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Mar 7, 2024

USACS Announces Annual Clinical Excellence Award Winners

CANTON, Ohio, March 7, 2024 – US Acute Care Solutions (USACS), the nation’s largest physician-owned provider of hospital-based emergency and inpatient medicine, is pleased to announce eight clinicians who have been named recipients of the National Clinical Governance Board’s (NCGB) Clinical Excellence Award. These recipients were honored during USACS’ annual Assembly meeting held in Denver, CO, last month. The Clinical Excellence Award was created to recognize outstanding clinical care by individual physicians and advanced practice providers (APPs) who do not serve in leadership or management roles and represent each USACS service line. Nominations are submitted year-round by clinical colleagues and are reviewed at the beginning of each calendar year. Recipients are selected and notified before the annual spring Assembly meeting. Congratulations to the following recipients of the 2024 Clinical Excellence Award: Matthew Baltz, MD, Bon Secours Memorial Regional Medical Center— Mechanicsville, VA Calen Hart, MD, AdventHealth Tampa—Tampa, FL Waleed Hussein, MD, Hazel Hawkins Memorial Hospital—Hollister, CA Omar Naji, MD, StoneSprings Hospital Center—Dulles, VA Ryan Nguyen, PA-C, Dell Children's Medical Center of Central Texas—Austin, TX James (Ian) Richardson, DO, Bon Secours Memorial Regional Medical Center—Mechanicsville, VA Nathan Scherer, DO, AdventHealth ER and Urgent Care at Meridian—Parker, CO Melissa Volpe, PA-C, Sentara Martha Jefferson Hospital—Charlottesville, VA National Director of Clinical Education and Vice Chair of the NCGB, Roya Caloia, DO, MPH, FACEP, shared, “These are the people you work alongside who make you want to be a better physician or APP. Their efforts and commitment to high-quality patient care remind you of why you chose to go into medicine in the first place. Congratulations to each recipient, I am honored to call each of you colleagues!” About USACS Founded by emergency medicine and inpatient physicians across the country, USACS is solely owned by its physicians and hospital system partners. The group is a national leader in integrated acute care, including emergency medicine, hospitalist, and critical care services. USACS provides high-quality care to approximately ten million patients annually across more than 400 programs and is aligned with many of the leading health systems in the country. Visit usacs.com for more. ### Media Contact Marty Richmond Corporate Communications Department US Acute Care Solutions 330.493.4443 x1406 [email protected]

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Case Study: Redesigning the Inpatient Case Management Team

The discharge planning arm of a patient’s hospital journey primarily lies with the patient’s case manager, a nurse who helps evaluate the patient’s discharge needs and collaborates on the best plan for the patient after discharge. The process for most patients is straightforward: they either go to another facility or gain some temporary support at home and connect with outpatient clinics.

At Boston Medical Center (BMC), however, the discharge planning process is complicated by its complex patient population, who may not have insurance, citizenship, or homes to discharge to. Delays in creating a safe discharge plan can result in unnecessary days in the hospital even after patients are medically cleared for discharge, resulting in unnecessary costs to our healthcare system, unavailable beds for those who need them, and frustration across staff.

Finding solutions to appropriately reduce length of stay and facilitate better throughput is top of mind for clinical operations — at BMC, our average morning occupancy was 98% on our Medical Surgical floors, for example, versus an industry target of just 80%. Further, every week, we identified at least 30–40 patients “stuck” in the hospital. Freeing these beds and back-filling them with new patients creates a significant financial opportunity associated with reducing length of stay.

The hospital’s Central Flow Unit (a team of physician, nursing, and administrative leaders that oversee and improve patient flow) partnered with our case management department to evaluate opportunities to support the team given the complexity of our patient population. We examined three core questions in consultation with other hospitals.

Should our case managers be responsible for discharge planning and utilization management, or split the tasks? Case management departments typically support both the discharge planning process and the utilization management function, which ensures appropriate payor reimbursement given the clinical profile of the patient. In different environments, case managers do both tasks or divide the responsibilities over two groups. Is a team-based, unit-based, or hybrid case management model most appropriate for our hospital’s needs? Case management can be structured to follow either a set number of beds (e.g., beds 1 – 20 on a unit) or a physician team (e.g., general medicine team). Both models have pros and cons that need to be assessed for each environment. Whereas some hospitals localize physician teams to specific units, this alignment was not the case at Boston Medical Center. What is the appropriate number of patients for a case manager to support? Based on the design of the unit vs. team-based alignment, and the inclusion or exclusion of utilization management, a hospital must determine how many patients a case manager can effectively support.

As a result, we designed a new discharge planning structure that has shown early success in reducing length of stay.

Context: What drove the redesign

We historically followed a unit-based structure where each case manager followed a set of beds — a maximum of 18 beds on a Medical Surgical unit — which facilitated strong relationships with patients’ families and other unit-based teams such as nursing. In this model, case managers were responsible for both the discharge planning and utilization management process.

Our physician teams were scattered across many units, increasing the number of case managers each physician team had to interact with, and likewise the number of physician teams each case manager had to interact with. In fact, a review of our data showed that our highest-volume teams were interacting with eight to nine case managers on average. This model created huge inefficiencies, and as they interacted with more case managers, patient length of stay also increased.

Balancing discharge planning and utilization management

After evaluating our systems, we chose a hybrid case management model — pairing the physician teams that were the most scattered with a team-based case manager, and assigning specific beds for the other case managers. This model requires more day-to-day management from leadership to distribute patients among case managers, but provides relief to the physician teams and case managers who were struggling with a high number of interactions.

Pre-COVID, we had settled on keeping the discharge planning and utilization management tasks associated with patients to one case manager. This was our incumbent model. It had synergies across the tasks, and it was also a team structure supported by half the institutions we consulted.

However, COVID-19 response necessitated that our case management department internally split the tasks. A central team managing denials and appeals took on the utilization management tasks for all patients in house, benefiting from the fact that we primarily cared for one diagnosis: COVID-19.

Anecdotally, our floor case managers appreciated the bandwidth to focus on discharge planning afforded by the split of responsibilities. We are now striving to maintain this split given the staff satisfaction.

Appropriate case mangement case load

Our final question concerned how many patients per case manager was appropriate to facilitate efficient and high-quality throughput. Our inquiry into the caseloads per case manager at other institutions quickly highlighted that our case managers were caring for significantly more patients — an average of 17 patients at BMC while the average at other hospitals was 12, accounting for differences in structures.

In the end, with the shift to team-based case management we reduced the case load for the case managers assigned to these teams, accounting for the fact that they will be spread out, an additional challenge in its own right. We maintained the case load for the other case managers, appreciating that they now could focus on discharge planning exclusively, bringing their case load on par with other institutions who have split functions.

Conclusions from case management redesign

Our decisions related to the structure of case management were anchored in additional recommendations meant to strengthen the processes and data systems within the department to make the environment that our case managers work in effective for them. Underscoring these efforts is collaboration across disciplines and strong, on-the-ground leadership ensuring these changes work for the front-line teams. We are assessing the impact of these changes with both qualitative and quantitative metrics and are excited for the potential these changes have for our patients and our staff — initial findings of 0.7 day reduction in LOS for teams in this new program compared to a baseline of five months indicate we are on the right path.

Boston Medical Center is a 514-bed hospital and houses the busiest emergency department in New England. In January 2019, we created the Central Flow Unit (CFU) which oversees patient flow and is co-led by physician, nursing and administrative leaders. The CFU, in collaboration with many stakeholders, has worked to improve patient flow and problems many hospitals encounter. Along the way, we have turned to the literature and our peers across the country to learn more about the challenges and progress against them. In the spirit of collaborating across institutions, we are sharing an inside look at some of our biggest successes in improving inpatient operations and care. Don’t forget to check out our other results in The Hospital Playbook series.

Neha Gaur is the senior director of inpatient operations and cancer care at Boston Medical Center. She co-leads the Central Flow Unit with nursing and physician partners. She graduated from the University of Pennsylvania and the Wharton School of Business with a master's degree in biotechnology, as well as bachelor of science and bachelor of arts degrees.

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• An Extended Stay A 64-year-old man with a number of health issues comes to the hospital because he is having trouble breathing. The care team helps resolve the issue, but forgets a standard treatment that causes unnecessary harm to the patient. A subsequent medication error makes the situation worse, leading a stay that is much longer than anticipated.
• Mutiny The behavior of a superior starts to put your patients at risk. What would you do? The University of Rochester’s Dr. Paul Griner presents the final installment in a series of case studies for the IHI Open School.
• On Being Transparent You are the CEO and a patient in your hospital dies from a medication error. What do you do next? The University of Rochester’s Dr. Paul Griner presents the fourth in a series of case studies.
• Locked In A cancer diagnosis leads to tears and heartache. But is it correct? Dr. Paul Griner, Professor Emeritus of Medicine at the University of Rochester, presents the third in a series of case studies for the IHI Open School.
• Confidentiality and Air Force One A difficult patient. A difficult decision. The University of Rochester’s Dr. Paul Griner presents the second in a series of case studies.
• The Protective Parent During a 50-year career in medicine, Dr. Paul Griner accumulated hundreds of patient stories. Most of his stories – including this case study "The Protective Parent" - are from the 1950s and 1960s, prior to what we now refer to as “modern medicine.”
• Advanced Case Study Between Sept. 30th and Oct. 14th, 2010, students and residents all over the world gathered in interprofessional teams and analyzed a complex incident that resulted in patient harm. Selected teams presented their work to IHI faculty during a series of live webinars in October.
• A Downward Spiral: A Case Study in Homelessness Thirty-six-year-old John may not fit the stereotype of a homeless person. Not long ago, he was living what many would consider a healthy life with his family. But when he lost his job, he found himself in a downward spiral, and his situation dramatically changed. John’s story is a fictional composite of real patients treated by Health Care for the Homeless. It illustrates the challenges homeless people face in accessing health care and the characteristics of high-quality care that can improve their lives.
• What Happened to Alex? Alex James was a runner, like his dad. One day, he collapsed during a run and was hospitalized for five days. He went through lots of tests, but was given a clean bill of health. Then, a month later, he collapsed again, fell into a deep coma, and died. His father wanted to know — what had gone wrong? Dr. John James, a retired toxicologist at NASA, tells the story of how he uncovered the cause of his son’s death and became a patient safety advocate.
• Improving Care in Rural Rwanda When Dr. Patrick Lee and his teammates began their quality improvement work in Kirehe, Rwanda, last year, the staff at the local hospital was taking vital signs properly less than half the time. Today, the staff does that task properly 95% of the time. Substantial resource and infrastructure inputs, combined with dedicated Rwandan partners and simple quality improvement tools, have dramatically improved staff morale and the quality of care in Kirehe.

Hospital Case Management: A Review: 2019-2022

Affiliations.

• 1 Mary McLaughlin Davis, DNP, MSN, ACNS-BC, NEA-BC, CCM, is a certified case manager, clinical nurse specialist, and senior director for Case Management Cleveland Clinic Main Campus and Akron General Hospital. She served as an executive board member of the Case Management Society of America from 2013 to 2019 and president from 2016 to 2018.
• 2 Colleen Morley, DNP, RN, CCM, CMC, CMCN, ACM-RN, FCM, is a certified case manager and the associate chief clinical operations officer, Care Continuum, University of Illinois Health System. She is president of Chicago Case Management Society of America, served on the national executive board of directors from 2019 to the present and is the national president elect.
• PMID: 35901252
• DOI: 10.1097/NCM.0000000000000565

Purpose/objectives: In June 2019, a Case Management Society of America (CMSA) task force published "The Practice of Hospital Case Management: A White Paper." This was an important first step to outline the value of hospital case managers (HCMs) and to put forward recommendations for how to operationalize a major change in most hospitals for how case managers can practice.The SARS-CoV2 (COVID-19) pandemic drastically changed the practice of all interdisciplinary work within hospitals. The White Paper recommended that HCMs follow a select patient population through the hospital. Hospital case manager leaders realized that HCMs can work remotely and communicate with patients because meeting them in person was not an option. Hospital case managers are still resistant to leaving the hospital unit-based model, even after they experienced the value of this concept during the height of the pandemic.

Primary practice setting: Acute care hospitals.

Findings/conclusions: The White Paper recommended separating HCMs from utilization management. One unintended consequence is the loss of necessary knowledge and competencies. These are related to compliance with the Centers for Medicare & Medicaid Services Conditions of Participation and regulatory mandates that can affect patient care and financial well-being. Hospital case manager leaders must stay current with these government requirements for hospitals and for all levels of care and keep the case managers informed, proficient, and fluent when coordinating the care of patients.

Implications for case management practice: Hospital case manager practice is evolving; change is the single constant in health care. This review of the CMSA Hospital Case Management Whitepaper demonstrates that in just three short years, the landscape of health care can change dramatically.Today's HCM leader must proactively address a multigenerational workforce, lack of title protection, and the COVID-19-induced "Great Resignation." The value of the HCM has never been more apparent as during the pandemic as the need to "empty beds" is critical, and the HCM is the professional who has the skill to provide efficient and patient-centered care coordination. The HCM leader practices positive leadership techniques that benefit the leader, the HCM, and most importantly the patient.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

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• Case Management
• United States

• Research article
• Open access
• Published: 14 November 2019

Organisational change in hospitals: a qualitative case-study of staff perspectives

• Chiara Pomare   ORCID: orcid.org/0000-0002-9118-7207 1 ,
• Kate Churruca 1 ,
• Janet C. Long 1 ,
• Louise A. Ellis 1 &
• Jeffrey Braithwaite 1  

BMC Health Services Research volume  19 , Article number:  840 ( 2019 ) Cite this article

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Organisational change in health systems is common. Success is often tied to the actors involved, including their awareness of the change, personal engagement and ownership of it. In many health systems, one of the most common changes we are witnessing is the redevelopment of long-standing hospitals. However, we know little about how hospital staff understand and experience such potentially far-reaching organisational change. The purpose of this study is to explore the understanding and experiences of hospital staff in the early stages of organisational change, using a hospital redevelopment in Sydney, Australia as a case study.

Semi-structured interviews were conducted with 46 clinical and non-clinical staff working at a large metropolitan hospital. Hospital staff were moving into a new building, not moving, or had moved into a different building two years prior. Questions asked staff about their level of awareness of the upcoming redevelopment and their experiences in the early stage of this change. Qualitative data were analysed using thematic analysis.

Some staff expressed apprehension and held negative expectations regarding the organisational change. Concerns included inadequate staffing and potential for collaboration breakdown due to new layout of workspaces. These fears were compounded by current experiences of feeling uninformed about the change, as well as feelings of being fatigued and under-staffed in the constantly changing hospital environment. Nevertheless, balancing this, many staff reported positive expectations regarding the benefits to patients of the change and the potential for staff to adapt in the face of this change.

Conclusions

The results of this study suggest that it is important to understand prospectively how actors involved make sense of organisational change, in order to potentially assuage concerns and alleviate negative expectations. Throughout the processes of organisational change, such as a hospital redevelopment, staff need to be engaged, adequately informed, trained, and to feel supported by management. The use of champions of varying professions and lead departments, may be useful to address concerns, adequately inform, and promote a sense of engagement among staff.

Peer Review reports

Change is a common experience in complex health care systems. Staff, patients and visitors come and go [ 1 ]; leadership, models of care, workforce and governing structures are reshaped in response to policy and legislative change [ 2 ], and new technologies and equipment are introduced or retired [ 3 ]. In addition to these common changes experienced throughout health care, the acute sector in many countries is constantly undergoing major changes to the physical hospital infrastructure [ 4 , 5 ]. In New South Wales, Australia, several reports have described the increase in hospital redevelopment projects as a ‘hospital building boom’ [ 4 , 6 ], with approximately 100 major health capital projects (i.e., projects over AUD$10 million) currently in train [ 7 ]. In addition to meeting the needs of a growing and ageing population [ 8 ], the re-design and refurbishment of older hospital infrastructure is supported by a range of arguments and anecdotal evidence highlighting the positive relationship between the hospital physical environment and patient [ 9 ] and staff outcomes [ 10 ]. While there are many reasons why hospital redevelopments are taking place, we know little about how hospital staff prospectively perceive change, and their experiences, expectations, and concerns. Hospital staff encapsulates any employee working in the hospital context. This includes clinical and non-clinical staff who provide care, support, cleaning, catering, managerial and administrative duties to patients and the broader community.

One reason as to why little research has explored the perspectives of hospital staff during a redevelopment may be because hospital redevelopment is often considered a physical, rather than organisational change. Organisational change means that not only the physical environment is altered, but also the behavioural operations, structural relationships and roles, and the hospital organisational culture may transform. For example, changing the physical health care environment can affect job satisfaction, stress, intention to leave [ 11 ], and the way staff work together [ 12 ].

Redeveloping a hospital can be both an exciting and challenging time for staff. In a recent notable example of opening a new hospital building in Australia, staff attitudes shifted from appreciation and excitement in the early stages of change to frustration and angst as the development progressed [ 13 ]. Similar experiences have been reported elsewhere, such as in a study describing the consequences for staff of hospital change in South Africa [ 14 ]. However, these examples explored staff attitudes towards change retrospectively and considered the change as a physical redevelopment, rather than organisational change. Such retrospective reports may be limited in validity [ 15 ] as prospective experiences and understanding of change reported by staff may be conflated with the final outcome of the change. The hospital redevelopment literature has also prospectively assessed health impacts of proposed redevelopment plans as a means to predetermine the impact of a large change on the population [ 16 ]; while prospective, this research again considers redevelopment as a physical modification, rather than an organisational change. Thus, while the literature has reported retrospective accounts of staff experiences in large hospital change and prospective assessment of the impact of the change, there is little research examining the understanding and experiences of staff in the early stages of redevelopmental change in hospitals through a lens of organisational change.

Seminal research in the organisational change literature highlights that the role of frontline workers (in this case hospital staff) is crucial to implementation of any process or change [ 17 , 18 ]. Specifically, that the support of actors (understanding, owning, and engaging) can determine the success of a change [ 19 ]. This is consistent with complexity science accounts which suggest that any improvement and transformation of health systems is dependent upon the actors involved, and the extent and quality of their interactions, their emergent behaviours, and localised responses [ 1 , 20 ]. In health care, change can be resisted when it is imposed on actors (in this case, hospital staff), but may be better accepted when people are involved and adopt a sense of ownership of the changes that will affect them [ 21 ]. This may include being involved in the design process. For this reason, it is important to examine the understanding and experiences of actors involved in a change (i.e., hospital staff in a redevelopment), in order to understand and potentially address their concerns, alleviating negative expectations prior to the change.

This study is part of a larger project exploring how hospital redevelopment influences the organisation, staff and patients involved [ 22 ]. The present study aimed to explore the understanding and experiences of staff prior to moving into a new building as one stage in a multidimensional organisational change project. The research questions were: How do staff make sense of this organisational change? How well informed do they feel? What are their expectations and concerns? What are the implications for hospitals undergoing organisational change, particularly redevelopment?

The study protocol has been published elsewhere [ 22 ]. The Consolidated criteria for reporting qualitative research (COREQ) guidelines were used to ensure comprehensive reporting of the qualitative study results (Additional file 1 ) [ 23 ] .

Study setting and participants

This study was conducted at a large metropolitan, publicly-funded hospital in Sydney, Australia. The facility is undergoing a multimillion-dollar development project to meet the growing needs of the community. This hospital has undergone a number of other changes over the last two decades, including incremental increases in size. Since its opening in the mid 1990s (with approximately 150 beds), several buildings have been added over the years. The hospital now has multiple buildings and over 500 beds.

During the time of this study, the hospital was in the second stage of the multi-stage redevelopment. This stage included: the opening of a new acute services building, the relocation of several wards to this new building (e.g., Intensive care unit (ICU) and Maternity), increases in resources (e.g., equipment, staffing), and the adoption of new ways of working (e.g., activity-based workspaces for support staff). Essentially, the redevelopment involves the opening of a new state-of-the-art building which will include moving services (and staff) from the old to the new building, with some wards staying in the old building. For the wards moving into the new building, this change does not initially involve more patients in existing services, but is intended to increase the number of staff because there will be more physical space to cover and new models of care introduced (e.g., ICU changing to single-bed rooms, more staff needed to individually attend to patients). The current redevelopment includes space for future expansion to account for the growing population. In addition to the redevelopment of the physical infrastructure, the way staff work together is also planned to change. Hospital leadership is aiming to foster a cultural shift towards greater cohesion and unity; highlighting that the hospital redevelopment can be conceptualised as an organisational change of considerable importance and magnitude.

Participants were hospital staff (clinical and non-clinical) working at the hospital under investigation. Staff working on four wards were targeted for interviews, with the intention to capture diverse experiences of the redevelopment and the broader organisational change; two of these wards would be moving into the new building (ICU and Maternity), one ward was not moving (Surgical), and one ward had moved into a new building two years prior (Respiratory). Interviews were also conducted with staff who held responsibilities across wards (e.g., General Services Department: cleaners, porters). The hospital staff were purposively recruited by department heads and snowballed from participants. Fifty staff members were approached (until data saturation was met) with four refusing to participate because they did not have the time.

Semi-structured interviews

Semi-structured interviews were conducted in private settings at the participants’ place of work (e.g., ward interview rooms, private offices). In the event a participant was unable to meet the researcher in person, interviews were conducted over the phone. A semi-structured interview guide was created in collaboration with key stakeholders from the hospital under investigation and following a literature review. The guide (Additional file 2 ) included questions aimed at exploring participants’: (1) understanding of the hospital’s culture and current ways of working; (2) understanding of the redevelopment and other hospital changes; and (3) concerns or expectations about the organisational change. The interviews were audio-taped and transcribed verbatim by the first author who is trained and experienced in conducting semi-structured interviews. No field notes were made during the interview nor were transcripts returned to participants for comment or correction due to the time poor characteristics of the study participants (hospital staff). Participants were informed that the research was part of the first author’s doctoral studies.

Interview data were analysed via thematic analysis [ 24 ] using NVivo [ 25 ]. This approach followed Braun and Clarke’s (2006) six phases of thematic analysis: familiarise, generate initial codes, develop themes, review potential themes, define and name themes, produce the report. Data were initially read multiple times by the first author, then descriptively and iteratively coded according to semantic features. The analysis included the use of inductive coding to identify patterns driven by the data, together with deductive coding, keeping the research questions in mind. Through examination of codes and coded data, themes were developed. The broader research team (KC, LAE, JCL) were included throughout each stage of the analysis process, with frequent discussions concerning the categorization of codes and themes. This process of having one researcher responsible for the analysis while other researchers then checked and clarified emerging themes throughout contributes to the trustworthiness of the findings [ 26 ].

In presenting the results, extracts have been edited minimally to enhance readability, without altering meaning or inference. Where extracts are presented, staff are coded according to their department (G: General – works across several wards; ICU: Intensive care unit; MAT: Maternity ward; RES: Respiratory ward; SUR: Surgical ward) and profession (AD: Administrative staff; CHGTEAM: Change management team staff; DR: Medical staff; GS: General services staff; MW: Midwifery staff; N: Nursing staff; OTH: Other profession).

Forty-six staff members participated in the semi-structured interviews. Interviews were typically conducted face-to-face ( n  = 41; 89.1%), with five interviews conducted over the phone. No differences were discerned in content between these different mediums. Hospital staff taking part in interviews included those from: nursing and midwifery, medical, general services, administrative, and change management (Table  1 ). Change management staff are external to the hospital staff, and do not report to hospital executives. Interviews ranged from seven to 33 min in length ( M  = 17 min). Participating staff had worked at the hospital for on average 10.5 years (range 5 months and 30 years).

Five themes were identified related to hospital staff’s understanding and experiences (i.e., expectations and concerns) of the change: staffing; benefits to patients; collaboration; fatigue; and adaptability. These expectations and concerns are schematically presented in Fig.  1 , with shades of red indicating negative expectations and concerns associated with the theme, and green representing positive expectations. Intensity of the colour demonstrated the frequency of positivity or negativity associated with that theme (i.e., deeper shades of red indicate frequency of negative discussion of this theme by different hospital staff). This figure also highlights the complexity and interrelatedness of these themes (e.g., the concern of inadequate staffing for the new building was linked with concerns about patient care, which could possibly impede the way the team work together, leading to staff feeling overworked and worn out; these expectations were all mitigated by the staff member’s understanding and awareness of the change). Explanations and examples are presented below.

Thematic visualisation of staff understanding and expectations of the change

Hospital staff consistently held staffing to be a major concern in this redevelopment. To them, the opening of the new building, and with it the increase in physical size and addition of new services, meant that an increase in staff was crucial to successfully implement the change: “ My biggest uncertainty at the moment is the fact that I’m really concerned about whether I’m actually going to get enough staff ” (GS1). Many participants suggested that this issue would determine the success of the new hospital building. This was particularly important for staff moving into the new building with a bigger work space: “ We just need more staff. Yeah I think that’s the main issue - if we fix that then I believe everything should be smooth ” (ICUN4). For the most part, staff were unaware about how many new staff they would have in the new building. This uncertainty involved two related issues: (1) will we get the budget for new staff that we need? And if so, (2) where will we find all these new staff to employ?

On the first point, staff reported concerns that they would not have enough staff to cover the increased physical space and new ways of working within the new building. This lingering uncertainty was the result of external factors, specifically unresolved budget issues: “ But I suppose some of the issues stem from the fact that you never know how many beds we are able to open based on the funding from the government, and that is what is still up in the air ” (ICUDR1).

Regarding the second point, staff noted that even if budgetary issues were resolved, and there was enough money to hire new staff to fill the new building, a challenge would be finding the staff to recruit: “ I don’t know where these new staff are going to come from” (GN3). Some participants suggested that they already encountered difficulties with employing enough appropriately qualified staff and reported concerns that this issue would be compounded when they moved into the new building: “ Excitement will be way gone. It’s more to deal with that stress and the workload of other staff ” (ICUN4). Participants working on wards that were not moving into the new building also reported concerns about staffing. They noted that, despite not being directly involved in previous stages of the redevelopment, they had still been affected by these changes, because their colleagues were taken from their ward without consultation and moved into a new area. Hence, even staff not moving in the next stage of the redevelopment had concerns that their staffing levels would be affected: “ We have been told that we are not moving in there. And hopefully they don’t take our staff there ” (SURN5).

Benefits to patients

Many hospital staff expressed a positive expectation of the move related to benefits for patients. This was consistent across wards, departments and professions. Staff expected patients to experience benefits including reductions in infection rates and improved satisfaction, due to staying in a well-controlled and physically appealing environment with natural light: “ Any new place will give some joy or some happiness to people… The major change will be that because there are individual rooms, the infection rate will be lower and that I’m very pleased with” (ICUDR1).

Despite these participants reporting the improved physical environment was expected to positively affect patients, they also raised concerns that being in the new building might negatively affect patient safety because the increased physical space could introduce more room for error with the greater workload: “ Brings with it the fear, of how will we treat so many patients with nursing when you have one to one and the rooms are closed. That is a constant worry ” (ICUDR1). Participants indicated that this issue would be compounded if staffing levels were not increased.

Collaboration

Staff expressed multiple negative expectations or concerns about how their ways of working together would be affected by moving into the new building. Staff understood the change as more than just a physical expansion, but as an organisational change that would affect their ways of working. This understanding led to concern regarding how to work together in the new building. Specifically, staff moving into the new building were worried about the new layout of ICU, where nurses would be working alone in rooms with single patients. This would disrupt their ability to easily ask for support currently done by asking the nurse at an adjacent bed, or signalling to someone visible across the room: “ Single rooms are great for patients and everything but I think it becomes a bit more isolated for staffing ” (ICUOTH1). These concerns were also recognised among staff working in the change management team, who may not be directly affected by the change, but acknowledged that this is a major consequence of the move into the new building: “ All the beds, they were able to see each other all the time whereas now it’s a different work environment. They’re a bit more isolated… So that’s what we find is the challenge” (CHGTEAM2). Further, staff were concerned about working in open plan spaces that limit opportunity for private discussions, for example with other staff about workplace conflict or personal matters: “ I’m very concerned about insufficient space for private stuff ” (ICUAD1).

Staff reported negative expectations of collaboration breakdown not only within wards, but across the hospital. The organisational change will include far-flung staff and expanded infrastructure, which may decrease opportunity to collaborate directly. For several participants, the growing size of the hospital was seen as a fracturing of the positive, cohesive culture of what was once a smaller hospital—“ It used to be that the general manager would walk through and know everybody by name, the cleaner, maintenance crew, everybody knew everybody’s name ” (GN1)—into more disconnected, subunits: “ Now we’re very separate ” (ICUOTH1).

During interviews, many participants reported feeling over-worked and under-resourced. While some described being fatigued and unhappy at work, the redevelopment was, nevertheless, clearly a positive: “ We’re not happy because we’re under so much pressure and stress. But, you know, we are looking forward to the new build, it’ll be a beautiful building” (GN3). For others, there were concerns that their feelings of being over-worked would not subside with the opening of the new hospital building and that there was a lack of time to even consider the change. This was expressed by staff moving in to the new building, as well as those not moving:

Who has got the time to go and look at those decorative things ! (SURN5).

I can’t see how it will make a big difference to me… I don’t pay a lot of attention to the looks (MATDR1).

It doesn’t really matter… I could be providing it [patient care] in a tent or a building . (MATMW2).

Further, hospital staff expressed frustration in having to endure poor resourcing, which tempered their excitement for the new building: “We’ve all put up with whatever since whenever and I’m done, I’m so done” (ICUAD1). Some participants reported negative expectations related to the increase in physical space in the new building, as adding to the work load of clinical staff and requiring they travel further to get supplies and attend to patients: “They are worried about, hang on I’m going to have to do so many more laps” (ICUAD1). Similarly, an issue expressed on behalf of staff in the General Services Department was whether they will be able to adequately clean and cater for physically larger areas: “ I’m sitting here and looking at [a previous building that was opened] and seeing how filthy it is ” (CHGTEAM3). Concerns about being over-worked in the face of the redevelopment were further emphasised by some interviewees who discussed a problem with turnover: “ We’ve actually had a few people, I have had three people, which is unusual for us, who have looked for other jobs and are probably resigning. You know which is sort of the opposite of what we’d expect at this time, we’d expect they’d be excited for the new building ” (ICUN5). However, most staff in more junior positions had not seen the new building and thus were unaware of the layout and the degree to which it may impact their work: “ Because I have not seen the actual structure of the area, and I don’t know what they based it on and how they figured out a way to be friendly for both staff and patients at the same time ” (ICUN3). The unawareness and lack of understanding accentuated concerns and negative expectations among staff as they expected the worst.

Also contributing to reports of experiencing fatigue, staff described numerous other large changes taking place at the hospital over the years, in addition to the redevelopment: “ Basically for seven years we’ve been undergoing changes since I’ve been here. It is utterly exhausting having this many changes all the time ” (GS1). This highlights that while this study captures prospective insights to the change, change is constant in health care. While the move into the new building has not yet occurred, the move is part of a broader organisational change grander than the physical expansion of infrastructure. While this was a major concern for many staff, some of the senior medical staff dismissed this as being an issue, suggesting constant change is part of health care and should not lead to staff feeling worn out: “ I think once you get to my level you get good at kind of jumping through hoops… As you get more experienced, you just go with the flow a bit more” (SURDR2).

Adaptability

An additional theme involved staff’s positive expectation that they would be able to adapt to the changes brought about by the move into the new building. Reflecting on past experiences of organisational and infrastructure changes at the hospital, staff expressed that it could take time to adapt and see the benefits of the change: “ At the beginning, of course, everybody was scared of the changes and stuff like that, but eventually we got used to it. ” (SURN3). However, some staff reported that they saw adapting to the new building as a concern, potentially because of a lack of knowledge pertaining to what the new building entails: “ I just don’t know. I’m worried because I don’t know what we’re walking in to ” (ICUN2). In general, staff expressed an understanding of the change as one of physical growth (hospital redevelopment) and changes in ways of working (organisational change): “Getting bigger. So, basically taking all of our acute services and putting it in a brand spanking new building where they’re significantly expanding” (GN1); “ The biggest change is changing the way they work. Changing the way they deliver care .” (CHGTEAM2). When asked why the change was happening, hospital staff were consistent in attributing the need for redevelopment to population growth: “ To develop more resources to accommodate for the growing number of patients ” (SURDR3).

Feeling uninformed and uncertain about the change was expressed by staff of different professions and different levels throughout the hospital. In fact, even wards that were not moving to the new building were unsure if this was the case: “ There’s been no communication from anyone really. I hear from different people yes we are moving and then somebody says no we’re not. We’re staying here in the old building. So, I’m not sure exactly who’s going” (SURN1).

Our findings suggest that in the early stages of hospital redevelopment, staff experience both positive and negative expectations that are dependent upon the level of personal understanding, awareness of the change to come, and how well-resourced they already feel. Interviews with hospital staff highlighted a general understanding of the change as involving physical expansion of the hospital. However, participants also reported feeling inadequately informed about what is to come and described a range of sometimes differing expectations about the organisational effects of this change (e.g., on collaboration, for patients). This supports the conceptualisation of hospital redevelopment as not only a physical change, but an organisational one too.

The present study is the first to empirically explore the experiences and understanding of staff in the early stages of a hospital redevelopment, and conceptualised this as an organisational change. This conceptualisation is an important contribution to the organisational change literature because we show that change, even when based on the best evidence-based design, can be disappointing and bring about negative experiences for staff. The concerns and negative expectations of the change expressed by staff in the present study echo past research that retrospectively explored the experiences of staff during a hospital change, in Australia [ 13 ], and elsewhere [e.g., 14]. In the present study, staffing was a major concern reported by hospital staff. This is consistent with other reports of hospital redevelopment in the Australian context. For example, in a report into the opening of a new children’s hospital, staff were frustrated about the progression of the change and that a lack of staffing impacted on service planning. Staffing was also emphasised as an issue in another Australian hospital redevelopment project, where the building opened with insufficient staffing and resources [ 27 ]. Additionally, hospital staff in the present study indicated that they felt fatigued, so much so that excitement for the opening of the new building was diminishing. Reports of low staff morale in hospital redevelopment projects has also been documented in other Australian and international studies [ 13 , 14 ]. Further, participants in this study reported a lack of awareness of the redevelopment, something that appears to be common with a report of hospital revitalisation in the United States reporting a similar finding [ 28 ].

One source of many of the issues expressed by staff was uncertainty, a common and often inevitable experience in health care [ 29 ], for example, systems uncertainty about staffing levels and uncertainty about whether collaboration and support would break down as the hospital expands. While some types of uncertainty cannot be eradicated, it is important to manage uncertainty in times where information is available. One way to do this is to make sure front-line actors have a platform to seek information and ask questions during organisational change; having access to information is a predictor of success for organisational change in healthcare [ 30 ]. This may help alleviate stress associated with change and make the transition period less uncertain for staff, particularly in early stages where uncertainty may be greater. While it is not always possible for all the concerns and expectations of staff to be individually acknowledged and addressed by those coordinating the change (e.g., change management team or hospital executives), an alternative is through the use of ‘champions’ or ‘opinion leaders’. Opinion leaders are actors with a brokerage role; they carry information across social boundaries, such as between groups of professionals or different hospital wards [ 31 ]. Otherwise referred to as a ‘champion’, by virtue of their trustworthiness and connectedness, these actors are able to lead the opinions of others and are integral in the adoption and diffusion of new phenomena. Successful champions are enthusiastic and motivated about the change they are promoting [ 32 ]. In this case, a successful champion in a hospital undergoing organisational change is a staff member who can inform others and influence acceptance, and provide a positive frame for the change.

Implications

While findings may be localised to the hospital we researched, it is important to note that the hospital redevelopment under investigation is similar to other hospital redevelopments in metropolitan cities in Australia [ 7 ] and worldwide [ 5 ]. Specifically, the redevelopment is an expansion of infrastructure to meet the growing needs of the community which the hospital serves. The perceptions and experiences maintained by hospital staff will differ dependent on the state of the new facilities; these findings broadly generalise to any hospital redevelopment where a newer, larger building is opened. The implications of this study provide broad suggestions for other hospitals undergoing this type of hospital redevelopment.

Firstly, hospital redevelopment should be considered as more than physical change, but as an organisational change, in order to recognise the ripple effects of changing the infrastructure and how this may influence social and behavioural processes. From this study’s findings of the expectations and present experiences of organisational change, we recommend four strategies to aid in the early stages of hospital redevelopment: engage actors; plan and train; learn from the past; and increase managerial engagement (see Table  2 ). These recommendations correspond with suggestions from a past review examining transforming systems in health care [ 33 ]. Effort must be taken to ensure staff are informed of the change and rectify any confusions about who, what, when, and how the change is taking place. This is consistent with organisational change theory that maintains that large scale change requires significant effort and planning to ensure its success [ 19 ]. Therefore, an implication of this study lies in the importance of exploring the understanding and expectations of staff preceding a large organisational change in order to aid in the acceptance of, rather than resistance to, the change [ 21 ]. Further, this study also highlights the importance of studying the experiences of actors not directly involved in the organisational change but who are a part of the broader system (i.e., wards not moving implied they will be affected).

Strengths and limitations

A strength of this study lies in the number of participants and variability in the professions that contribute to the transferability of the study findings. Further, checking and clarifying themes with other researchers throughout the coding process increases the trustworthiness of the findings [ 26 ]. As to limitations, interviews were on average 17 min long, with the shortest interview lasting seven minutes. While this may be perceived as a short duration for collecting interview data it was appropriate for participants who were incredibly time poor (e.g., nurses on shift who could only get a 10 min break to talk to the researcher). It is important that the opinions of these busy staff are captured to reflect the true nature of a sample of varied hospital staff. Further, the findings may not be generalisable to other instances of organisational change and may be specific to the four wards and hospital examined in this study. Wards were purposively chosen rather than randomised. While findings may be specific to the hospital under investigation, the research has been designed to optimise research credibility in this qualitative analysis. Further, considerable context was provided to help readers infer relevance to different settings. This in-depth analysis of how staff understand and interpret organisational change in hospitals provides the opportunity to uncover theoretical insights into the processes of change in the health care system and the perspectives of staff during times of organisational change.

This study explored the prospective understanding and experiences of staff in organisational change in hospitals, using an Australian hospital redevelopment as a case exemplar. Findings indicated that staff were concerned about staffing levels, fatigue, and the potential for a breakdown of current collaborative working. These concerns are similar to past reports of redevelopment in hospitals. This paper presents recommendations for the early stages of organisational change in hospitals. For present and future hospital organisational change projects, it is important that staff concerns are addressed and that staff are informed adequately about the ongoing changes in order to improve their engagement and ownership of the change.

Availability of data and materials

The datasets analysed during the current study are not publicly available due to individual privacy, but are available from the corresponding author on reasonable request.

Abbreviations

Administrative staff

Change management team staff

Medical staff

General – works across several wards

General services staff

Intensive care unit

Maternity ward

Midwifery staff

Nursing staff

Other profession

Respiratory ward

Surgical ward

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Acknowledgements

We thank the hospital executives, ward directors and nursing unit managers for their support in recruitment of interview participants. The authors also thank and acknowledge the interview participants.

CP was funded by the Australian Government Research Training Program (RTP) PhD Scholarship. JB is supported by multiple grants, including the National Health and Medical Research Council (NHMRC) Partnership Grant for Health Systems Sustainability (ID: 9100002). The funders had no role in the design, analysis and drafting of the manuscript.

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CP and JB conceptualised the project. CP collected and analysed the data, and drafted the manuscript. KC, LAE and JCL assisted in the coding and interpretation of data. All authors read and approved the final manuscript.

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Correspondence to Chiara Pomare .

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The study was approved by the relevant Ethics Committee in Sydney, New South Wales, Australia (no: 18/233). Due to ethical requirements, the committee cannot be named because it may lead to the identification of the study site. Informed consent was obtained from all study participants.

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Additional file 1..

Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist.

Additional file 2.

Semi-structured interview guide.

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Pomare, C., Churruca, K., Long, J.C. et al. Organisational change in hospitals: a qualitative case-study of staff perspectives. BMC Health Serv Res 19 , 840 (2019). https://doi.org/10.1186/s12913-019-4704-y

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Hospital Case Study

We can use case studies to gain an up-close and personal understanding of a subject in its natural context. Although it doesn’t hold as much evidence as empirical investigation , we can still gain insights about the perils of the medical community from hospital case studies. Because they are a method of research that concerns a small, nonrepresentative group, they are generally exhaustive in terms of details and information.

What Is a Hospital Case Study?Hospital Case Study

Case studies, in its fundamental form, is an in-depth analysis of a situation with a proposal for changes. Hospital case studies are like  medical case studies . However, instead of focusing on novel, rare, and undocumented cases of diseases and patient conditions, these case studies are about cases and propositions that will, ultimately, improve hospital operation . We need case studies because there will always be an exemption to the rule. Real experience may not always be the same for everyone. What works for nine hospitals may be inefficient for the 10th. That doesn’t mean that that one hospital will have to follow the general rule or process at the cost of service quality.

Harbinger of death

Hospitals are supposed to be where the sick regains health. However, around the 1800s, these places were home to hundreds of mysterious deaths. Mothers were dying painfully after giving birth. The alarming fact is that delivery complications did not cause mortality. The tragic thing was that infections were the ones claiming lives. After investigation, physician Ignaz Semmelweis  caught the culprit barehanded. Medical students and professors unknowingly transmitted harmful streptococci bacteria to the patients. And it wasn’t because they were purposely harming the mothers. Gloveless, the medical personnel would perform autopsies on corpses. After, they would go the wards and examine laboring women. The number of deaths declined when the doctors and students started to wash their hands as part of the hospital protocol.

Forward momentum

Our quality of health and health care has improved since the 1800s. Hospitals are still riddled with disease-causing pathogens, but because of improvement in healthcare practice, we have fewer chances of dying when we go see the doctor. Keeping the patients alive is not a paramount prerequisite of quality health care. There are aspects of the hospital that are indirect contributors to health care, but when neglected can spell disaster. These features may not be present in all hospitals or have a different derivative. Hospital case studies work best for local-scale improvements. Even though case studies are still meant to be made public for transparency and future reference. Because, like the handwashing story, a proposition can improve the entire medical practice.

Case permutations

There are different types of case studies . But because they are fruits of the same tree, they typically have the same structure. Think of it as an evolutionary descent of case studies, where though there have been multiple divergences of lineages over time to suit a situation, they contain a genetic code that remained unchanged. The mitochondrial DNA of case studies are as follows:

Title: A good title goes a long way. It informs your readers on what the study is about. It doesn’t have to be boring. You can create a catchy title that encapsulates the content of the case study in a few words.

Executive summary:  Although some people are using abstract sections, the summary is a brief about your entire case. Generally, readers refer to this section to know if they’re looking at the right case study for reference.

Background:  This section introduces the subject of your research. In clinical case studies , this page orients the readers about the patient. For hospital case studies, this can be about the institution and the case to be presented.

Evaluation:  This part explains in detail the problem that needs to be addressed. It tells how the issue came to be, its effect on the concerned department, and how it hampers the function of the institution.

Plan:  This segment provides suggested resolutions to the problem. There can be multiple solutions. The chosen solution has to be justified by feasibility , appropriateness, and efficacy.

Results:  Like any initiative, a program does not stop at the execution of the proposed strategy. This page shows the feedback and progress of the action. This serves as the basis in deciding if the solution will be fully integrated into the system.

Redefining health care

Health care providers in the United States and the rest of the world are striving to keep up with the times. They are on the lookout of ways that they can better patient care and hospital operations and processes. The following are examples of hospital case studies that investigated and presented projects and initiatives, from practice to infrastructure, on what can hospitals do to update their system.

Hospital Case Study Examples

1. patient care case study.

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2. Hospital Architecture Study

3. Hospital Layout Study

Size: 435 KB

4. Patient Care Study

Size: 470 KB

5. Rural Health Care Study

Size: 138 KB

6. Hospital Case Study

7. Medical Practice Study

Size: 573 KB

8. Hospital Improvement Study

Size: 723 KB

9. Compilation of Case Studies

10. Obesity Case Study

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11. Hospital Data Management

Size: 192 KB

12. Hospital Workforce Study

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13. Process Improvement Study

14. Hospital Care Study

15. Medical Records Study

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16. Hospital Merger Study

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Use or Misuse: Case study

The usefulness of a hospital case study, despite it being about a more personal encounter than evidence-based research, lies on its effect on the institution. How do you determine if the challenge at hand requires a case study?

1. Does the Shoe Fit?

Despite the advantages of case studies in improving hospital operations, not all problems require in-depth treatment. Before spending the organization’s resources, ask yourself first if there is a need to conduct the study? There might be faster solutions. Case studies, because of their nature, takes time. Instead of helping you, making a case study might mean more losses for your institution in this case.

2. Nose in the Book

Before you spend time and resources for your case study, you have to research the subject first. A similar problem may have already been resolved. You can gain insight into how others dealt with the issue and apply their solutions to the challenge at hand. By consulting with available sources first, you save yourself and the institution from paying heftily for a reiterated solution.

3. Know your Enemy

After you decided that the issue needs to be resolved with the help of case studies, you have to determine the focus of your research. This means that you have to specify the problem and see it for what it really is. You have to zero in on the issue. If you don’t, all your succeeding efforts to find resolution wouldn’t be fruitful. To solve the problem, you have to identify it first. Determine their causes and how they affect the hospital.

4. Fairest of Them All

Too much of a good thing is bad. After you have analyzed the situation, you are stumped with an unlikely predicament. There are too many choices on how to resolve the issue at hand. You might be tempted to apply everything. This is counterintuitive. Your best approach in this scenario is ranking the choices and deciding which ones will be most appropriate for the problem. This is where tracking the initiative’s progress will help you. You can use it as a basis to integrate or scrap a project.

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Based on a composite of a number of real sentinel event reports to The Joint Commission, Case Examples can be used for educational purposes to identify lapses in patient safety and missed opportunities for developing a safety culture. This learning resource highlights safety actions and strategies to have a better result. Stay current with what is happening at The Joint Commission by subscribing to our free publications.

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CASE STUDY OF HOSPITAL MANAGEMENT SYSTEM (HMS

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International Journal for Research in Applied Science & Engineering Technology (IJRASET)

IJRASET Publication

Hospital Management System includes registration of patients, storing the details into the system and appointing doctors online. Our software has the facility to give a unique id for every patient and stores the details of every patient and list of all the doctors which work in the hospital. It includes a search availability of a doctor and the details of a patient using the id. Our system gives each doctor a unique code due to which patients can book their appointments online. The Hospital Management System can be entered using a username and a password. It is accessible by an administrator, doctor and the patient as well. Each doctor has their unique username and password which can be logged in by their correspond email-id , like the doctor patient also have their unique username and pass. But the admin has access to both the doctors and patients details and everything which would help the admin to keep an eye over its hospital management. The interface is simple and userfriendly. The data are well protected for personal use and makes the data processing very fast.

Ijaems Journal

— Health institution requires quality data and information management to function effectively and efficiently. It is an understatement to say that many organizations, institutions or government agencies have become critically dependent on the use of database system for their successes especially in the hospital. This work aims at developing an improved hospital information management system using a function-based approach. An efficient HIMS that can be used to manage patient information and its administration is presented in this work. This is with the goal of eradicating the problem of improper data keeping, inaccurate reports, wastage of time in storing, processing and retrieving information faced by the existing hospital information system in order to improve the overall efficiency of the health institution. The system was developed with Hypertext Markup Language (HTML), Cascading Style Sheets (CSS), Hypertext Preprocessor (PHP), and My Structured Query Language (MySQL). The new system was tested using data collected from Renewal Clinic, Ibadan, Nigeria was used as case study were the data for the research was collected and the system was tested. The system provides a vital platform of information storage and retrieval in hospitals.

The paper developed an automated system that is used to manage patient information and its administration. This was with a view to eliminate the problem of inappropriate data Keeping, inaccurate reports, time wastage in storing, processing and retrieving information encountered by the traditional hospital system in order to improve the overall efficiency of the organization. The tools used to implement the system are Hypertext Markup Language (HTML), Cascading Style Sheets (CSS), Hypertext Preprocessor (PHP), and My Structured Query Language(MySQ).The Proposed system was tested using the information collected from Murab Hospital, Ilorin, kwara State , Nigeria and compared with the existing traditional hospital system. The design provides excellent patient services and improved information infrastructure.

Mohammed Aman

OBJECTIVE : Hospitals currently use a manual system for the management and maintenance of critical information. The current system requires numerous paper forms, with data stores spread throughout the hospital management infrastructure. Often information (on forms) is incomplete, or does not follow management standards. Forms are often lost in transit between departments requiring a comprehensive auditing process to ensure that no vital information is lost. Multiple copies of the same information exist in the hospital and may lead to inconsistencies in data in various data stores. A significant part of the operation of any hospital involves the acquisition, management and timely retrieval of great volumes of information. This information typically involves; patient personal information and medical history, staff information, room and ward scheduling, staff scheduling, operating theater scheduling and various facilities waiting lists. All of this information must be managed in an efficient and cost wise fashion so that an institution's resources may be effectively utilized HMS will automate the management of the hospital making it more efficient and error free. It aims at standardizing data, consolidating data ensuring data integrity and reducing inconsistencies. PROJECT OVERVIEW : The Hospital Management System (HMS) is designed for Any Hospital to replace their existing manual, paper based system. The new system is to control the following information; patient information, room availability, staff and operating room schedules, and patient invoices. These services are to be provided in an efficient, cost effective manner, with the goal of reducing the time and resources currently required for such tasks. A significant part of the operation of any hospital involves the acquisition, management and timely retrieval of great volumes of information. This information typically involves; patient personal information and medical history, staff information, room and ward scheduling, staff scheduling, operating theater scheduling and various facilities waiting lists. All of this

International Journal of Computer Theory and Engineering

Ezenwa Nwawudu

emeka ajoku

ABSTRACT This study investigated online hospital management system as a tool to revolutionize medical profession. With many writers decrying how patients queue up for hours in order to receive medical treatment, and some end-up being attended to as „spillover‟, the analyst investigated the manual system in detail with a view to finding out the need to automate the system. Subsequently, a computer-aided program was designed to bring about improvement in the care of individual patients, taking the advantage of computer speed, storage and retrieved facilities. The software designed will take care of patient‟s registration, billing, treatment and payments. The programming language employed in this work was Microsoft C#.

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Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Case study: 33-year-old female presents with chronic sob and cough.

Sandeep Sharma ; Muhammad F. Hashmi ; Deepa Rawat .

Affiliations

Last Update: February 20, 2023 .

• Case Presentation

History of Present Illness:  A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies:  No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

• Initial Evaluation

Laboratory Studies:  Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram staining.

Chest X-ray

Impression:  Mild interstitial pneumonitis

• Differential Diagnosis
• Aspiration pneumonitis and pneumonia
• Bacterial pneumonia
• Immunodeficiency state and Pneumocystis jiroveci pneumonia
• Carcinoid lung tumors
• Tuberculosis
• Viral pneumonia
• Chlamydial pneumonia
• Coccidioidomycosis and valley fever
• Recurrent Legionella pneumonia
• Mediastinal cysts
• Mediastinal lymphoma
• Recurrent mycoplasma infection
• Pancoast syndrome
• Pneumococcal infection
• Sarcoidosis
• Small cell lung cancer
• Aspergillosis
• Blastomycosis
• Histoplasmosis
• Actinomycosis
• Confirmatory Evaluation

CT of the chest was performed to further the pulmonary diagnosis; it showed a diffuse centrilobular micronodular pattern without focal consolidation.

On finding pulmonary consolidation on the CT of the chest, a pulmonary consultation was obtained. Further history was taken, which revealed that she has two pet doves. As this was her third day of broad-spectrum antibiotics for a bacterial infection and she was not getting better, it was decided to perform diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections and to rule out malignancy (Image 1).

Bronchoalveolar lavage returned with a fluid that was cloudy and muddy in appearance. There was no bleeding. Cytology showed Histoplasma capsulatum .

Based on the bronchoscopic findings, a diagnosis of acute pulmonary histoplasmosis in an immunocompetent patient was made.

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe, or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks total. The response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving work of respiration. [1] [2] [3]

Histoplasmosis, also known as Darling disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's lung, is a disease caused by the dimorphic fungi  Histoplasma capsulatum native to the Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of Histoplasma are the mycelial phase and the yeast phase.

Etiology/Pathophysiology 

Histoplasmosis is caused by inhaling the microconidia of  Histoplasma  spp. fungus into the lungs. The mycelial phase is present at ambient temperature in the environment, and upon exposure to 37 C, such as in a host’s lungs, it changes into budding yeast cells. This transition is an important determinant in the establishment of infection. Inhalation from soil is a major route of transmission leading to infection. Human-to-human transmission has not been reported. Infected individuals may harbor many yeast-forming colonies chronically, which remain viable for years after initial inoculation. The finding that individuals who have moved or traveled from endemic to non-endemic areas may exhibit a reactivated infection after many months to years supports this long-term viability. However, the precise mechanism of reactivation in chronic carriers remains unknown.

Infection ranges from an asymptomatic illness to a life-threatening disease, depending on the host’s immunological status, fungal inoculum size, and other factors. Histoplasma  spp. have grown particularly well in organic matter enriched with bird or bat excrement, leading to the association that spelunking in bat-feces-rich caves increases the risk of infection. Likewise, ownership of pet birds increases the rate of inoculation. In our case, the patient did travel outside of Nebraska within the last year and owned two birds; these are her primary increased risk factors. [4]

Non-immunocompromised patients present with a self-limited respiratory infection. However, the infection in immunocompromised hosts disseminated histoplasmosis progresses very aggressively. Within a few days, histoplasmosis can reach a fatality rate of 100% if not treated aggressively and appropriately. Pulmonary histoplasmosis may progress to a systemic infection. Like its pulmonary counterpart, the disseminated infection is related to exposure to soil containing infectious yeast. The disseminated disease progresses more slowly in immunocompetent hosts compared to immunocompromised hosts. However, if the infection is not treated, fatality rates are similar. The pathophysiology for disseminated disease is that once inhaled, Histoplasma yeast are ingested by macrophages. The macrophages travel into the lymphatic system where the disease, if not contained, spreads to different organs in a linear fashion following the lymphatic system and ultimately into the systemic circulation. Once this occurs, a full spectrum of disease is possible. Inside the macrophage, this fungus is contained in a phagosome. It requires thiamine for continued development and growth and will consume systemic thiamine. In immunocompetent hosts, strong cellular immunity, including macrophages, epithelial, and lymphocytes, surround the yeast buds to keep infection localized. Eventually, it will become calcified as granulomatous tissue. In immunocompromised hosts, the organisms disseminate to the reticuloendothelial system, leading to progressive disseminated histoplasmosis. [5] [6]

Symptoms of infection typically begin to show within three to17 days. Immunocompetent individuals often have clinically silent manifestations with no apparent ill effects. The acute phase of infection presents as nonspecific respiratory symptoms, including cough and flu. A chest x-ray is read as normal in 40% to 70% of cases. Chronic infection can resemble tuberculosis with granulomatous changes or cavitation. The disseminated illness can lead to hepatosplenomegaly, adrenal enlargement, and lymphadenopathy. The infected sites usually calcify as they heal. Histoplasmosis is one of the most common causes of mediastinitis. Presentation of the disease may vary as any other organ in the body may be affected by the disseminated infection. [7]

The clinical presentation of the disease has a wide-spectrum presentation which makes diagnosis difficult. The mild pulmonary illness may appear as a flu-like illness. The severe form includes chronic pulmonary manifestation, which may occur in the presence of underlying lung disease. The disseminated form is characterized by the spread of the organism to extrapulmonary sites with proportional findings on imaging or laboratory studies. The Gold standard for establishing the diagnosis of histoplasmosis is through culturing the organism. However, diagnosis can be established by histological analysis of samples containing the organism taken from infected organs. It can be diagnosed by antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assay. The diagnosis also can be made by testing for antibodies again the fungus. [8]

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks. The patient's response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving the work of respiration.

The disseminated disease requires similar systemic antifungal therapy to pulmonary infection. Additionally, procedural intervention may be necessary, depending on the site of dissemination, to include thoracentesis, pericardiocentesis, or abdominocentesis. Ocular involvement requires steroid treatment additions and necessitates ophthalmology consultation. In pericarditis patients, antifungals are contraindicated because the subsequent inflammatory reaction from therapy would worsen pericarditis.

Patients may necessitate intensive care unit placement dependent on their respiratory status, as they may pose a risk for rapid decompensation. Should this occur, respiratory support is necessary, including non-invasive BiPAP or invasive mechanical intubation. Surgical interventions are rarely warranted; however, bronchoscopy is useful as both a diagnostic measure to collect sputum samples from the lung and therapeutic to clear excess secretions from the alveoli. Patients are at risk for developing a coexistent bacterial infection, and appropriate antibiotics should be considered after 2 to 4 months of known infection if symptoms are still present. [9]

Prognosis 

If not treated appropriately and in a timely fashion, the disease can be fatal, and complications will arise, such as recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive fibrosis of lymph nodes. Acute pulmonary histoplasmosis usually has a good outcome on symptomatic therapy alone, with 90% of patients being asymptomatic. Disseminated histoplasmosis, if untreated, results in death within 2 to 24 months. Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent without treatment.

• Pearls of Wisdom

While illnesses such as pneumonia are more prevalent, it is important to keep in mind that more rare diseases are always possible. Keeping in mind that every infiltrates on a chest X-ray or chest CT is not guaranteed to be simple pneumonia. Key information to remember is that if the patient is not improving under optimal therapy for a condition, the working diagnosis is either wrong or the treatment modality chosen by the physician is wrong and should be adjusted. When this occurs, it is essential to collect a more detailed history and refer the patient for appropriate consultation with a pulmonologist or infectious disease specialist. Doing so, in this case, yielded workup with bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing a pulmonary consolidation as exemplified here where the results showed small, budding, intracellular yeast in tissue sized 2 to 5 microns that were readily apparent on hematoxylin and eosin staining and minimal, normal flora bacterial growth. 

• Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

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Histoplasma Contributed by Sandeep Sharma, MD

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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