify how changes in the qualifications of social service staffing affect changes in patient outcomes, through exploiting a federal regulation that requires 1 full-time QSW for SNFs with at least 121 beds.ResultsSNFs with a greater proportion of QSWs improved behavioral symptoms that affected residents or others and reduced the use of antipsychotic medications. Marginally significant improvements were also found in patients' rejecting care, wandering, and having any behavioral symptoms. There was no statistically significant change in delusions.Conclusions and implicationsAlthough the focus of most research and effects on improving patient outcomes in SNFs has focused on nursing staff, our results underscore the importance of staffing in social services. Specifically, social service staff with higher qualifications are integral to improving care through reducing patients' behavioral symptoms and avoiding the use of antipsychotic medications. It may be time for SNFs to revisit efforts to improve staffing in social services.     

基层医疗卫生机构居家护理服务的安全支持和医务人员服务意愿调查研究

背景 人口老龄化趋势下，罹患多种慢性病的失能或半失能老年人对居家医疗护理服务需求迫切，但基层医务人员提供居家医疗护理服务存在较大的医疗风险和安全隐患，加强居家医疗护理服务的安全管理，有利于提高基层医务人员提供居家医疗护理服务的意愿。 目的 调查基层医疗卫生机构对居家护理服务的安全支持情况和医务人员的服务意愿，为进一步推动居家医疗护理服务发展提供参考依据。 方法 2021年8—10月，采用便利抽样法在四川省五大经济区抽取49所基层医疗卫生机构的1 131例医务人员。自行设计调查问卷，以"问卷星"电子问卷的形式收集资料。问卷内容包括医务人员的一般情况（8个条目）、提供居家医疗护理服务的经历（2个条目）、医疗机构对医务人员的安全支持（7个条目）、医务人员的居家医疗护理服务意愿（1个条目）。比较不同特征医务人员提供居家医疗护理服务的意愿，采用二元Logistic回归分析医务人员提供居家医疗护理服务意愿的影响因素。 结果 1 131例基层医务人员中，692例（61.18%）报告有过居家医疗护理服务的经历，193例（17.06%）报告在服务过程中发生过不良事件/安全事件，531例（46.95%）报告其所在医疗机构未评估过患者接受居家医疗护理服务的安全风险，199例（17.60%）表示所在机构评估了医务人员提供居家医疗护理服务的安全风险，299例（26.44%）在居家医疗护理服务过程中使用APP定位系统，273例（24.14%）由机构配备报警、延迟预警等设备，807例（71.35%）表示居家医疗护理服务过程中没有获得所在机构内其他医务人员的支持措施，303例（26.79%）表示机构曾组织居家医疗护理服务的专项研讨活动，352例（31.12%）表示接受过有关居家医疗护理服务专项培训，853例（75.42%）表示愿意提供居家医疗护理服务。二元Logistic回归分析结果显示，就职的基层医疗卫生机构类型，目前受聘的专业技术职称，医疗机构是否评估过患者接受居家医疗护理服务的安全风险，在居家医疗护理服务过程中是否配备报警、延迟预警等设备，是否参加过有关居家医疗护理服务的专项培训，对医务人员提供居家医疗护理服务意愿有影响（P<0.05）。 结论 现阶段居家医疗护理服务的安全支持不足，多种因素影响基层医务人员提供居家医疗护理服务的意愿。基层医疗卫生机构应加强对患者接受居家医疗护理服务安全风险的评估，为提供居家医疗护理服务的医务人员配备报警、延迟预警等设备，积极举办居家医疗护理服务相关的专项培训并鼓励医务人员参加，以降低医务人员提供居家医疗护理服务的风险，保障其人身安全。