Sukhanov, B P; Kerimova, M G; Elizarova, E V
A review is aimed to help professionals, who provide state sanitary control of dietary (clinical and prophylactic) nutrition in health care organizations. Taking into account the new modern legislative framework and the scientific and practical publications, the basic requirements for standardization, harmonization and individualization (personalization) of nutritional therapy and monitoring of their implementation in health care organizations by state sanitary authorities has been set out. The attention is focused on the optimization of clinical nutrition, as well as the methods of assessment of balance and nutritive value of the standard diets, their proper correction with dry protein composite blends and other specialized products of dietary clinical and prophylactic nutrition, including foods fortified with dietary and biologically active substances and food supplements (nutraceuticals). The paper describes ways to improve the organization of state sanitary and dietary nutritional care in health care organizations, outlines priority issues to be addressed to improve the nutritional care.
Abelman, Steve; Schulkin, Jay; Williams, Jennifer L.; Fassett, Elizabeth M.
Objectives: To review what past studies have found with regard to existing clinical practices and approaches to providing preconception care. Methods: A literature review between 1966 and September 2005 was performed using Medline. Key words included preconception care, preconception counseling, preconception surveys, practice patterns, pregnancy outcomes, prepregnancy planning, and prepregnancy surveys. Results: There are no current national recommendations that fully address preconception care; as a result, there is wide variability in what is provided clinically under the rubric of preconception care. Conclusions: In 2005, the Centers for Disease Control and Prevention sponsored a national summit regarding preconception care and efforts are underway to develop a uniform set of national recommendations and guidelines for preconception care. Understanding how preconception care is presently incorporated and manifested in current medical practices should help in the development of these national guidelines. Knowing where, how, and why some specific preconception recommendations have been successfully adopted and translated into clinical practice, as well as barriers to implementation of other recommendations or guidelines, is vitally important in developing an overarching set of national guidelines. Ultimately, the success of these recommendations rests on their ability to influence and shape women's health policy. PMID:16897374
In his influential 1987 essay, "Equipoise and The Ethics of Randomized Clinical Research," Benjamin Freedman argued that Charles Fried's theoretical equipoise requirement threatened clinical research because it was overwhelmingly fragile and rendered unethical too many randomized clinical trials. Freedman, therefore, proposed an alternative requirement, the clinical equipoise requirement, which is now considered to be the fundamental or guiding principle concerning the ethics of enrolling patients in randomized clinical trials. In this essay I argue that Freedman's clinical equipoise requirement is ambiguous and can be interpreted in (at least) two different ways. I furthermore claim that, ironically, the best interpretation of the clinical equipoise requirement opens Freedman to the same objection that he leveled against Fried twenty-five years ago; namely, that it (Freedman's clinical equipoise requirement) renders unethical too many randomized clinical trials.
White, Brittany Lynn; Zomorodi, Meg
To compare the noise levels perceived by critical care nurses in the Intensive Care Unit (ICU) to actual noise levels in the ICU. Following a pilot study (n=18) and revision of the survey tool, a random sample of nurses were surveyed twice in a 3-day period (n=108). Nurses perception of noise was compared to the actual sound pressure level using descriptive statistics. Nurses perceived the ICUs to be noisier than the actual values. The ICU was louder than the recommended noise level for resotrative sleep. This finding raises the question of how we can assist nurses to reduce what they perceive to be a loud environment. Future work is needed to develop interventions specifically for nurses to raise awareness of noise in the ICU and to provide them with skills to assist in noise reduction. Copyright © 2016 Elsevier Ltd. All rights reserved.
Gordon, James A.; Alexander, Erik K.; Lockley, Steven W.; Flynn-Evans, Erin; Venkatan, Suresh K.; Landrigan, Christopher P.; Czeisler, Charles A.
Purpose The correlation between simulator-based medical performance and real-world behavior remains unclear. The authors conducted this study to explore whether the effects of extended work hours on clinical performance, as reported in prior hospital-based studies, could be observed in a simulator-based testing environment. Method Intern volunteers reported to the simulator laboratory in a rested state and again in a sleep-deprived state (after a traditional 24–30 hour overnight shift [n=17]). A subset also presented after a shortened overnight shift (maximum of 16 scheduled hours [n=8]). During each laboratory visit, participants managed two critically ill patients. An on-site physician scored each case, as did a blinded rater later watching videotapes of the performances (score=1 [worst] to 8 [best]; average of both cases = session score). Results Among all participants, the average simulator session score was 6.0 (95% CI: 5.6–6.4) in the rested state, and declined to 5.0 (95% CI: 4.6–5.4) after the traditional overnight shift (P<0.001). Among those who completed the shortened overnight shift, the average post-shift simulator session score was 5.8 (95% CI: 5.0–6.6) compared to 4.3 [95%CI: 3.8–4.9]) after a traditional extended shift (P<0.001). Conclusions In a clinical simulation test, medical interns performed significantly better after working a shortened overnight shift compared to a traditional extended shift. These findings are consistent with real-time hospital studies using the same shift schedule. Such an independent correlation not only confirms the detrimental impact of extended work hours on medical performance, but also supports the validity of simulation as a clinical performance assessment tool. PMID:20881679
Gilbert, Gregg H; Riley, Joseph L; Eleazer, Paul D; Benjamin, Paul L; Funkhouser, Ellen
Objectives Use of a rubber dam during root canal treatment is considered the standard of care because it enhances patient safety and optimises the odds of successful treatment. Nonetheless, not all dentists use a rubber dam, creating disconnect between presumed standard of care and what is actually done in clinical practice. Little is known about dentists’ attitudes towards use of the rubber dam in their practices. The objectives were to: (1) quantify these attitudes and (2) test the hypothesis that specific attitudes are significantly associated with rubber dam use. Setting National Dental Practice-Based Research Network (NationalDentalPBRN.org). Participants 1490 network dentists. Outcome measures Dentists completed a questionnaire about their attitudes towards rubber dam use during root canal treatment. Three attitude scales comprised 33 items that used a 5-point ordinal scale to measure beliefs about effectiveness, inconvenience, ease of placement, comparison to other isolation techniques and patient factors. Factor analysis, cluster analysis and multivariable logistic regression analysed the relationship between attitudes and rubber dam use. Results All items had responses at each point on the 5-point scale, with an overall pattern of substantial variation across dentists. Five attitudinal factors (rubber dam effectiveness; inconvenient/time-consuming; ease of placement; effectiveness compared to Isolite; patient factors) and 4 clusters of practitioners were identified. Each factor and cluster was independently and strongly associated with rubber dam use. Conclusions General dentists have substantial variation in attitudes about rubber dam use. Beliefs that rubber dam use is not effective, inconvenient, time-consuming, not easy to place or affected by patient factors, were independently and significantly associated with lower rubber dam use. These attitudes explain why there is substantial discordance between presumed standard of care and actual practice
Chew, Han Ei; Faber, Johannes; Liu, Zhiming; Madera, Vanessa; Qamar, Nafees
Population aging looms over countries all over the world. The social and economic implications of this phenomenon extend beyond the individual person and the immediate family, affecting broader society and the global community in profound ways. Aging populations increase pressure on already over-burdened public health care services and expenditures. To address this impending predicament, many health care providers and countries have turned to technological solutions. The near-ubiquity of mobile devices entails that mHealth will rapidly become a key component of technologically-enabled health care delivery services. This poster presents research and engineering challenges for a sustainable ICT solution that supports information exchange for mobile geriatric care.
This study is set against the backdrop of the evolving order of a health care system in a province implementing a set of concurrent reforms. The study investigates how 'knowledge work' of multi-disciplinary health care teams is actually done and how it is co-ordinated across sites. Knowledge work involves three processes: the creation of new knowledge during the transfer of knowledge, in the context of the application of knowledge to their collective clinical decision-making. Institutional ethnography is used to explore the social and institutional forces that shape the knowledge work of health care providers in and across multi-disciplinary teams by way of examining how the texts trans-locally organise the formation and functioning of multi-disciplinary teams. The study confirms that in the course of their collective clinical decision-making, teams' dialogical exchange facilitates the articulation of tacit knowledge and opens up the communicative space for the creation of new knowledge. In addition to this confirmatory finding, the study contributes to the existing health-related knowledge management by illustrating the importance of the social, communicative aspects of the knowledge processes, and in particular, the relationship between knowledge and the social organisation of power.
Ricketts, Thomas C; Fraher, Erin P
There is growing consensus that the health care workforce in the United States needs to be reconfigured to meet the needs of a health care system that is being rapidly and permanently redesigned. Accountable care organizations and patient-centered medical homes, for instance, will greatly alter the mix of caregivers needed and create new roles for existing health care workers. The focus of health system innovation, however, has largely been on reorganizing care delivery processes, reengineering workflows, and adopting electronic technology to improve outcomes. Little attention has been paid to training workers to adapt to these systems and deliver patient care in ever more coordinated systems, such as integrated health care networks that harmonize primary care with acute inpatient and postacute long-term care. This article highlights how neither regulatory policies nor market forces are keeping up with a rapidly changing delivery system and argues that training and education should be connected more closely to the actual delivery of care.
Saba, Virginia K; Arnold, Jean M
To provide a means for calculating the cost of nursing care using the Clinical Care Classification System (CCCS). Three CCCS indicators of care components, actions, and outcomes in conjunction with Clinical Care Pathways (CCPs). The cost of patient care is based on the type of action time multiplied by care components and nursing costs. The CCCM for the CCCS makes it possible to measure and cost out clinical practice. The CCCM may be used with CCPs in the electronic patient medical record. The CCPs make it easy to track the clinical nursing care across time, settings, population groups, and geographical locations. Collected data may be used many times, allowing for improved documentation, analysis, and costing out of care.
Bigdeli, Shoaleh; Pakpour, Vahid; Aalaa, Maryam; Shekarabi, Robabeh; Sanjari, Mahnaz; Haghani, Hamid; Mehrdad, Neda
Background: Educational clinical environment has an important role in nursing students' learning. Any difference between actual and expected clinical environment will decrease nursing students’ interest in clinical environments and has a negative correlation with their clinical performance. Methods: This descriptive cross-sectional study is an attempt to compare nursing students' perception of the actual and expected status of clinical environments in medical-surgical wards. Participants of the study were 127 bachelor nursing students of Iran University of Medical Sciences in the internship period. Data gathering instruments were a demographic questionnaire (including sex, age, and grade point average), and the Clinical Learning Environment Inventory (CLEI) originally developed by Professor Chan (2001), in which its modified Farsi version (Actual and Preferred forms) consisting 42 items, 6 scales and 7 items per scale was used. Descriptive and inferential statistics (t-test, paired t-test, ANOVA) were used for data analysis through SPSS version 16. Results: The results indicated that there were significant differences between the preferred and actual form in all six scales. In other word, comparing with the actual form, the mean scores of all items in the preferred form were higher. The maximum mean difference was in innovation and the highest mean difference was in involvement scale. Conclusion: It is concluded that nursing students do not have a positive perception of their actual clinical teaching environment and this perception is significantly different from their perception of their expected environment. PMID:26034726
Chisholm, Marie A.; Wade, William E.
Evaluates the use of actual patients in a required clinical applications course at the University of Georgia College of Pharmacy. Patients discuss their illness and how it affects their lives with the first-year students. On 12 of 13 items, students scored significantly higher on an attitude survey following the first patient presentation than…
Brinker, Mary Catherine
The purpose of this existential-phenomenological study was to address the first-person perspective of what it is like to experience clinical reasoning during a simulation. It was not known how a novice nurse would describe the experience of actualizing clinical reasoning during the academic simulation experience. In order to maintain the…
Brinker, Mary Catherine
The purpose of this existential-phenomenological study was to address the first-person perspective of what it is like to experience clinical reasoning during a simulation. It was not known how a novice nurse would describe the experience of actualizing clinical reasoning during the academic simulation experience. In order to maintain the…
Mullaney, J A
Each year, 19 million clients are treated for depressive episodes lasting 6 to 12 months. With depression's economic costs between 16 to 43 billion dollars annually, managed care has reduced clinician time, currently averaging 25 minutes per visit. The purpose of this phenomenological study is to describe the essential structure of the lived experience of depressed women who enter therapy and experience Watson's actual caring occasion (ACO) within the transpersonal caring relationship (TCR). A purposive sample of 11 depressed women related their subjective experiences in therapy over 6 months. Spiegelberg's phenomenological method was used for data analysis of 110 pages of therapist's notes transcribed verbatim. Five essential themes emerged from data analysis. All participants stated Watson's ACO caused them to persist in treatment and adopt health-seeking behaviors. This finding supports the expense of appropriate clinician time for holistic healing in the TCR.
Martich, G Daniel; Waldmann, Carl S; Imhoff, Michael
Health care information systems have the potential to enable better care of patients in much the same manner as the widespread use of the automobile and telephone did in the early 20th century. The car and phone were rapidly accepted and embraced throughout the world when these breakthroughs occurred. However, the automation of health care with use of computerized information systems has not been as widely accepted and implemented as computer technology use in all other sectors of the global economy. In this article, the authors examine the need, risks, and rewards of clinical informatics in health care as well as its specific relationship to critical care medicine.
Eloy, Philippe; Poirrier, Anne Lise; De Dorlodot, Clotilde; Van Zele, Thibaut; Watelet, Jean Baptiste; Bertrand, Bernard
Rhinosinusitis (RS) is a heterogeneous group of diseases. It is a significant and increasing health problem that affects about 15% of the population in Western countries. It has a substantial impact on patients' health-related quality of life and daily functioning and represents a huge financial burden to society and the health care system as a result of the direct and indirect costs. In addition, RS is not well-understood, and little is known about the etiology and pathophysiology. In the past decade, many papers have been published that have changed our understanding of RS. RS is commonly classified into acute and chronic RS based on symptom duration. In acute RS, an inflammatory reaction initiated by a viral infection characterizes most uncomplicated, mild to moderate cases. Therefore, the first line of treatment for these cases are intranasal steroids and not antibiotics. In severe and complicated cases, antibiotics combined with topical steroids remain the treatment of choice. On the other hand, chronic RS is actually subdivided into two distinct entities (chronic rhinosinusitis with and without polyps), as growing evidence indicates that these entities have specific inflammatory pathways and cytokine profiles. The authors review recent data regarding the clinical presentations, cytokine profiles, tissue remodeling, and modalities of treatment for each form of RS.
Tang, Chiung-Ya; Lin, Yi-Ling; Masri, Maysoun Dimachkie
Background The Accountable Care Organization (ACO) is one of the new models of health care delivery in the U.S. To date, little is known about the characteristics of health care organizations that have joined ACOs. We report on the findings of a survey of primary care clinics, the objective of which was to investigate the opinions of clinic management about participation in ACOs, and the characteristics of clinic organizational structure that may contribute to joining ACOs or be willing to do so. Methods A 27-item survey questionnaire was developed and distributed by mail in 3 annual waves to all Rural Health Clinics (RHCs) in 9 states. Two dependent variables - participation in ACOs and willingness to join ACOs - were created and analyzed using a generalized estimating equation (GEE) approach. Results 257 RHCs responded to the survey. A small percentage (5.2%) of the respondent clinics reported that they were participating in ACOs. RHCs in isolated areas were 78% less likely to be in ACOs (odds= 0.22, p= 0.059). Non-profit RHCs indicated a higher willingness to join an ACO than for-profit RHCs (B= 1.271, p= 0.054). There is a positive relationship between RHC size and willingness to join an ACO (B= 0.402, p=0.010). Conclusions At this early stage of ACO development, many RHC personnel are unfamiliar with the ACO model. Rural providers’ limited technological and human resources, and the lack of ACO development in rural areas, may delay or prevent their participation in ACOs. PMID:26900587
Rose, Warren E.; Fox, Barry C.; Andes, David R.; Buhr, Kevin A.; Fish, Jeffrey T.
Daptomycin use at our institution changed to ideal body weight dosing based on a published analysis of pharmacokinetic-pharmacodynamic efficacy target attainment, bacterial ecology, and a desire to reduce drug toxicity. The current study compared outcomes between actual body weight and ideal body weight dosing of daptomycin before and after this intervention. In the evaluable group, 69 patients received doses based on actual body weight and 48 patients received doses based on ideal body weight. Patients were treated for documented Enterococcus species, Staphylococcus aureus, or coagulase-negative Staphylococcus infections, including bloodstream, intraabdominal, skin and soft tissue, urinary, and bone. There was no statistically significant difference in clinical success between the groups (88.9% for actual body weight compared to 89.1% for ideal body weight, P = 0.97). After we adjusted for gender, age, body mass index, concomitant 3-hydroxy-3-methylglutaryl–coenzyme A reductase inhibitors, infection type, and organism type, clinical success rates remained similar between groups (adjusted odds ratio of 0.68 in favor of actual body weight, 95% confidence interval [CI] of 0.13 to 3.55). Microbiological outcomes, length of stay, mortality, and adverse effects were also similar between groups. Further studies are warranted to confirm that ideal body weight dosing provides similar outcomes to actual body weight dosing for all patients and types of infections and organisms. PMID:24145531
Shao, Ming-Yi; Liu, Bao-Yan; He, Li-Yun; Zhang, Run-Shun
Data authenticity is the basic requirement of clinical studies. In actual clinical conditions how to establish formatted case report forms (CRF) in line with the requirement for data authenticity is the key to ensure clinical data quality. On the basis of the characteristics of clinical data in actual clinical conditions, we determined elements for establishing formatted case report forms by comparing differences in data characteristics of CRFs in traditional clinical studies and in actual clinical conditions, and then generated formatted case report forms in line with the requirement for data authenticity in actual clinical conditions. The data of formatted CRFs generated in this study could not only meet the requirement for data authenticity of clinical studies in actual clinical conditions, but also comply with data management practices for clinical studies, thus it is deemed as a progress in technical methods.
Rankin, Janet M
This paper uses Dorothy Smith's institutional ethnography to examine technological advances designed to improve nurses' work. The analysis interrogates how nurses' work is coordinated, in disquieting ways, in an apparent commitment to 'patient and family centred care'. The discussion is part of a larger programme of research that focuses ethnographic attention on nurses' activating technological managerial improvement strategies. This discussion paper describes suboptimal hospital experiences to show how they were organized. The institutional ethnographic analysis addresses discrepancies that arise between the different organizational standpoints. Overall the discussion focuses on how institutional ethnographers enquire into people's everyday activities to discover and make understandable, in the material world, what actually happens that shapes them. Data include observations and interviews with nurses, nurse managers, patients and families. It also includes screenshots of computer fields and other documents being used by nurses. Nursing work is methodically being oriented to interests that undermine nurses' capacity to contribute their knowledgeable activity to intervene in people's health and well-being. Nurses' work is overwhelmed with the imperative to discharge patients. This happens with an ideological construction of patient centred care that obscures what is actually happening. © 2014 John Wiley & Sons Ltd.
Lamers, Ilse; Kerkhofs, Lore; Raats, Joke; Kos, Daphne; Van Wijmeersch, Bart; Feys, Peter
The real-life relevance of frequently applied clinical arm tests is not well known in multiple sclerosis (MS). This study aimed to determine the relation between real-life arm performance and clinical tests in MS. Thirty wheelchair-bound MS patients and 30 healthy controls were included. Actual and perceived real-life arm performance was measured by using accelerometry and a self-reported measure (Motor Activity Log). Clinical tests on 'body functions & structures' (JAMAR handgrip strength, Motricity Index (MI), Fugl Meyer (FM)) and 'activity' level (Nine Hole Peg Test (NHPT), Action Research Arm test) of the International Classification of Functioning were conducted. Statistical analyses were performed separately for current dominant and non-dominant arm. For all outcome measures, MS patients scored with both arms significantly lower than the control group. Higher correlations between actual arm performance and clinical tests were found for the non-dominant arm (0.63-0.80). The FM (55%) was a good predictor of actual arm performance, while the MI (46%) and NHPT (55%) were good predictors of perceived arm performance. Real-life arm performance is decreased in wheelchair-bound MS patients and can be best predicted by measures on 'body functions & structures' level and fine motor control. Hand dominance influenced the magnitude of relationships.
Shivers, Eleanor; Hasson, Felicity; Slater, Paul
Clinical learning is a vital component of nurse education and assessing student's experiences can provide useful insights for development. Whilst most research in this area has focused on the acute setting little attention has been given to all pre-registration nurses' experience across the clinical placements arenas. To examine of pre-registration nursing students (first, second and third year) assessment of their actual experiences of their most recent clinical learning clinical learning experience. A cross sectional survey involving a descriptive online anonymous questionnaire based on the clinical learning environment inventory tool. One higher education institution in the United Kingdom. Nursing students (n=147) enrolled in an undergraduate nursing degree. This questionnaire included demographic questions and the Clinical Learning Environment Inventory (CLEI) a 42 item tool measuring student's satisfaction with clinical placement. SPPS version 22 was employed to analyse data with descriptive and inferential statistics. Overall students were satisfied with their clinical learning experience across all placement areas. This was linked to the 6 constructs of the clinical learning environment inventory; personalization, innovation, individualization, task orientation, involvement, satisfaction. Significant differences in student experience were noted between age groups and student year but there was no difference noted between placement type, age and gender. Nursing students had a positive perception of their clinical learning experience, although there remains room for improvement. Enabling a greater understanding of students' perspective on the quality of clinical education is important for nursing education and future research. Copyright © 2017. Published by Elsevier Ltd.
Starfield, B; Gérvas, J; Mangin, D
Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.
Woksepp, H; Hällgren, A; Borgström, S; Kullberg, F; Wimmerstedt, A; Oscarsson, A; Nordlund, P; Lindholm, M-L; Bonnedahl, J; Brudin, L; Carlsson, B; Schön, T
Patients in the intensive care unit (ICU) are at risk for suboptimal levels of β-lactam antibiotics, possibly leading to poor efficacy. Our aim was to investigate whether the actual minimum inhibitory concentration (MIC) compared to the more commonly used arbitrary epidemiological cut-off values (ECOFFs) would affect target attainment in ICU patients on empirical treatment with broad-spectrum β-lactam antibiotics and to identify risk factors for not reaching target. In a prospective, multicenter study, ICU patients ≥18 years old and treated with piperacillin/tazobactam, meropenem, or cefotaxime were included. Clinical and laboratory data were recorded. Serum trough antibiotic levels from three consecutive days were analyzed by liquid chromatography-mass spectrometry (LC-MS). The target was defined as the free trough concentration above the MIC (100% fT>MIC). MICECOFF was used as the target and, when available, the actual MIC (MICACTUAL) was applied. The median age of the patients was 70 years old, 52% (58/111) were males, and the median estimated glomerular filtration rate (eGFR) was 48.0 mL/min/1.73 m(2). The rate of patients reaching 100% fT > MICACTUAL was higher (89%, 31/35) compared to the same patients using MICECOFF (60%, p = 0.002). In total, 55% (61/111) reached 100% fT > MICECOFF. Increased renal clearance was independently associated to not reaching 100% fT > MICECOFF. On repeated sampling, >77% of patients had stable serum drug levels around the MICECOFF. Serum concentrations of β-lactam antibiotics vary extensively between ICU patients. The rate of patients not reaching target was markedly lower for the actual MIC than when the arbitrary MIC based on the ECOFF was used, which is important to consider in future studies.
Han, Eui-Ryoung; Chung, Eun-Kyung
INTRODUCTION This study examines the relationship between the clinical performance of medical students and their performance as doctors during their internships. METHODS This retrospective study involved 63 applicants of a residency programme conducted at Chonnam National University Hospital, South Korea, in November 2012. We compared the performance of the applicants during their internship with their clinical performance during their fourth year of medical school. The performance of the applicants as interns was periodically evaluated by the faculty of each department, while their clinical performance as fourth-year medical students was assessed using the Clinical Performance Examination (CPX) and the Objective Structured Clinical Examination (OSCE). RESULTS The performance of the applicants as interns was positively correlated with their clinical performance as fourth-year medical students, as measured by the CPX and OSCE. The performance of the applicants as interns was moderately correlated with the patient-physician interaction items addressing communication and interpersonal skills in the CPX. CONCLUSION The clinical performance of medical students during their fourth year in medical school was related to their performance as medical interns. Medical students should be trained to develop good clinical skills through actual encounters with patients or simulated encounters using manikins, to enable them to become more competent doctors. PMID:26768172
Han, Eui-Ryoung; Chung, Eun-Kyung
This study examines the relationship between the clinical performance of medical students and their performance as doctors during their internships. This retrospective study involved 63 applicants to a residency programme conducted at the Chonnam National University Hospital, South Korea, in November 2012. We compared the performance of the applicants during their internship with the clinical performance of the applicants during their fourth year of medical school. The performance of the applicants as interns was periodically evaluated by the faculty of each department, while the clinical performance of the applicants as fourth year medical students was assessed using the Clinical Performance Examination (CPX) and the Objective Structured Clinical Examination (OSCE). The performance of the applicants as interns was positively correlated with their clinical performance as fourth year medical students, as measured by CPX and OSCE. The performance of the applicants as interns was moderately correlated with the patient-physician interactions items addressing communication and interpersonal skills in the CPX. The clinical performance of medical students during their fourth year in medical school was related to their performance as medical interns. Medical students should be trained to develop good clinical skills, through actual encounters with patients or simulated encounters using manikins, so that they are able to become competent doctors. Copyright © Singapore Medical Association.
opportunities, satisfactory supervision, and self-actualization. One study indicated that nursing education promotes self-actualization at least to... nursing education achieved in burnout syndrome symptoms? 8. Is there a difference by level of nursing education achieved in self-actualization...level of nursing education achieved in the burnout scores or the self-actualization scores. The exception was that the associate degree nurses scored
Under the Pol Pot Khmer Rouge regime, most physicians with clinical experience were either killed or fled the country. The few practitioners who managed to survive were forced to hide their knowledge; much of that knowledge and experience is now lost. As part of a general process of national rehabilitation, Cambodia has trained since the 1980s hundreds of physicians and physician assistants. There were 700 physicians, 1300 physician assistants, and 4000 nurses in the country by 1992. Problems do, however, remain with medical education in Cambodia. In particular, the medical texts and lectures are in French, a language which very few of the younger generation speak; instructional texts are designed to meet the needs of developing nations, not a rehabilitating one like Cambodia; emphasis is upon curative health care, hospitals, and vertical programs instead of primary and preventive health care; Cambodian physicians are used to a system based upon the division of patients by ability to pay instead of by age, disease, or need; corruption has grown as the cost of living has outstripped the level of official salaries; and there is neither professional contact, feedback, nor program evaluation within health care programs. The authors is a resident in obstetrics and gynecology at the University of Chicago who worked at two clinics during a stay in Phnom Penh. She recommends that instead of simply training more doctors, these training-related problems should be addressed, including a revision of the curriculum to include both primary health care medicine and psychiatry. Moreover, people in Cambodia need to be taught the importance of preventive health care, which should then reduce the number of visits to physicians. This process will be accomplished more effectively with the cooperation of physicians, the government, nongovernmental organizations, and international organizations associated with health care.
Lee, Ho Sup; Min, Chang-Ki
Multiple myeloma is an incurable malignant plasma cell-originating cancer. Although its treatment outcomes have improved with the use of glucocorticoids, alkylating drugs, and novel agents, including proteasome inhibitors (bortezomib and carfilzomib) and immunomodulatory drugs (thalidomide, lenalidomide, and pomalidomide), relapse remains a serious problem. Strategies to improve outcomes following autologous stem cell transplantation and frontline treatments in non-transplant patients include consolidation to intensify therapy and improve the depth of response and maintenance therapy to achieve long-term disease control. Many clinical trials have reported increased progression-free and overall survival rates after consolidation and maintenance therapy. The role of consolidation/maintenance therapy has been assessed in patients eligible and ineligible for transplantation and is a valuable option in clinical trial settings. However, the decision to use consolidation and/or maintenance therapy needs to be guided by the individual patient situation in actual clinical practice. This review analyzes the currently available evidence from several reported clinical trials to determine the optimal consolidation and maintenance therapy in clinical practice. PMID:27604793
Sulmasy, Daniel P
Interest in the relationship between spirituality, religion, and clinical care has increased in the last 15 years, but clinicians need more concrete guidance about this topic. This article defines spirituality and religion, identifies the fundamental spiritual issues that serious illness raises for patients, and argues that physicians have a moral obligation to address patients' spiritual concerns. Religions often provide patients with specific moral guidance about a variety of medical issues and prescribe rituals that are important to patients. Religious coping can be both positive and negative, and it can impact patient care. This article provides concrete advice about taking a spiritual history, ethical boundaries, whether to pray with patients, and when to refer patients to chaplains or to their own personal clergy.
Babenko-Mould, Yolanda; Ferguson, Karen; Riddell, Thelma; Hancock, Michele; Atthill, Stephanie
To examine students' structural empowerment during simulated learning and actual nursing practice, and assess students' self-efficacy for public health nursing competencies (PHNC) after involvement in a mass influenza vaccination clinic as a community practice experience. A nonexperimental survey design was used with a sample of year three baccalaureate nursing students. Students completed a demographic form after the simulated clinic experience, they were assessed for perceptions of empowerment after being involved in the simulated and actual clinic settings, and self-efficacy was assessed after the actual clinic experience. Students perceived themselves as structurally empowered after completing the simulated and actual community vaccination clinics. Students reported a high level of self-efficacy for PHNC after their actual community vaccination clinic involvement. There was a significant correlation between empowerment and self-efficacy, which suggests that when students have access to empowering structures, they feel more confident to enact PHNC that align with practice in the clinics. This study suggests that nursing students acquired the necessary knowledge and skills for safe vaccination administration through the combination of simulated practice and participating in an actual public health vaccination clinic. © 2014 Wiley Periodicals, Inc.
Catlin, Anita; Taylor-Ford, Rebecca L
To determine whether provision of Reiki therapy during outpatient chemotherapy is associated with increased comfort and well-being. Double-blind, randomized clinical controlled trial. Outpatient chemotherapy center. 189 participants were randomized to actual Reiki, sham Reiki placebo, or standard care. Patients receiving chemotherapy were randomly placed into one of three groups. Patients received either standard care, a placebo, or an actual Reiki therapy treatment. A demographic tool and pre- and post-tests were given before and after chemotherapy infusion. Reiki therapy, sham Reiki placebo therapy, standard care, and self-reported levels of comfort and well-being pre- and postintervention. Although Reiki therapy was statistically significant in raising the comfort and well-being of patients post-therapy, the sham Reiki placebo also was statistically significant. Patients in the standard care group did not experience changes in comfort and well-being during their infusion session. The findings indicate that the presence of an RN providing one-on-one support during chemotherapy was influential in raising comfort and well-being levels, with or without an attempted healing energy field. An attempt by clinic nurses to provide more designated one-to-one presence and support for patients while receiving their chemotherapy infusions could increase patient comfort and well-being.
da Silva, Rafael Celestino; Ferreira, Márcia de Assunção; Apostolidis, Thémistoklis; Brandão, Marcos Antônio Gomes
to propose a conceptual framework for clinical nursing care in intensive care. descriptive and qualitative field research, carried out with 21 nurses from an intensive care unit of a federal public hospital. We conducted semi-structured interviews and thematic and lexical content analysis, supported by Alceste software. the characteristics of clinical intensive care emerge from the specialized knowledge of the interaction, the work context, types of patients and nurses characteristic of the intensive care and care frameworks. the conceptual framework of the clinic's intensive care articulates elements characteristic of the dynamics of this scenario: objective elements regarding technology and attention to equipment and subjective elements related to human interaction, specific of nursing care, countering criticism based on dehumanization.
Mehrotra, Ateev; Dean, Katie M; Sinaiko, Anna D; Sood, Neeraj
The growing awareness of the wide variation in health care prices, increased availability of price data, and increased patient cost sharing are expected to drive patients to shop for lower-cost medical services. We conducted a nationally representative survey of 2,996 nonelderly US adults who had received medical care in the previous twelve months to assess how frequently patients are price shopping for care and the barriers they face in doing so. Only 13 percent of respondents who had some out-of-pocket spending in their last health care encounter had sought information about their expected spending before receiving care, and just 3 percent had compared costs across providers before receiving care. The low rates of price shopping do not appear to be driven by opposition to the idea: The majority of respondents believed that price shopping for care is important and did not believe that higher-cost providers were of higher quality. Common barriers to shopping included difficulty obtaining price information and a desire not to disrupt existing provider relationships. Project HOPE—The People-to-People Health Foundation, Inc.
Blanchette, Patricia Lanoie; And Others
This issue includes 18 theme articles that examine clinical care, conditions, and practice as they relate to older adults. It contains articles on the following: men's and women's health, depression, dementia, hypertension, incontinence, bone pain, infections, preventive medicine, geriatric medicine, health care delivery, managed care, long-term…
Cappiello, Joyce D; Beal, Margaret W; Simmonds, Katherine E
This article provides an overview of the clinical issues in post-abortion care, including types of abortion procedures, expected post-abortion course, possible complications, and the components of the post-abortion visit. By providing follow-up care to their patients, NPs can increase continuity of care and promote successful contraceptive use.
Blanchette, Patricia Lanoie; And Others
This issue includes 18 theme articles that examine clinical care, conditions, and practice as they relate to older adults. It contains articles on the following: men's and women's health, depression, dementia, hypertension, incontinence, bone pain, infections, preventive medicine, geriatric medicine, health care delivery, managed care, long-term…
Fakhri, Shoaib; Engelberg, Ruth A; Downey, Lois; Nielsen, Elizabeth L; Paul, Sudiptho; Lahdya, Alexandria Z; Treece, Patsy D; Curtis, J Randall
Discussions about end-of-life care are often difficult for patients and clinicians, and inadequate communication poses a barrier to patients receiving the care they desire. To understand factors that facilitate end-of-life care discussions that guide interventions to improve care. We examined baseline data from an ongoing randomized trial to evaluate associations between patients' self-reported desire for, and occurrence of, discussions about end-of-life care and factors influencing these discussions. Factors included emotional symptoms and barriers and facilitators to discussions. The sample included patients with serious illness (n = 473) and their primary or specialty care clinicians (n = 128). Regression analyses were adjusted for confounders and clustered patients under clinicians. Patients who endorsed each of three barriers to discussions were less likely to have had a discussion with their clinician (P-values ranging from <0.001 to 0.046). One facilitator (having had family/friends who died) was associated with past discussions (P = 0.037), and two facilitators were associated with wanting future discussion (P < 0.001): 1) concerns about future quality of life, 2) worries about being a burden on friends/family. Depression and anxiety were not associated with past discussions. However, patients with more anxiety were more likely to want future discussions (P = 0.001), as were patients with more depressive symptoms who had had discussions in the past (P < 0.001). The occurrence of, and desire for, patient-clinician communication about end-of-life care is associated with patient factors including communication barriers and facilitators and symptoms of depression and anxiety. Understanding these factors may facilitate design of effective communication interventions. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Rehnsfeldt, Arne; Arman, Maria; Lindström, Unni Å
Clinical caring science will be described from a theory of science perspective. The aim of this theoretical article to give a comprehensive overview of clinical caring science as a human science-based discipline grounded in a theory of science argumentation. Clinical caring science seeks idiographic or specific variations of the ontology, concepts and theories, formulated by caring science. The rationale is the insight that the research questions do not change when they are addressed in different contexts. The academic subject contains a concept order with ethos concepts, core and basic concepts and practice concepts that unites systematic caring science with clinical caring science. In accordance with a hermeneutic tradition, the idea of the caring act is based on the degree to which the theory base is hermeneutically appropriated by the caregiver. The better the ethos, essential concepts and theories are understood, the better the caring act can be understood. In order to understand the concept order related to clinical caring science, an example is given from an ongoing project in a disaster context. The concept order is an appropriate way of making sense of the essence of clinical caring science. The idea of the concept order is that concepts on all levels need to be united with each other. A research project in clinical caring science can start anywhere on the concept order, either in ethos, core concepts, basic concepts, practice concepts or in concrete clinical phenomena, as long as no parts are locked out of the concept order as an entity. If, for example, research on patient participation as a phenomenon is not related to core and basic concepts, there is a risqué that the research becomes meaningless. © 2016 Nordic College of Caring Science.
Hunt, Linda M.; Truesdell, Nicole D.; Kreiner, Meta J.
Race, although an unscientific concept, remains prominent in health research and clinical guidelines, and is routinely invoked in clinical practice. In interviews with 58 primary care clinicians we explored how they understand and apply concepts of racial difference. We found wide agreement that race is important to consider in clinical care. They explained the effect of race on health, drawing on common assumptions about the biological, class, and cultural characteristics of racial minorities. They identified specific race-based clinical strategies for only a handful of conditions and were inconsistent in the details of what they said should be done for minority patients. We conclude that using race in clinical medicine promotes and maintains the illusion of inherent racial differences and may result in minority patients receiving care aimed at presumed racial group characteristics, rather than care selected as specifically appropriate for them as individuals. [race and genetics, primary care, health disparities, racial profiling] PMID:23804331
Halldorsdottir (1990) investigated students’ perspective of a caring student- teacher encounter. Students described a caring teacher as being professionally...Nursing. Gaut, D. (1986). Evaluating caring nursing competencies in nursing practice. Topics in Clinical Nursing. 8(2), 77-83. Halldorsdottir , S. (1990
O'Toole, Thomas P; Freyder, Paul J; Gibbon, Jeanette L; Hanusa, Barbara J; Seltzer, Debora; Fine, Michael J
We report findings from a community-based two-city survey of homeless adults comparing the level of substance abuse treatment assigned to them using the ASAM Patient Placement Criteria with care actually received during the previous 12 months. Overall 531 adults were surveyed with 382 meeting DSM-IIIR criteria of being in need of treatment or having a demand for treatment. Of those with a treatment need, 1.5% met criteria for outpatient care, 40.3% intensive outpatient/partial hospitalization care, 29.8% medically monitored care and 28.8% managed care levels. In contrast, of those receiving treatment (50.5%, 162 persons), almost all care received by this cohort was either inpatient or residential based (83.6%). Unsheltered homeless persons and those without insurance were significantly more likely to report not receiving needed treatment. Lack of treatment availability or capacity, expense, and changing one's mind while on a wait list were the most commonly cited reasons for no treatment.
Norris, Deborah J.; Guss, Shannon
Quality Rating Improvement Systems (QRIS) frequently include the Infant-Toddler Environment Rating Scale-Revised (ITERS-R) as part of rating and improving child care quality. However, studies utilizing the ITERS-R consistently report low quality, especially for basic caregiving items. This research examined whether the low scores reflected the…
Norris, Deborah J.; Guss, Shannon
Quality Rating Improvement Systems (QRIS) frequently include the Infant-Toddler Environment Rating Scale-Revised (ITERS-R) as part of rating and improving child care quality. However, studies utilizing the ITERS-R consistently report low quality, especially for basic caregiving items. This research examined whether the low scores reflected the…
van der Kooij, C H; Dröes, R M; de Lange, J; Ettema, T P; Cools, H J M; van Tilburg, W
Successful implementation is a vital precondition for investigating the outcome of care innovation. This study concerned the evaluation of the implementation of integrated emotion-oriented care (IEOC) in psychogeriatric nursing home wards. The main question was whether the trained caregivers actually applied the knowledge and techniques of IEOC during their daily work. The study was conducted within the framework of a randomized clinical trial into the effectiveness of IEOC in 16 wards. Preceding the experimental period, staff from 16 wards were educated and trained to work with a standardized care plan, resulting in a similar level of quality of care at the start of the trial. On the experimental wards IEOC was then implemented by training on the job in addition to training courses for personnel. To examine the implementation effectiveness, a self-report questionnaire, 'Emotion-oriented Skills in the Interaction with Elderly People with Dementia', was administered at baseline and after 7 months to a sample of caregivers from the experimental and the control wards. In addition, participant observation was conducted on four experimental and four control wards, and time spent by care personnel on different type of care tasks was registered. The implementation of IEOC resulted in increased emotion-oriented skills and more knowledge of the residents among the caregivers. Providing IEOC was not more time consuming for the caregivers than providing usual care. This study shows that the implementation of IEOC was effective. It is recommended that in intervention studies the correct application of a new intervention or care approach is examined before jumping to conclusions about the effectiveness of the intervention or care approach itself.
Ma, Fang; Li, Jiping; Zhu, Dan; Bai, Yangjuan; Song, Jianhua
In light of the call for humanistic caring in the contemporary health care system globally and in China, the issue of improving the caring skills that are essential to student success, high-quality nursing practice and positive patient outcomes is at the forefront of nursing education. The aim of this mixed-methods quantitative and qualitative study was to investigate baccalaureate nursing students' caring ability in the context of China and to explore the role of clinical practice learning in the development of students' caring skills. A two-phase, descriptive study utilising a mixed methodology consisting of a caring ability survey and focus group interviews was conducted. In the quantitative phase, 598 baccalaureate nursing students at two colleges in Yunnan Province in southwest China were surveyed using the Caring Ability Inventory (CAI). In the qualitative phase, 16 of the students who had participated in the quantitative phase were interviewed. Students obtained lower scores on the CAI than have been reported elsewhere by other researchers. In addition, students in the clinical stage of training scored lower than students in the pre-clinical stage. Three themes concerning facilitation by and three themes concerning the obstructive effects of clinical practice learning in the development of caring ability were identified. Themes pertaining to facilitation were: (i) promoting a sense of professional responsibility and ethics; (ii) providing an arena in which to practise caring, and (iii) learning from positive role models. Themes pertaining to obstruction were: (i) a critical practice learning environment; (ii) encountering inappropriate clinical teachers, and (iii) experiencing shock at the contrast between an idealised and the real environment. The key to developing students' ability to care lies in highlighting caring across the entire health care system. By diminishing exposure to negative role models, and adopting appropriate pedagogical ideas about
Chow, Vinca W; Hepner, David L; Bader, Angela M
Fragmented and variable perioperative care exposes patients to unnecessary risks and handoff errors. The perioperative surgical home aims to optimize quality, value-based care. We performed a retrospective evaluation of how a preoperative assessment center could coordinate care through e-mails sent to a patient's healthcare team that initiate discussion on critical clinical information. During 100 clinic days on which 8122 patients were evaluated, 606 triggered e-mails, with a potential impact on 19 elements across the perioperative care spectrum. Four cases were canceled, and 42 cases were rescheduled. By fostering information exchange, these communications could advance patient-centered, value-enhanced quality and safety outcomes.
Lawlor-Klean, Phyllis; Lefaiver, Cheryl A; Wiesbrock, Jeanne
The purposes of this study were to examine nurses' perception of feeding temperature practices and to compare the nurses' temperature estimation with the measured temperature of milk at the time of delivery to the infant. A descriptive exploratory study was conducted in 3 level III neonatal intensive care units (NICUs). A convenience sample of nurses from 3 level III NICUs in the Midwest. In addition, temperatures from bottle/syringe samples of formula/breast milk were measured and recorded. The Feeding Practices and Temperature Survey, a 10-item survey measuring nurses' perception of the effect of feeding temperature on infant condition, was distributed to subjects. Afterward for select feedings, researchers recorded the type of milk, delivery method, nurses' estimated temperature of the milk, and the measured infrared temperature of milk just before feeding delivery. To compare perception with actual practice patterns, the measured milk temperature was compared with the nurses' estimated temperature, standard room temperature, and body temperature using descriptive statistics of the survey responses and t test comparisons. A total of 141 surveys were analyzed. More than 50% of respondents reported feeding temperature as clinically very significant. A range of 35.5°C to 37.2°C was reported as the ideal temperature of breast milk at delivery. Recordings of 419 temperatures were used for analysis. Measured milk temperature just before feeding ranged from 22°C to 46.4°C. The mean measured temperatures were 31.0°C (SD = 2.8°C) for warmed milk in a bottle and 30.5°C (SD = 2.5°C) for milk warmed in a syringe. The measured milk temperature and the nurse-estimated temperature were significantly lower than body temperature (P = 0.000) and significantly higher than room temperature (P = 0.000). Current warming methods yield wide variation in milk temperature. Nurses' estimation of milk temperature was not consistent with measured temperature at the time of delivery
Evans, Steven W
To discuss the impact of retail health clinics, also known as convenient care clinics (CCC), on the changing landscape of health care in the United States. Selected articles from the scientific literature and data from the industry literature. The concept of the CCC has been well-received by the public, and nurse practitioners (NPs) have been intimately involved in the development and expansion of these clinics. The professional association of CCCs has been instrumental in promoting operational standards for CCCs to insure a high quality of service. Some resistance to the concept from physicians remains but the convenience for consumers appears to drive the high levels of satisfaction reported. Collaboration among all healthcare providers is essential to expand access to care for everyone. NPs are crucial to the operation of CCCs and provide care that is well-received by consumers.
Robertson-Steel, I; Edwards, S; Gough, M
This article seeks to discover and recognize the importance of clinical governance within a new and emerging quality National Health Service (NHS) system. It evaluates the present state of prehospital care and recommends how change, via clinical governance, can ensure a paradigm shift from its currently fragmented state to a seamless ongoing patient care episode. Furthermore, it identifies the drivers of a quality revolution, examines the monitoring and supervision of quality care, and evaluates the role of evidence-based practice. A frank and open view of immediate care doctors is presented, with recommendations to improve the quality of skill delivery and reduce the disparity that exists. Finally, it reviews the current problems with pre-hospital care and projects a future course for quality and patient care excellence. PMID:11383428
Lester, William T; Zai, Adrian H; Grant, Richard W; Chueh, Henry C
The gap between best practice and actual patient care continues to be a pervasive problem in our healthcare system. Efforts to improve on this knowledge-performance gap have included computerised disease management programs designed to improve guideline adherence. However, current computerised reminder and decision support interventions directed at changing physician behaviour have had only a limited and variable effect on clinical outcomes. Further, immediate pay-for-performance financial pressures on institutions have created an environment where disease management systems are often created under duress, appended to existing clinical systems and poorly integrated into the existing workflow, potentially limiting their real-world effectiveness. The authors present a review of disease management as well as a conceptual framework to guide the development of more effective health information technology (HIT) tools for translating clinical information into clinical action.
Atienza, Gerardo; Bañeres, Joaquim; Gracia, Francisco Javier
Clinical practice guidelines are intended to serve as a bridge between the decision levels and the sources of knowledge, giving decision makers the best synthesis of scientific evidence and an analysis of context, to provide elements of judgement and to transfer scientific knowledge into clinical practice. However, the actual impact on health care is variable and effectiveness in changing medical practice, moderate. Qualitative and quantitative studies show that most primary care physicians consider that the guides are a valuable source of advice and training and a kind of improving the quality of healthcare. However, they underline its rigidity, the difficulty to apply to individual patients and that their main goal is to reduce healthcare costs. In Spain, there are several experiences as GuíaSalud in developing clinical practice guidelines aimed specifically at primary care. However, the proper implementation of a clinical practice guideline includes not only the quality and thoroughness of the evidence, but the credibility of professionals and organizations and other contextual factors such as characteristics of patients, providers and organizations or systems. An important step in future research is to develop a better theoretical understanding of organizational change that is required for management and professionals to give appropriate guidance to the implementation of the clinical practice guidelines.
Responding to changes in health care financing, government policy, technology, and clinical judgment, and the rise of managed care, hospitals are shifting services from inpatient to outpatient settings and moving them into the community. Institutions are evolving into integrated delivery systems, developing the capacity to provide a continuum of coordinated services in an array of settings and to share financial risk with physicians and managed care organizations. Over the past several years, hospitals in New York City have shifted considerable resources into ambulatory care. In their drive to expand and enhance services, however, they face serious challenges, including a well-established focus on hospitals as inpatient centers of tertiary care and medical education, a heavy reliance upon residents as providers of medical care, limited access to capital, and often inadequate physical plants. In 1995, the United Hospital Fund awarded $600,000 through its Ambulatory Care Services Initiative to support hospitals' efforts to meet the challenges of reorganizing services, compete in a managed care environment, and provide high-quality ambulatory care in more efficient ways. Through the initiative, 12 New York City hospitals started projects to reorganize service delivery and build an infrastructure of systems, technology, and personnel. Among the projects undertaken by the hospitals were:--broad-based reorganization efforts employing primary care models to improve and expand existing ambulatory care services, integrate services, and better coordinate care;--projects to improve information management, planning and testing new systems for scheduling appointments, registering patients, and tracking ambulatory care and its outcomes;--training programs to increase the supply of primary care providers (both nurse practitioners and primary care physicians), train clinical and support staff in the skills needed to deliver more efficient and better ambulatory care, prepare staff
Muldoon, Becky T; Mai, Vinh Q; Burch, Henry B
Over the last century, much has been learned about the pathogenesis, manifestations, and management of Graves' disease leading to the establishment of evidence-based clinical practice guidelines. The joint clinical practice guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists give recommendations on both the diagnosis and treatment of hyperthyroidism. A survey of clinicians performed that same year, however, revealed that current practices diverge from these recently published guidelines in multiple areas. These differences will need to be assessed serially to determine the impact of the guidelines on future clinical practice and perhaps vice versa.
Lobis, Samantha; Mbaruku, Godfrey; Kamwendo, Francis; McAuliffe, Eilish; Austin, Judy; de Pinho, Helen
Policy, regulation, training, and support for cadres adopting tasks and roles outside their historical domain have lagged behind the practical shift in service-delivery on the ground. The Health Systems Strengthening for Equity (HSSE) project sought to assess the alignment between national policy and regulation, preservice training, district level expectations, and clinical practice of cadres providing some or all components of emergency obstetric care (EmOC) in Malawi and Tanzania. A mixed methods approach was used, including key informant interviews, a survey of District Health Management Teams, and a survey of health providers employed at a representative sample of health facilities. A lack of alignment between national policy and regulation, training, and clinical practice was observed in both countries, particularly for cadres with less preservice training; a closer alignment was found between district level expectations and reported clinical practice. There is ineffective use of cadres that are trained and authorized to provide EmOC, but who are not delivering care, especially assisted vaginal delivery. Better alignment between policy and practice, and support and training, and more efficient utilization of clinical staff are needed to achieve the quality health care for which the Malawian and Tanzanian health ministries and governments are accountable. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
McIlfatrick, S; Keeney, S; McKenna, H; McCarley, N; McIlwee, G
The aim of this study was to investigate the actual and the potential role of the primary care nurse (PCN) in the prevention of cancer. International studies have indicated that a range of strategies can have an impact on the incidence of cancer. Due to their frequent front-line contact with the public, PCNs can play an important role in the primary prevention of cancer. Nonetheless, there is a lack of information on their actual and potential role in cancer prevention. A sequential confirmatory mixed methods approach was used. Postal questionnaires were administered to PCNs [n = 500; 225 returns (response rate 45%)] followed by semi-structured interviews (n = 15). PCNs provided high levels of cancer prevention activities, specifically focusing on smoking cessation, obesity and cervical screening. They considered that their cancer prevention role could be improved through additional practice-based training and more collaborative inter-professional working. They also identified the need for a better understanding of how to change people's attitudes and behaviours regarding cancer prevention. Evidence from this study provide important insights into the potential of the PCN to empower individuals to take responsibility for their own health and make more informed lifestyle choices. © 2013 John Wiley & Sons Ltd.
Söderhamn, Ulrika; Dale, Bjørg; Söderhamn, Olle
Self-care is an activity of mature persons who have developed their abilities to take care of themselves. Individuals can choose to actualize their self-care abilities into self-care activities to maintain, restore, or improve health and well-being. It is of importance to understand the meaning of the actualization of self-care resources among older people. The aim of this study was to investigate the meaning of the actualization of self-care resources, i.e., actions taken to improve, maintain, or restore health and well-being, among a group of older home-dwelling individuals with a high sense of coherence. The design of this study was to reanalyse narratives revealing self-care activities from 11 (five females and six males) Norwegian older home-dwelling people (65 years or older) identified as having a high sense of coherence. In order to reveal the meaning and get an understanding of why these self-care resources were realized or actualized, a Gadamerian-based research method was chosen. The analysis revealed four themes that showed the meaning of actualization of self-care resources in the study group: "Desire to carry on", "Be of use to others", "Self-realization", and "Confidence to manage in the future". The findings showed what older people found meaningful to strive for, and this information can be used as a guide for health professionals when supporting older people in their self-care. Older people with self-care resources can also be an important resource for others in need of social contact and practical help. These resources have to be asked for in voluntary work among older people in need of help and, thereby, can be a valuable supplement to the community health care system.
Söderhamn, Ulrika; Dale, Bjørg; Söderhamn, Olle
Self-care is an activity of mature persons who have developed their abilities to take care of themselves. Individuals can choose to actualize their self-care abilities into self-care activities to maintain, restore, or improve health and well-being. It is of importance to understand the meaning of the actualization of self-care resources among older people. The aim of this study was to investigate the meaning of the actualization of self-care resources, i.e., actions taken to improve, maintain, or restore health and well-being, among a group of older home-dwelling individuals with a high sense of coherence. The design of this study was to reanalyse narratives revealing self-care activities from 11 (five females and six males) Norwegian older home-dwelling people (65 years or older) identified as having a high sense of coherence. In order to reveal the meaning and get an understanding of why these self-care resources were realized or actualized, a Gadamerian-based research method was chosen. The analysis revealed four themes that showed the meaning of actualization of self-care resources in the study group: “Desire to carry on”, “Be of use to others”, “Self-realization”, and “Confidence to manage in the future”. The findings showed what older people found meaningful to strive for, and this information can be used as a guide for health professionals when supporting older people in their self-care. Older people with self-care resources can also be an important resource for others in need of social contact and practical help. These resources have to be asked for in voluntary work among older people in need of help and, thereby, can be a valuable supplement to the community health care system. PMID:23601788
Felder, Kay; Felt, Ulrike; Penkler, Michael
In recent years, there has been a substantial increase in bariatric surgery rates. This form of obesity treatment is often subjected to the critique that it turns patients into passive objects of medical intervention. Similarly, efforts to 'rationalize' medicine, as in evidence-based medicine, are sometimes denounced for imposing a 'one-size-fits-all' approach that neglects patient diversity. We argue that these critiques fail to do justice to the complexities of actual care situations. In our ethnographic study of a project for bariatric pre- and aftercare, we show how research protocols not only close down but also open up spaces for patient-centered care. Despite professional cautions, experiences of stigma and broader imaginations of biomedical care often lead patients to embrace surgery as a treatment conceptualized as a technological fix. We argue that investigations of how research and clinical practice intertwine need to be both empirically grounded and sensitive to wider societal contexts.
Patterson, C; Sinkewich, M; Short, J; Callas, E
The first step in redesigning the health care delivery process for ambulatory care begins with the patient and the business processes that support the patient. Patient-related business processes include patient access, service documentation, billing, follow-up, collection, and payment. Access is the portal to the clinical delivery and care management process. Service documentation, charge capture, and payment and collection are supporting processes to care delivery. Realigned provider networks now demand realigned patient business services to provide their members/customers/patients with improved service delivery at less cost. Purchaser mandates for cost containment, health maintenance, and enhanced quality of care have created an environment where every aspect of the delivery system, especially ambulatory care, is being judged. Business processes supporting the outpatient are therefore being reexamined for better efficiency and customer satisfaction. Many health care systems have made major investments in their ambulatory care environment, but have pursued traditional supporting business practices--such as multiple access points, lack of integrated patient appointment scheduling and registration, and multiple patient bills. These are areas that are appropriate for redesign efforts--all with the customer's needs and convenience in mind. Similarly, setting unrealistic expectations, underestimating the effort required, and ignoring the human elements of a patient-focused business service redesign effort can sabotage the very sound reasons for executing such an endeavor. Pitfalls can be avoided if a structured methodology, coupled with a change management process, are employed. Deloitte & Touche Consulting Group has been involved in several major efforts, all with ambulatory care settings to assist with the redesign of their business practices to consider the patient as the driver, instead of the institution providing the care.
Jurisic, Vladimir; Radenkovic, Sandra; Konjevic, Gordana
Lactate dehydrogenase (LDH) among many biochemical parameters represents a very valuable enzyme in patients with cancer with possibility for easy routine measurement in many clinical laboratories. Previous studies where mostly based on investigated LDH in serum of patients with cancer with aims to estimate their clinical significance. The new directions in investigation of LDH where based on the principle that tumor cells release intracellular enzymes trough damaged cell membrane, that is mostly consequence in intracellular mitochondrial machinery alteration, and apoptosis deregulation. This consideration can be used not only in-vitro assays, but also in respect to clinical characteristics of tumor patients. Based on new techniques of molecular biology it is shown that intracellular characteristics of LDH enzyme are very sensitive indicators of the cellular metabolic state, aerobic or anaerobic direction of glycolysis, activation status and malignant transformation. Using different molecular analyses it is very useful to analyzed intracellular LDH activity in different cell line and tumor tissues obtained from patients, not only to understanding complexity in cancer biochemistry but also in early clinical diagnosis. Based on understandings of the LDH altered metabolism, new therapy option is created with aims to blocking certain metabolic pathways and stop tumors growth.
Sun, Yuelian; Gregersen, Hans; Yuan, Wei
China has gone through a comprehensive health care insurance reform since 2003 and achieved universal health insurance coverage in 2011. The new health care insurance system provides China with a huge opportunity for the development of health care and medical research when its rich medical resources are fully unfolded. In this study, we review the Chinese health care system and its implication for medical research, especially within clinical epidemiology. First, we briefly review the population register system, the distribution of the urban and rural population in China, and the development of the Chinese health care system after 1949. In the following sections, we describe the current Chinese health care delivery system and the current health insurance system. We then focus on the construction of the Chinese health information system as well as several existing registers and research projects on health data. Finally, we discuss the opportunities and challenges of the health care system in regard to clinical epidemiology research. China now has three main insurance schemes. The Urban Employee Basic Medical Insurance (UEBMI) covers urban employees and retired employees. The Urban Residence Basic Medical Insurance (URBMI) covers urban residents, including children, students, elderly people without previous employment, and unemployed people. The New Rural Cooperative Medical Scheme (NRCMS) covers rural residents. The Chinese Government has made efforts to build up health information data, including electronic medical records. The establishment of universal health care insurance with linkage to medical records will provide potentially huge research opportunities in the future. However, constructing a complete register system at a nationwide level is challenging. In the future, China will demand increased capacity of researchers and data managers, in particular within clinical epidemiology, to explore the rich resources.
Smith, Alexander K; Thai, Julie N; Bakitas, Marie A; Meier, Diane E; Spragens, Lynn H; Temel, Jennifer S; Weissman, David E; Rabow, Michael W
Many health care organizations are interested in instituting a palliative care clinic. However, there are insufficient published data regarding existing practices to inform the development of new programs. Our objective was to obtain in-depth information about palliative care clinics. We conducted a cross-sectional survey of 20 outpatient palliative care practices in diverse care settings. The survey included both closed- and open-ended questions regarding practice size, utilization of services, staffing, referrals, services offered, funding, impetus for starting, and challenges. Twenty of 21 (95%) practices responded. Practices self-identified as: hospital-based (n=7), within an oncology division/cancer center (n=5), part of an integrated health system (n=6), and hospice-based (n=2). The majority of referred patients had a cancer diagnosis. Additional common diagnoses included chronic obstructive pulmonary disease, neurologic disorders, and congestive heart failure. All practices ranked "pain management" and "determining goals of care" as the most common reasons for referrals. Twelve practices staffed fewer than 5 half-days of clinic per week, with 7 operating only one half-day per week. Practices were staffed by a mixture of physicians, advanced practice nurses or nurse practitioners, nurses, or social workers. Eighteen practices expected their practice to grow within the next year. Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage. Billing and institutional support were the most common funding sources. Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing (11) and being overwhelmed with referrals (8). Once established, outpatient palliative care practices anticipate rapid growth. In this context, outpatient practices
Sun, Yuelian; Gregersen, Hans; Yuan, Wei
China has gone through a comprehensive health care insurance reform since 2003 and achieved universal health insurance coverage in 2011. The new health care insurance system provides China with a huge opportunity for the development of health care and medical research when its rich medical resources are fully unfolded. In this study, we review the Chinese health care system and its implication for medical research, especially within clinical epidemiology. First, we briefly review the population register system, the distribution of the urban and rural population in China, and the development of the Chinese health care system after 1949. In the following sections, we describe the current Chinese health care delivery system and the current health insurance system. We then focus on the construction of the Chinese health information system as well as several existing registers and research projects on health data. Finally, we discuss the opportunities and challenges of the health care system in regard to clinical epidemiology research. China now has three main insurance schemes. The Urban Employee Basic Medical Insurance (UEBMI) covers urban employees and retired employees. The Urban Residence Basic Medical Insurance (URBMI) covers urban residents, including children, students, elderly people without previous employment, and unemployed people. The New Rural Cooperative Medical Scheme (NRCMS) covers rural residents. The Chinese Government has made efforts to build up health information data, including electronic medical records. The establishment of universal health care insurance with linkage to medical records will provide potentially huge research opportunities in the future. However, constructing a complete register system at a nationwide level is challenging. In the future, China will demand increased capacity of researchers and data managers, in particular within clinical epidemiology, to explore the rich resources. PMID:28356772
Berglund, Catharina Bau; Gustafsson, Eva; Johansson, Hemming; Bergenmar, Mia
The aims of the present study were to investigate patients' satisfaction with nurse-led clinics, patients' perception of received information and associations between continuity of care and satisfaction with information. Questionnaires on patient satisfaction were sent to consecutive samples of patients after they attended a nurse-led clinic at the Department of Oncology, Karolinska University Hospital in 2007, 2009, 2011 and 2013. Patients' perceptions of received information were evaluated in 2011 and 2013, by the EORTC QLQ-INFO25. Data on registered continuity of care were retrieved from the patients' medical record. A total of 962 patients responded (79%) to one of the four surveys. Patients' satisfaction with nurse-led clinics was stable over time. More than 90% rated nurses' interpersonal manners and the care at the clinic as "good", the waiting time as "acceptable", and the length of appointments as "sufficient". Over 90% responded that it was important to meet the same nurse and 62% reported they actually did so and 52% stated they were assigned a named nurse navigator. More than 75% rated the information at their latest visit at a nurse-led clinic as "completely" sufficient. However, 48% expressed wish for more information "during the current disease". No statistical significant associations were found between "satisfaction with information" and continuity of care. Patients' satisfaction with nurse-led clinics was stable over time with generally high figures with the exception for continuity of care and information, areas in which improvements are needed. The wide variety in information needs might require a person-centred approach. Copyright © 2015 Elsevier Ltd. All rights reserved.
The laboratory tests supplied by clinical laboratory comprise an increasing volume in most hospitals. Consultation and effective utilization of laboratory data are important aspects of evidence-based medicine. Effective utilization of laboratory data will also contribute to the efficiency of hospital practice. Questionnaire surveys were conducted to investigate the actual situation in the information office of clinical laboratories in national, public and private facilities of 80 medical universities in Japan. Few facilities demonstrated efficient functioning, although information offices had been opened in six national, one public, and four private universities. The office staff received many questions on specimen handling and analytical methods. In the future, the office will be expected to be actively involved in mutual communications with clinical physicians and an information system such as computerized web is anticipated. Furthermore, a full-time laboratory physician and technicians are expected to provide support as experts in patient diagnosis.
Weinger, M B; Gonzales, D C; Slagle, J; Syeed, M
Experience from other domains suggests that videotaping and analyzing actual clinical care can provide valuable insights for enhancing patient safety through improvements in the process of care. Methods are described for the videotaping and analysis of clinical care using a high quality portable multi-angle digital video system that enables simultaneous capture of vital signs and time code synchronization of all data streams. An observer can conduct clinician performance assessment (such as workload measurements or behavioral task analysis) either in real time (during videotaping) or while viewing previously recorded videotapes. Supplemental data are synchronized with the video record and stored electronically in a hierarchical database. The video records are transferred to DVD, resulting in a small, cheap, and accessible archive. A number of technical and logistical issues are discussed, including consent of patients and clinicians, maintaining subject privacy and confidentiality, and data security. Using anesthesiology as a test environment, over 270 clinical cases (872 hours) have been successfully videotaped and processed using the system.
Gable, Eileen M.
Describes the innovative content and structure of an introductory course on clinical patient care at the Illinois College of Optometry. Critiques its success based on student grades and feedback, concluding that it was successful in imparting skills of data analysis but had minimal impact on students' ability to empathize with patients. (EV)
Fowler, L P
This descriptive study provides insight into home health nurses' thinking processes as they planned care for chronically ill clients. The author interviewed five experienced home health nurses to elicit think-aloud data about 10 different chronically ill clients, obtaining 20 interviews. The researcher used verbal protocol analysis, a content analysis interpretive strategy, to unravel the concepts and label the cognitive processes used in the thinking task of planning nursing care. The following cognitive strategies were discovered: hypothesizing, cue logic, framing, reflexive comparison, prototype case reasoning, and testing. Findings support the importance of content, clinical context, and experience whenever reasoning to plan care. Findings did not support problem-solving models of thinking such as the nursing process. The findings for this study are applicable to staff development and education programs. Theoretical models of clinical reasoning need to be further developed and tested.
Thai, Julie N.; Bakitas, Marie A.; Meier, Diane E.; Spragens, Lynn H.; Temel, Jennifer S.; Weissman, David E.; Rabow, Michael W.
Abstract Background Many health care organizations are interested in instituting a palliative care clinic. However, there are insufficient published data regarding existing practices to inform the development of new programs. Objective Our objective was to obtain in-depth information about palliative care clinics. Methods We conducted a cross-sectional survey of 20 outpatient palliative care practices in diverse care settings. The survey included both closed- and open-ended questions regarding practice size, utilization of services, staffing, referrals, services offered, funding, impetus for starting, and challenges. Results Twenty of 21 (95%) practices responded. Practices self-identified as: hospital-based (n=7), within an oncology division/cancer center (n=5), part of an integrated health system (n=6), and hospice-based (n=2). The majority of referred patients had a cancer diagnosis. Additional common diagnoses included chronic obstructive pulmonary disease, neurologic disorders, and congestive heart failure. All practices ranked “pain management” and “determining goals of care” as the most common reasons for referrals. Twelve practices staffed fewer than 5 half-days of clinic per week, with 7 operating only one half-day per week. Practices were staffed by a mixture of physicians, advanced practice nurses or nurse practitioners, nurses, or social workers. Eighteen practices expected their practice to grow within the next year. Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage. Billing and institutional support were the most common funding sources. Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing (11) and being overwhelmed with referrals (8). Conclusions Once established, outpatient palliative care practices
Stoddard, Hugh A; O'Dell, David V
Medical students and residents are familiar with clinical teaching methods in which a faculty member poses a series of questions to them. This technique is often called the "Socratic method," but it is frequently perceived by learners as an attempt to demean them, a practice that is colloquially known as "pimping." The distinction between Socratic teaching and pimping lies in the perception of "psychological safety." Psychological safety allows learners to answer questions or ask for help without threats to their dignity or worthiness. In a psychologically safe clinical teaching context, learners recognize that questions posed by attending physicians probe their current understanding and guide them to expand their knowledge. In pimping, questions are posed to embarrass the learner and to reinforce the teacher's position of power over them. Absent a threat of disparagement or condemnation, learners are able to focus on building schema for knowledge, skills, and attitudes, rather than worrying about shielding their self-worth. This article presents the proper Socratic method, as intended by Socrates, and contrasts it with pimping. This perspective defines psychological safety as the pivotal factor distinguishing Socratic teaching from pimping, and establishes the foundation for empirical studies of these common practices in medical education.
Padovani, Aline Rodrigues; Moraes, Danielle Pedroni; Sassi, Fernanda Chiarion; Andrade, Claudia Regina Furquim de
To report the results of the full clinical swallowing assessment in acute-care population in a large Brazilian teaching hospital. A prospective, descriptive clinical study was conducted during three months in a 30-bed adult clinical emergency ICU from a large Brazilian teaching hospital. Thirty-five patients consecutively referred to the Speech-Language Pathology Service according to our standard clinical practice were included. A full clinical swallowing assessment was completed and includes a Preliminary Assessment Protocol (PAP), a Dysphagia Risk Evaluation Protocol (DREP) and an Oral Feeding Transition Protocol (OFTP). In this study, the prevalence of OD in the ICU setting was of 63%, most of which were classified as moderate and moderate-severe (39%). Patients submitted to orotracheal intubation were very frequently referred to swallowing assessment (74%). The results of the statistical analyses revealed clinical indicators that could correctly classify patients as either having or not having OD on clinical tests. These include cough strength, coordination between breathing and speaking, dysphonia severity, and laryngeal elevation. Twenty six patients (74%) completed all protocols. Of these total, 38% were able to eat a regular diet. The practice with standardized protocols adds an important option for the management of oropharyngeal dysphagia in intensive care unit.
Park, Hyejin; Tucker, Denise A
The purpose of the study was to identify key nursing diagnoses with related factors and signs/symptoms using NANDA-I for patients with heart failure (HF). A retrospective descriptive design was used to address the research questions. Data were obtained from the records of patients discharged for 1 year with the medical diagnoses of HF from a Midwestern community hospital. A total of 272 inpatient records were analyzed to describe the frequency and percentage of NANDA-I diagnosis with related factors and signs/symptoms. The top 10 NANDA-I diagnoses associated with related factors and signs/symptoms were identified. Further research related to standardized nursing terminologies such as NANDA-I using large clinical databases from health information systems is needed to support evidence-based nursing diagnosis decision making. © 2015 NANDA International, Inc.
Smith, Peter C; Araya-Guerra, Rodrigo; Bublitz, Caroline; Parnes, Bennett; Dickinson, L Miriam; Van Vorst, Rebecca; Westfall, John M; Pace, Wilson D
The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical information has not been explicitly investigated in the primary care setting. To describe primary care clinicians' reports of missing clinical information. Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded. Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering. Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/dictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10
St-Pierre, Michèle; Juneau, Lucille; Legault-Mercier, Samuel; Bernardino, Elizabeth
Background The complexity of chronic disease management activities and the associated financial burden have prompted the development of organizational models, based on the integration of care and services, which rely on primary care services. However, since the institutions providing these services are continually undergoing reorganization, the Centre hospitalier affilié universitaire de Québec wanted to innovate by adapting the Chronic Care Model to create a clinic for the integrated follow-up of chronic disease that relies on hospital-based specialty care. Objective The aim of the study is to follow the project in order to contribute to knowledge about the way in which professional and management practices are organized to ensure better care coordination and the successful integration of the various follow-ups implemented. Methods The research strategy adopted is based on the longitudinal comparative case study with embedded units of analysis. The case study uses a mixed research method. Results We are currently in the analysis phase of the project. The results will be available in 2015. Conclusions The project’s originality lies in its consideration of the macro, meso, and micro contexts structuring the creation of the clinic in order to ensure the integration process is successful and to allow a theoretical generalization of the reorganization of practices to be developed. PMID:25689840
Background Voluntary Counselling and Testing (VCT) is an important component of any HIV/AIDS control and prevention activities. VCT makes people aware of their HIV serostatus and enables early identification of those who need care. It is an important link to HIV care and support. The main aim of this study is to describe the HIV burden at VCT and define the relationship between the VCT Center and the HIV Chronic Care Clinic of the University of Gondar (UoG) Hospital. Methods It is a record based descriptive study undertaken by using data collected by health professionals at the VCT center and the HIV chronic care clinic of the UoG Hospital. Patient data collected from 2005/06 to 2008/09 was investigated. Analysis was carried out using the SPSS version 16.0. Results A total of 19,168 people were tested for HIV and a prevalence of 25.4% was obtained. 4298 HIV positive people were referred to the HIV chronic care clinic but only 27% actually registered at the clinic. Chi-square analyses showed residence, age and time of VCT visit showed significant relations with hospital care attendance. Conclusion The overall HIV prevalence is high. The data obtained at the HIV care clinic regarding patients’ clinical conditions at acceptance were incomplete. Improvements are required on the link between VCT and HIV care and documentation of data. PMID:23171415
Hearn, Cherie; Govier, Adam; Semciw, Adam Ivan
Objective Clinical care ratios (CCRs) are a useful tool that can be used to quantify and benchmark the clinical and non-clinical workloads of allied health professionals. The purpose of this study was to determine if CCRs are influenced by level of seniority, type of role or profession. This will provide meaningful information for allied health service managers to better manage service demand and capacity.Method Data was collected from 2036 allied health professionals from five professions across 11 Australian tertiary hospitals. Mean (95% confidence intervals) CCRs were calculated according to profession, seniority and role type. A two-way ANOVA was performed to assess the association of CCRs (dependent variable) with seniority level and profession (independent variables). Post-hoc pairwise comparisons identified where significant main or interaction effects occurred (α = 0.05).Results Significant main effects for seniority level and profession were identified (P < 0.05), but there was no interaction effect. Post-hoc comparisons revealed significant differences between all tier combinations (P < 0.05) with more senior staff having the lowest CCRs.Conclusion The direct and non-direct clinical components of the allied health professional's workload can be quantified and benchmarked with like roles and according to seniority. The benchmarked CCRs for predominantly clinical roles will enable managers to compare and evaluate like roles and modify non-direct clinical components according to seniority and discipline.What is known about the topic? CCRs are a useful tool to quantify, monitor and compare workloads of allied health professionals. They are thought to change with increased seniority of roles. The CCRs for different allied health professional roles has yet to be defined in the literature.What does this paper add? CCRs decrease as level of seniority increases, indicating higher seniority increases non-clinical time. CCRs differ across professions, suggesting
In a climate of a cash-strapped medical system in the UK, there is acknowledgement that the need to provide safe, clinically effective, cost-efficient and patient-friendly medical care has never been more apparent. Recent legal cases in infertility and other specialties have made it clear that the trust of the public in healthcare providers is low. The response of the profession to this crisis of confidence needs to be swift and effective. The concept of standards setting is not new outside medical care. Regulatory structures now exist within medicine, and infertility investigation and treatment is now high on the agenda for careful scrutiny. The professions involved in reproductive medicine services urgently need to engage with government regulatory authorities as the agenda for the development of clinical standards and the potential for accreditation of clinics gathers momentum. This article examines the current status of clinical standards setting in the UK and recommends that in future the professional societies together with the Royal College of Obstetricians and Gynaecologists play a major role, in both the public and private sector, in advising existing assessors of quality.
Asefzadeh, Saeed; Yarmohammadian, Mohammad H.; Nikpey, Ahmad; Atighechian, Golrokh
Background: Clinical risk management focuses on improving the quality and safety of health care services by identifying the circumstances and opportunities that put patients at risk of harm and acting to prevent or control those risks. The goal of this study is to identify and assess the failure modes in the ICU of Qazvin's Social Security Hospital (Razi Hospital) through Failure Mode and Effect Analysis (FMEA). Methods: This was a qualitative-quantitative research by Focus Discussion Group (FDG) performed in Qazvin Province, Iran during 2011. The study population included all individuals and owners who are familiar with the process in ICU. Sampling method was purposeful and the FDG group members were selected by the researcher. The research instrument was standard worksheet that has been used by several researchers. Data was analyzed by FMEA technique. Results: Forty eight clinical errors and failure modes identified, results showed that the highest risk probability number (RPN) was in respiratory care “Ventilator's alarm malfunction (no alarm)” with the score 288, and the lowest was in gastrointestinal “not washing the NG-Tube” with the score 8. Conclusions: Many of the identified errors can be prevented by group members. Clinical risk assessment and management is the key to delivery of effective health care. PMID:23930171
Osewski, Wojciech; Dolla, Łukasz; Radwan, Michał; Szlag, Marta; Rutkowski, Roman; Smolińska, Barbara; Ślosarek, Krzysztof
Aim To present practical examples of our new algorithm for reconstruction of 3D dose distribution, based on the actual MLC leaf movement. Background DynaLog and RTplan files were used by DDcon software to prepare a new RTplan file for dose distribution reconstruction. Materials and methods Four different clinically relevant scenarios were used to assess the feasibility of the proposed new approach: (1) Reconstruction of whole treatment sessions for prostate cancer; (2) Reconstruction of IMRT verification treatment plan; (3) Dose reconstruction in breast cancer; (4) Reconstruction of interrupted arc and complementary plan for an interrupted VMAT treatment session of prostate cancer. The applied reconstruction method was validated by comparing reconstructed and measured fluence maps. For all statistical analysis, the U Mann–Whitney test was used. Results In the first two and the fourth cases, there were no statistically significant differences between the planned and reconstructed dose distribution (p = 0.910, p = 0.975, p = 0.893, respectively). In the third case the differences were statistically significant (p = 0.015). Treatment plan had to be reconstructed. Conclusion Developed dose distribution reconstruction algorithm presents a very useful QA tool. It provides means for 3D dose distribution verification in patient volume and allows to evaluate the influence of actual MLC leaf motion on the dose distribution. PMID:25337416
Guglielmi, Valeria; Bellia, Alfonso; Pecchioli, Serena; Medea, Gerardo; Parretti, Damiano; Lauro, Davide; Sbraccia, Paolo; Federici, Massimo; Cricelli, Iacopo; Cricelli, Claudio; Lapi, Francesco
There are some inconsistencies on prevalence estimates of familial hypercholesterolemia (FH) in general population across Europe due to variable application of its diagnostic criteria. We aimed to investigate the FH epidemiology in Italy applying the Dutch Lipid Clinical Network (DLCN) score, and two alternative diagnostic algorithms to a primary care database. We performed a retrospective population-based study using the Health Search IMS Health Longitudinal Patient Database (HSD) and including active (alive and currently registered with their general practitioners (GPs)) patients on December 31, 2014. Cases of FH were identified by applying DLCN score. Two further algorithms, based on either ICD9CM coding for FH or some clinical items adopted by the DLCN, were tested towards DLCN itself as gold standard. We estimated a prevalence of 0.01% for "definite" and 0.18% for "definite" plus "probable" cases as per the DLCN. Algorithms 1 and 2 reported a FH prevalence of 0.9 and 0.13%, respectively. Both algorithms resulted in consistent specificity (1: 99.10%; 2: 99.9%) towards DLCN, but Algorithm 2 considerably better identified true positive (sensitivity=85.90%) than Algorithm 1 (sensitivity=10.10%). The application of DLCN or valid diagnostic alternatives in the Italian primary care setting provides estimates of FH prevalence consistent with those reported in other screening studies in Caucasian population. These diagnostic criteria should be therefore fostered among GPs. In the perspective of FH new therapeutic options, the epidemiological picture of FH is even more relevant to foresee the costs and to plan affordable reimbursement programs in Italy. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Altobelli, Emma; Maccarone, Mara; Petrocelli, Reimondo; Marziliano, Ciro; Giannetti, Alberto; Peris, Ketty; Chimenti, Sergio
Background Over recent years the public health system has shown increasing interest in patients' views for use as guideline criteria in evaluating the quality of assistance above all for those patients with chronic diseases. Hence the interest in psoriasis, which is a chronic disease frequently associated with diabetes mellitus, hypertension, obesity, and cardiovascular diseases. The aims of our study were to describe clinic characteristics of patients with psoriasis, the quality of the assistance perceived by patients arrived at outpatients clinics and the information received, in order to identify areas in Italy requiring improvement. Methods 1954 patients, aged between 18 and 85 years, were consecutively enrolled at outpatients clinics across 21 Italian provinces over the period December 2004 – January 2006. A standardized questionnaire was developed in collaboration with an Italian Association of Psoriatic Patients (A.DI.PSO) and tested in a pilot study. The questionnaire was divided into three sections: the first section included social, demographic and individual variables; the second concerned the quality of the assistance perceived by the patients at public dermatologic clinics and the third focused on the need of information requirements of patients with psoriasis. The χ2 test was used to estimate the association between the categorical variables under study. Kruskal-Wallis test was applied to the interval and ordinal variables. Results The presence of psoriatic arthritis was reported in 26.0% of patients. Associated chronic diseases included depression (15.4%), hypertension (13.3%), obesity (8.9%) and type 2 diabetes mellitus (7.3%). The study highlighted the need of improvements of health care services at public dermatologic clinics especially in overcoming architectonic barriers and reducing appointment wait-times, particularly in South Italy. However, patients reported a positive relationship with Health System employers due to the confidentiality
With development of managed care markets, health care delivery systems face increasing clinical and financial risk. For an integrated delivery system to survive, strategies for clinical integration and care management are essential. CareMap tools, collaborative practice groups, and case management serve as the foundation to accomplish care management over the health continuum. Coordination of care, within an institution and across traditional health settings, to achieve the best clinical and cost outcomes is the goal. The article discusses strategies for clinical integration, categories for measurement of performance, and the need to incorporate automated solutions into the strategic business plan.
Bruckert, Eric; Ferrières, Jean
The use of pharmacological lipid-lowering intervention in individuals with hypercholesterolaemia and known cardiovascular disease or diabetes/chronic kidney disease is well established. Current European Society of Cardiology guidelines recommend immediate initiation of drugs in adjunct to lifestyle intervention in these patients at high or very high cardiovascular risk. In these clinical settings, statins are generally chosen as the first-choice drug intervention, in consideration of the robust evidence showing a reduction in all-cause mortality and major adverse cardiac events (MACE). In contrast, primary prevention with statins, even in the subset of patients at high-risk of cardiovascular events, is not well implemented. This might be related to a lack of public awareness regarding the actual risk associated with prolonged exposure to high concentrations of low-density lipoprotein cholesterol (LDL-C) and uncertainties in the clinical evidence coming from the earliest trials in this patient subset. However, recent observational studies suggest that lowering LDL-C earlier in life and for a longer duration can substantially decrease the burden of cardiovascular disease and mortality. Moreover, results from recent well-conducted large meta-analyses of randomized clinical trials showed that primary prevention with statins reduced all-cause mortality by 14% and MACE by > 20% - findings similar to those observed for the use of statins in secondary prevention. Recently published American Heart Association/American College of Cardiology guidelines on the treatment of blood cholesterol emphasize that primary prevention using high-dose statins in individuals with LDL-C ≥ 190 mg/dL induces a benefit in atherosclerotic cardiovascular risk reduction that clearly exceeds the potential for adverse effects. We aim in this review to discuss the new data that advocate the use of statins in primary prevention earlier and more frequently, putting the efficacy evidence into
Weissman, David E; Morrison, R Sean; Meier, Diane E
Data collection and analysis are vital for strategic planning, quality improvement, and demonstration of palliative care program impact to hospital administrators, private funders and policymakers. Since 2000, the Center to Advance Palliative Care (CAPC) has provided technical assistance to hospitals, health systems and hospices working to start, sustain, and grow nonhospice palliative care programs. CAPC convened a consensus panel in 2008 to develop recommendations for specific clinical and customer metrics that programs should track. The panel agreed on four key domains of clinical metrics and two domains of customer metrics. Clinical metrics include: daily assessment of physical/psychological/spiritual symptoms by a symptom assessment tool; establishment of patient-centered goals of care; support to patient/family caregivers; and management of transitions across care sites. For customer metrics, consensus was reached on two domains that should be tracked to assess satisfaction: patient/family satisfaction, and referring clinician satisfaction. In an effort to ensure access to reliably high-quality palliative care data throughout the nation, hospital palliative care programs are encouraged to collect and report outcomes for each of the metric domains described here.
Kamo, Toshiko; Ujiie, Yuri; Tamura, Atsuko
The emergency hostel of Tokyo Metropolitan Women's Counseling Center, established in 1957, provides protection and care for about 600 Japanese or foreign women per year. The women housed there need social support for various reasons such as prostitution, poverty, somatic or mental diseases, or domestic violence (DV). We investigated the sociodemographic characteristics, psychiatric diagnoses and social prognoses of 2667 women who consulted the psychiatric clinic in the emergency hostel between 1961 and 1997. Seventy-four women consulted the psychiatric clinic per year, on average. Most were aged between 20 and 49. During the study period, there was a gradual decline in the number referred through the prostitution prevention law. Psychiatric diagnoses at the first visit varied widely. Annual comparison showed a gradual decrease in schizophrenia and manic-depressive illness, but an increase in substance abuse, psychogenic reaction, and personality disorder. Sociodemographically, most subjects appeared to have been children from underprivileged backgrounds. The social prognoses of 930 cases judged in March 1998 were good in 25%, moderate in 23% and poor in 48%. The poor prognosis group contained significantly more women with schizophrenia and personality disorder than the other two groups. The poor prognosis group tended to include more cases of substance abuse, while the good prognosis group contained more cases of depression and mental retardation. Women in the DV group tended to have more children than those in the non-DV group, and to have a higher prevalence of psychogenic reaction and a lower prevalence of schizophrenia. The DV group also tended to include more subjects with a moderate social prognosis and fewer subjects with a poor social prognosis. Specialized treatment should be provided for women after emergency admission to the hostel and this treatment needs to be aimed at improving social adaptation of the hostel residents, especially those with
Braaf, Sandra; Manias, Elizabeth; Riley, Robin
The time-out procedure is a critically important communication interaction for the preservation of patient safety in the surgical setting. While previous research has examined influences shaping the time-out procedure, limited information exists on how actual time-out communication is performed by multidisciplinary surgical team members in the clinical environment. An institutional ethnographic study was undertaken. The study was conducted over three hospital sites in Melbourne, Australia. In total, 125 healthcare professionals from the disciplines of surgery, anaesthesia and nursing participated in the study. Data were generated through 350 h of observation, two focus groups and 20 semi-structured interviews. An institutional ethnographic analysis was undertaken. Analysis revealed healthcare professionals adapted the content, timing and number of team members involved in the time-out procedure to meet the demands of the theatre environment. Habitually, the time-out procedure was partially completed, conducted after surgery had commenced and involved only a few members of the surgical team. Communication was restricted and stifled by asynchronous workflows, time restrictions, a hierarchical culture and disinclination by surgeons and anaesthetists to volunteer information and openly communicate with each other and nurses. Healthcare professionals became normalised to performing an abbreviated time-out procedure. Patient safety was relegated in importance as productivity, professional and hierarchical discourses configured the communication practices of surgical team members to limit active, open and direct communication. Examining how the time-out procedure was conducted in the clinical environment enables possibilities to emerge for facilitating compliance with hospital and WHO guidelines.
Berkman, Benjamin E; Hull, Sara Chandros; Eckstein, Lisa
While the development of next-generation sequencing technology has had a paradigm-changing impact on biomedical research, there is likely to be a gap between discovery of therapeutic benefits in research and actual adoption of the new technology into clinical practice. This gap can create pressure on the research enterprise to provide individualized care more typical of the clinic setting because it is uniquely accessible in research. This blurring of the line between research and clinical care is understandable, and perhaps even inevitable. But even if the gap is only transitory, such a blurring can have lasting implications, both by expanding obligations imposed on researchers, but also by challenging long-held ethical views. We explore this idea, focusing on how the dissolving distinction between research and clinical care has influenced the vigorous debate around how researchers should manage genetic findings (sometimes separated into primary and incidental or secondary findings) resulting from research. PMID:25506378
Carney, K L
Cardiac care is an expanding sector of home care. As with other specialty fields in the industry, clinical nurse specialists who have extensive knowledge of this particular arena can greatly benefit both their patients and their agencies.
Samsel, Chase; Ribeiro, Monique; Ibeziako, Patricia; DeMaso, David R
Comorbid behavioral and physical health conditions are accompanied by troubling symptom burden, functional impairment, and treatment complexity. Pediatric subspecialty care clinics offer an opportunity for the implementation of integrated behavioral health (BH) care models that promote resiliency. This article reviews integrated BH care in oncology, palliative care, pain, neuropsychiatry, cystic fibrosis, and transplantation. Examples include integrated care mandates, standards of care, research, and quality improvement by child and adolescent psychiatrists (CAPs) and allied BH clinicians. The role of CAPs in integrated BH care in subspecialty care is explored, focusing on cost, resource use, financial support, and patient and provider satisfaction. Copyright © 2017 Elsevier Inc. All rights reserved.
Reid, Rachel O; Ashwood, J Scott; Friedberg, Mark W; Weber, Ellerie S; Setodji, Claude M; Mehrotra, Ateev
An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care. To assess the association between retail clinic use and receipt of key primary care functions. We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009. We identified patients who had a visit for a simple acute condition in 2008, the "index visit". We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic. We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice-Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias. Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice-Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management. Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.
Feo, Rebecca; Conroy, Tiffany; Alderman, Jan; Kitson, Alison
Modern healthcare environments are becoming increasingly complex. Delivering high-quality fundamental care in these environments is challenging for nurses and has been the focus of recent media, policy, academic and public scrutiny. Much of this attention arises from evidence that fundamental care is being neglected or delivered inadequately. There are an increasing number of standards and approaches to the delivery of fundamental care, which may result in confusion and additional documentation for nurses to complete. This article provides nurses with an approach to reframe their thinking about fundamental care, to ensure they meet patients' care needs and deliver holistic, person-centred care.
L'Ecuyer, Kristine M; Shatto, Bobbi J; Hoffmann, Rosemary L; Crecelius, Matthew L
Challenges of the current health system in the United States call for collaboration of health care professionals, careful utilization of resources, and greater efficiency of system processes. Innovations to the delivery of care include the introduction of the clinical nurse leader role to provide leadership at the point of care, where it is needed most. Clinical nurse leaders have demonstrated their ability to address needed changes and implement improvements in processes that impact the efficiency and quality of patient care across the continuum and in a variety of settings, including critical care. This article describes the role of the certified clinical nurse leader, their education and skill set, and outlines outcomes that have been realized by their efforts. Specific examples of how clinical nurse leaders impact critical care nursing are discussed.
Anastasio, G D; Shaughnessy, A F
To determine salary and selected fringe benefits of members of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy, we developed a self-administered questionnaire that surveyed demographic information, schooling and training, academic appointments, yearly salary (as of February 1, 1995), source of salary, outside income, annual raise, vacation time, financial support for continuing education, and board certification. Ninety-nine surveys were returned (return rate 46%). Respondents were mostly women (58%), their average age was 34 years (range 25-51 yrs), and they had a median of 5 years in the work force. Most respondents (67%) had residency training, whereas only 21% had fellowship experience. Board certification was reported by 46%. The median salary was $53,500 (average $55,861, range $35-90 k), with progression for academic rank. The last salary increase averaged 3.7%. Most (93%) respondents received an average of $1509 for travel. The survey represents a young work force. The salaries vary but show progression for accomplishment.
Unwin, Brian K; Porvaznik, Mary; Spoelhof, Gerard David
Understanding the distinctions between the management of clinical problems in nursing homes compared with the community setting helps improve the overall care of nursing home residents. Liberalizing diets helps avoid unintentional weight loss in nursing home residents, although the use of feeding tubes usually does not improve nutrition or decrease aspiration risk. Medical assessment, treatment of comorbidities, and appropriate use of rehabilitation therapies minimize the frequency of falls. Toileting programs may be used to treat incontinence and retention in cooperative patients. Adverse effects and drug interactions should be considered when initiating pharmacologic treatment of overactive bladder. Urinary tract infection and pneumonia are the most common bacterial infections in nursing home residents. Signs and symptoms of infection include fever or hypothermia, and functional decline. Virus identification is recommended for influenza-like illnesses. Nonpharmacologic behavioral management strategies are the preferred treatment for dementia-related problem behaviors. The Beers criteria, which outline potentially inappropriate medication use in older persons, provide guidance for medication use in the nursing home.
Lawoko, Stephen; Oluwatosin, Abimbola
Abstract Background Healthcare providers have advocated for the screening and management of Intimate Partner Violence (IPV) against women and its consequences. Unfortunately, data from high income countries suggest that women may have varied preferences for being screened for IPV in healthcare. Although women's preference for screening in sub-Saharan countries has not been well researched, IPV remains an accepted societal norm in many of these countries, including Nigeria. Objective The objective of the study was to assess women's acceptance of screening for IPV in healthcare, the extent to which inquiry about IPV was carried out in healthcare and whether such inquiry impacted on satisfaction with care. Method Data on these variables were gathered through structured interviews from a sample of 507 women at a regional hospital in Kano, Nigeria. The study design was cross-sectional. Results The results found acceptance for screening in the sample to be high (76%), but few women (7%) had actually been probed about violence in their contact with care providers. Acceptance for screening was associated with being married and being employed. Actual screening was associated with ethnicity and religion, where ethnic and religious majorities were more likely to be screened. Finally, being screened for IPV seemed to improve satisfaction with care. Conclusion The findings demonstrate the need for adaptation of a screening protocol that is also sensitive to detect IPV amongst all ethnic and religious groups. The findings also have implications for further education of socio-economically disadvantaged women on the benefits of screening.
Hazzard, Anthony; Harris, Wendy; Howell, David
Human consciousness is inextricable from communication. The conditions of communication in the clinical context are defined by the caring intention and the unequal relationship, which imply special responsibilities on the part of the clinician. The conventional hermeneutic model of communication proposes a close examination of the context of the other, and an objective effort to get close to their consciousness by interpretation of their expressions. The clinician is supposed to lay aside subjective factors but make use of her/his clinical knowledge and skills. At University College Hospital Critical Care follow-up clinic, the communicative task involves history taking; partly by questionnaire and partly by attention to the patient's agenda - assessing needs, providing information and facilitating access to further help. In recent years the provision of Critical Care has become ever more complex, both in terms of the sophisticated medical and nursing techniques it can offer to patients and in the range of conditions it can undertake to treat. This range and complexity is reflected in the variety of problems and consequences that may be encountered at follow-up. Communicative techniques should take account of the emotional vulnerability of patients emerging from severe illness. Attentive listening should identify special anxieties, and care with phraseology aims to avoid further distress. Issues of memory, depression and trauma may be expected, and the interview technique must be flexible enough to offer emotional containment if need be. The consultation should be therapeutic in its conduct but should not embark upon actual psychotherapy or seek to dismantle the patient's defences. Contemporary hermeneutic perspectives emphasise the contextual situatedness of the clinician's consciousness, and propose a model of communication as 'blending of horizons' rather than as objective interpretation. Systems theory contributes to an understanding of the influence on
Derrett, Sarah; Gunter, Kathryn E.; Nocon, Robert S.; Quinn, Michael T.; Coleman, Katie; Daniel, Donna M.; Wagner, Edward H.; Chin, Marshall H.
Background Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients’ needs. Currently, little is known about care integration for rural patients. Objective To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. Research Design Qualitative case study. Participants Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. Methods Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. Results Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. Conclusions Care integration was supported by 2 fundamental changes to organize and deliver care to patients—(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities. PMID:25310637
Lee, Linda; Hillier, Loretta M; Molnar, Frank; Borrie, Michael J
Increasingly, primary care collaborative memory clinics (PCCMCs) are being established to build capacity for person-centred dementia care. This paper reflects on the significance of PCCMCs within the system of care for older adults, supported with data from ongoing evaluation studies. Results highlight timelier access to assessment with a high proportion of patients being managed in primary care within a person-centred approach to care. Enhancing primary care capacity for dementia care with interprofessional and collaborative care will strengthen the system's ability to respond to increasing demands for service and mitigate the growth of wait times to access geriatric specialist assessment.
Vallejos, Quirina M.; Quandt, Sara A.; Feldman, Steven R.; Fleischer, Alan B., Jr.; Brooks, Thanh; Cabral, Gonzalo; Heck, Judy; Schulz, Mark R.; Verma, Amit; Whalley, Lara E.; Arcury, Thomas A.
Context: Rural patients have limited access to dermatologic care. Farmworkers have high rates of skin disease and limited access to care. Purpose: This exploratory study assessed whether teledermatology consultations could help meet the needs of health care providers for farmworkers in rural clinics. Methods: Dermatologists provided 79…
Vallejos, Quirina M.; Quandt, Sara A.; Feldman, Steven R.; Fleischer, Alan B., Jr.; Brooks, Thanh; Cabral, Gonzalo; Heck, Judy; Schulz, Mark R.; Verma, Amit; Whalley, Lara E.; Arcury, Thomas A.
Context: Rural patients have limited access to dermatologic care. Farmworkers have high rates of skin disease and limited access to care. Purpose: This exploratory study assessed whether teledermatology consultations could help meet the needs of health care providers for farmworkers in rural clinics. Methods: Dermatologists provided 79…
Moore, Crystal Dea; Reynolds, Ashley M
To provide a clinical update on practical strategies to enhance the quality of communication in the palliative and end-of-life medical care settings. Published articles, textbooks, reports, and clinical experience. The components of effective and compassionate care throughout the advanced illness trajectory require thoughtful and strategic communication with patients, families, and members of the health care team. Unfortunately, few health care professionals are formally trained in communication skills. Nurses who possess self-awareness and are skilled in effective communication practices are integral to the provision of high-quality palliative care for patients and families coping with advanced malignancies. Copyright © 2013 Elsevier Inc. All rights reserved.
Lee, Linda; Hillier, Loretta M; Heckman, George; Gagnon, Micheline; Borrie, Michael J; Stolee, Paul; Harvey, David
The implementation in Ontario of 15 primary-care-based interprofessional memory clinics represented a unique model of team-based case management aimed at increasing capacity for dementia care at the primary-care level. Each clinic tracked referrals; in a subset of clinics, charts were audited by geriatricians, clinic members were interviewed, and patients, caregivers, and referring physicians completed satisfaction surveys. Across all clinics, 582 patients were assessed, and 8.9 per cent were referred to a specialist. Patients and caregivers were very satisfied with the care received, as were referring family physicians, who reported increased capacity to manage dementia. Geriatricians' chart audits revealed a high level of agreement with diagnosis and management. This study demonstrated acceptability, feasibility, and preliminary effectiveness of the primary-care memory clinic model. Led by specially trained family physicians, it provided timely access to high-quality collaborative dementia care, impacting health service utilization by more-efficient use of scarce geriatric specialist resources.
ClinicalKey is a new point-of-care resource for health care professionals. Through controlled vocabulary, ClinicalKey offers a cross section of resources on diseases and procedures, from journals to e-books and practice guidelines to patient education. A sample search was conducted to demonstrate the features of the database, and a comparison with similar tools is presented.
Rice, David H; Kotti, George; Beninati, William
The development of modern intensive care units (ICUs) has allowed the survival of patients with advanced illness and injury, although at a cost of substantial infrastructure. Natural disasters and military operations are two common situations that can create critically ill patients in an environment that is austere or has been rendered austere. This has driven the development of two related strategies to care for these casualties. Portable ICU capability can be rapidly established in the area of need, providing relatively advanced capability but limited capacity and sustainability. The other strategy is to rapidly evacuate critically ill and injured patients following their initial stabilization. This permits medical personnel in the austere location to focus resources on a larger number of less critical patients. It also permits the most vulnerable patients to receive care in an advanced center. This strategy requires careful planning to overcome the constraints of the transport environment. The optimal strategy has not been determined, but a combination of these two approaches has been used in recent disasters and military operations and is promising. The critical care delivered in an austere setting must be integrated with a long-term plan to provide follow-on care.
Rice, David H; Kotti, George; Beninati, William
The development of modern intensive care units (ICUs) has allowed the survival of patients with advanced illness and injury, although at a cost of substantial infrastructure. Natural disasters and military operations are two common situations that can create critically ill patients in an environment that is austere or has been rendered austere. This has driven the development of two related strategies to care for these casualties. Portable ICU capability can be rapidly established in the area of need, providing relatively advanced capability but limited capacity and sustainability. The other strategy is to rapidly evacuate critically ill and injured patients following their initial stabilization. This permits medical personnel in the austere location to focus resources on a larger number of less critical patients. It also permits the most vulnerable patients to receive care in an advanced center. This strategy requires careful planning to overcome the constraints of the transport environment. The optimal strategy has not been determined, but a combination of these two approaches has been used in recent disasters and military operations and is promising. The critical care delivered in an austere setting must be integrated with a long-term plan to provide follow-on care. PMID:18373882
da Silva, Kely Vanessa Leite Gomes; Monteiro, Ana Ruth Macedo
This is a theoretical reflection on the clinical nursing care in mental health that is offered to the family. In view of having a family member with mental suffering, the family would delegate the care to that relative to the mental institution, thus there should be collaboration between the nursing and medical team to organize the environment and ensure family and social isolation. With the Psychiatric Reform, based on the proposal for psychosocial care, the family becomes the center of attention for health care professionals. The necessary support for clinical nursing care includes making conceptual changes in implementing health education, interdisciplinary work, and in the broadened clinic, so as to ensure comprehensiveness and subjects' autonomy. Clinical nursing care should permeate the subjects' politicalization, in which the actors militate to reach autonomy, and the practices involve dignity, creativity, welcoming, interdisciplinarity, hearing, and knowledge sharing.
Wong, Ming Chao; Yee, Kwang Chien; Turner, Paul
Improving clinical communication is imperative to improving the quality and safety of patient care. Significant efforts have been made to improve clinical communication and patient safety, guided by the mantra of "the right information, to the right person, in the right place, at the right time". The design and implementation of information communication technologies (ICTs) has been considered as one of the major developments in improving patient care. Clinical communication in today's clinical practice is complex and involves multi-disciplinary teams using different types of media for information transfer. This paper argues that traditional communication theories fail to adequately capture and describe contemporary clinical communicative practices or to provide insight into how information transferred is actually assimilated and/or utilised for patient care. This paper argues for the need to more fully consider underlying assumptions about the role of information in clinical communication and to recognise how the attributes of information receivers, especially where ICTs are deployed influence outcomes. The paper presents a discussion regarding the need to consider information receivers as the foundation for clinical communication improvement and future design and development of ICTs to improve patient care.
Sussman, Andrew; Dunham, Lisette; Snower, Kristen; Hu, Min; Matlin, Olga S; Shrank, William H; Choudhry, Niteesh K; Brennan, Troyen
To better understand the impact of retail clinic use on a patient's annual total cost of care. A propensity score matched-pair, cohort design was used to analyze healthcare spending patterns among CVS Caremark employees in the year following a visit to a MinuteClinic, the retail clinics inside CVS pharmacies. De-identified medical and pharmacy claims for CVS Caremark employees and their dependents who received care at a retail clinic between June 1, 2009, and May 31, 2010, were matched to those of subjects who received care elsewhere. High-dimensional propensity score and greedy matching techniques were used to create a 1-to-1 matched cohort that was analyzed using generalized linear regression models. Individuals using a retail clinic had a lower total cost of care (-$262; 95% confidence interval, -$510 to -$31; P = .025) in the year following their clinic visit than individuals who received care in other settings. This savings was primarily due to lower medical expenses at physicians' offices ($77 savings, P = .008) and hospital inpatient care ($121 savings, P = .049). The 6022 retail clinic users also had 142 (12%) fewer emergency department visits (P = .01), though this was not related to significant cost savings. This study found that retail clinic use was associated with lower overall total cost of care compared with that at alternative sites. Savings may extend beyond the retail clinic visit itself to other types of medical utilization.
Creasy, Kerry Rae; Lutz, Barbara J.; Young, Mary Ellen; Stacciarini, Jeanne-Marie R.
Background and Purpose Most stroke survivors will be cared for at home by family caregivers with limited training. Families actively involved in rehabilitation feel more prepared for the new responsibilities of caring for the stroke survivor. The focus of this article is to highlight the relevant concepts of a family-centered model of care and provide general guidance on how integrating a family-centered mindset may be clinically applicable. Family-Centered Care Family-centered care is a model of healthcare that encourages collaboration and partnership among patients, families, and providers with respect to the planning, delivery, and evaluation of health care. Care provided within such a model can expand providers’ knowledge of the impact of illness and any issues that may affect eventual transition back home. Clinical Relevance and Conclusion Rehabilitation nurses should view stroke patients and family caregivers as a unit. Using family-centered strategies can help nurses provide appropriate, individualized care during rehabilitation. PMID:25648522
Turner, Karen; Tookman, Adrian; Bristowe, Katherine; Maddocks, Matthew
Background: Patients with advanced cancer frequently experience functional impairment and reduced quality of life. Therapeutic exercise can provide benefit and be made accessible through the use of tailored programmes. Most studies examining exercise programmes for people with advanced cancer have used quantitative outcome measures and focussed on objective physical function, therefore offer a limited perspective on the experience of exercise participation. Methods: This qualitative study explored patients' experiences of an exercise programme within a palliative care setting. The interviews focussed on the perceived impact on all aspects of quality of life. Results: Nine people with advanced cancer, attending a hospice-based exercise programme, completed a one-to-one interview with a senior physiotherapist to explore the physical, emotional, and social impacts of their participation. Interviews were audiotaped, transcribed verbatim and analysed using interpretive phenomenological analysis. Patients reported an awareness of the positive physical, psychological, and social consequences of exercising. Their experiences reflected on all dimensions of quality of life, the impact of others and the sense of meaning gained through participation in exercise. Conclusion: Our findings highlight that exercise in palliative care should not be viewed solely a physical intervention, but one that has potential to enhance many aspects of patients' quality of life. PMID:27453639
Nembhard, Ingrid M; Yuan, Christina T; Shabanova, Veronika; Cleary, Paul D
Aspects of the patient care experience, despite being central to quality care, are often problematic. In particular, patients frequently report problems with timeliness of care. As yet, research offers little insight on setting characteristics that contribute to patients' experience of timely care. The aims of this study were to assess the relationship between organizational climate and patients' reports of timely care in primary care clinics and to broadly examine the link between staff's work environment and patient care experiences. We test hypotheses about the relationship between voice climate--staff feeling safe to speak up about issues--and reported timeliness of care, consistency in reported voice climate across professions, and how climate differences for various professions relate to timely care. We conducted a cross-sectional study of employees (n = 1,121) and patients (n = 8,164) affiliated with 37 clinics participating in a statewide reporting initiative. Employees were surveyed about clinics' voice climate, and patients were surveyed about the timeliness of care. Hypotheses were tested using analysis of variance and generalized estimating equations. Clinical and administrative staff (e.g., nurses and office assistants) reported clinics' climates to be significantly less supportive of voice than did clinical leaders (e.g., physicians). The greater the difference in reported support for voice between professional groups, the less patients reported experiencing timely care in three respects: obtaining an appointment, seeing the doctor within 15 minutes of appointment time, and receiving test results. In clinics where staff reported climates supportive of voice, patients indicated receiving more timely care. Clinical leaders' reports of voice climate had no relationship to reported timeliness of care. Our findings suggest the importance of clinics developing a strong climate for voice, particularly for clinical and administrative staff, to support better
This video describes the Health Maintenance Facility (HMF). The HMF provides inflight medical care including prevention, diagnosis, and care during transport if the patient must be evacuated. A comparison to medical services found in a large hospital is used to describe the HMF's subsystems.
Polzer Casarez, Rebecca L; Engebretson, Joan C
The aim of this article was to analyse the scholarly discourse on the ethical issues of incorporating spirituality and religion into clinical practice. Spirituality is an important aspect of health care, yet the secularisation of health care presents ethical concerns for many health providers. Health providers may have conflicting views regarding if and how to offer spiritual care in the clinical setting. Discursive paper. The discourse analysis uncovered four themes: ethical concerns of omission; ethical concerns of commission; conditions under which health providers prefer to offer spiritual care; and strategies to integrate spiritual care. Ethical concerns of omission of spiritual care include lack of beneficence for not offering holistic care. Ethical concerns of commission are coercion and overstepping one's competence in offering spiritual care. Conditions under which providers are more likely to offer spiritual care are if the patient has a terminal illness, and if the patient requests spiritual care. Strategies for appropriate spiritual care include listening, and remaining neutral and sensitive to spiritual issues. Health providers must be aware of both the concerns of omission and commission. Aristotle's golden mean, an element of virtue ethics, supports a more moderate approach that can be achieved by avoiding the imposition of one's own personal beliefs of a religious persuasion or beliefs of extreme secularisation, and focusing on the beneficence to the patient. Relevance to clinical practice. Key components for health providers in addressing spiritual concerns are self-reflection, provision of individualised care, cultural competency and communication. © 2012 Blackwell Publishing Ltd.
da Silva, Rafael Celestino; Ferreira, Márcia de Assunção; Apostolidis, Thémistoklis; Brandão, Marcos Antônio Gomes
Objective: to propose a conceptual framework for clinical nursing care in intensive care. Method: descriptive and qualitative field research, carried out with 21 nurses from an intensive care unit of a federal public hospital. We conducted semi-structured interviews and thematic and lexical content analysis, supported by Alceste software. Results: the characteristics of clinical intensive care emerge from the specialized knowledge of the interaction, the work context, types of patients and nurses characteristic of the intensive care and care frameworks. Conclusion: the conceptual framework of the clinic's intensive care articulates elements characteristic of the dynamics of this scenario: objective elements regarding technology and attention to equipment and subjective elements related to human interaction, specific of nursing care, countering criticism based on dehumanization. PMID:26487133
Saunders, Mitzi M; Harris, Karen; Hale, Deborah L
The clinical nurse specialist (CNS) is positioned to influence spiritual care at three levels of practice: patient, nurse, and system. This study, the first to explore CNS spiritual care, reports on CNSs' perceptions in providing spiritual care. Four themes were extracted from interview data: 1) Providing direct spiritual support for patients, 2) Nurses need support in providing spiritual care, 3) Using existing resources, and 4) Spiritual care falls short. Not one CNS mentioned barriers to their direct provision of spiritual care. Results support that CNSs can improve spiritual care delivery.
Van Baalen, Mary; Mason, Sara S.; Taiym, Wafa; Wear, Mary L.; Moynihan, Shannan; Alexander, David; Hart, Steve; Tarver, William
Prior to 2010, several ISS crewmembers returned from spaceflight with changes to their vision, ranging from a mild hyperopic shift to frank disc edema. As a result, NASA expanded clinical vision testing to include more comprehensive medical imaging, including Optical Coherence Tomography and 3 Tesla Brain and Orbit MRIs. The Space and Clinical Operations (SCO) Division developed a clinical practice guideline that classified individuals based on their symptoms and diagnoses to facilitate clinical care. For the purposes of clinical surveillance, this classification was applied retrospectively to all crewmembers who had sufficient testing for classification. This classification is also a tool that has been leveraged for researchers to identify potential risk factors. In March 2014, driven in part by a more comprehensive understanding of the imaging data and increased imaging capability on orbit, the SCO Division revised their clinical care guidance to outline in-flight care and increase post-flight follow up. The new clinical guidance does not include a classification scheme
Nembhard, Ingrid M.; Yuan, Christina T.; Shabanova, Veronika; Cleary, Paul D.
Background Aspects of the patient care experience, despite being central to quality care, are often problematic. In particular, patients frequently report problems with timeliness of care. As yet, research offers little insight on setting characteristics that contribute to patients’ experience of timely care. Purpose The aims of this study were to assess the relationship between organizational climate and patients’ reports of timely care in primary care clinics and to broadly examine the link between staff’s work environment and patient care experiences. We test hypotheses about the relationship between voice climate—staff feeling safe to speak up about issues—and reported timeliness of care, consistency in reported voice climate across professions, and how climate differences for various professions relate to timely care. Methodology We conducted a cross-sectional study of employees (n = 1,121) and patients (n = 8,164) affiliated with 37 clinics participating in a statewide reporting initiative. Employees were surveyed about clinics’ voice climate, and patients were surveyed about the timeliness of care. Hypotheses were tested using analysis of variance and generalized estimating equations. Findings Clinical and administrative staff (e.g., nurses and office assistants) reported clinics’ climates to be significantly less supportive of voice than did clinical leaders (e.g., physicians). The greater the difference in reported support for voice between professional groups, the less patients reported experiencing timely care in three respects: obtaining an appointment, seeing the doctor within 15 minutes of appointment time, and receiving test results. In clinics where staff reported climates supportive of voice, patients indicated receiving more timely care. Clinical leaders’ reports of voice climate had no relationship to reported timeliness of care. Practical Implications Our findings suggest the importance of clinics developing a strong climate for
Young, Jessica; Egan, Tony; Jaye, Chrystal; Williamson, Martyn; Askerud, Anna; Radue, Peter; Penese, Maree
To understand how a vision of care is formed and shared by patients and the primary care professionals involved in their care. To achieve the best health outcomes, it is important for patients and those who care for them to have a mutual understanding about what is important to the patient in their everyday life and why, and what care is necessary to realise this vision. Shared or team care does not necessarily translate to a consistent and integrated approach to a patient's care. An individual patient's care network of clinical and lay participants can be conceptualised as the patient's own 'Community of Clinical Practice' of which they are the central member. Working alongside a long-term conditions nursing team, we conducted a focused ethnography of nine 'Communities of Clinical Practice' in one general practice setting. Participant observation, in-depth qualitative interviews with 24 participants including nine patients, and the patients' medical records. Data were analysed using a template organising style. Primary care professionals' insight into a patient's vision of care evolves through a deep knowing of the patient over time; this is shared between 'Community of Clinical Practice' members, frequently through informal communication and realised through respectful dialogue. These common values - respect, authenticity, autonomy, compassion, trust, care ethics, holism - underpin the development of a shared vision of care. A patient's vision of care, if shared, provides a focus around which 'Community of Clinical Practice' members cohere. Nurses play an important role in sharing the patient's vision of care with other participants. A shared vision of care is an aspirational concept which is difficult to articulate but with attentiveness, sustained authentic engagement and being driven by values, it should evolve amongst the core participants of a 'Community of Clinical Practice'. © 2017 John Wiley & Sons Ltd.
Goodwin, Andrew J
Optimizing care in the ICU is an important goal. The heightened severity of illness in patients who are critically ill combined with the tremendous costs of critical care make the ICU an ideal target for improvement in outcomes and efficiency. Incorporation of evidence-based medicine into everyday practice is one method to optimize care; however, intensivists have struggled to define optimal practices because clinical trials in the ICU have yielded conflicting results. This article reviews examples where such conflicts have occurred and explores possible causes of these discrepant data as well as strategies to better use critical care clinical trials in the future.
Ruymán Brito-Brito, Pedro; Rodríguez-Ramos, Mercedes; Pérez-García-Talavera, Carlos
This is the case of a 61-year-old patient woman that visits her nurse in Primary Health Care to get the control of blood pressure and glycemia. In the last two years has suffered the loss of her husband and of two brothers beside having lived through other vital stressful events that have taken her to a situation of complicated grief. The care plan is realized using the M. Gordon assessment system and standardized languages NANDA, NOC and NIC. The principal aims were the improvement of the depression level and the improvement in the affliction resolution. As suggested interventions were proposed to facilitate the grief and the derivation to a mental health unit. A follow-up of the patient was realized in nursing consultation at Primary health care to weekly intervals, in the beginning, and monthly, later. The evaluation of the care plan reflects an improvement in the criteria of Prigerson's complicated grief; an increase of the recreative activities; the retreat of the mourning that still she was guarding; as well as an improvement in the control of the blood pressure numbers. The attention of nurses before a case of complicated grief turns out to be complex. Nevertheless the suitable accomplishment of certain interventions orientated to facilitating the grief, with a follow-up in consultation, shows the efficiency. The difficulty in the boarding of the psychosocial problems meets increased at the moment of are necessary the nursing diagnostics adapted for every individual case. The work in group between nurses could improves the consensus.
Kruser, Jacqueline M; Cox, Christopher E; Schwarze, Margaret L
Many older adults in the United States receive invasive medical care near the end of life, often in an intensive care unit (ICU). However, most older adults report preferences to avoid this type of medical care and to prioritize comfort and quality of life near death. We propose a novel term, "clinical momentum," to describe a system-level, latent, previously unrecognized property of clinical care that may contribute to the provision of unwanted care in the ICU. The example of chronic critical illness illustrates how clinical momentum is generated and propagated during the care of patients with prolonged illness. The ICU is an environment that is generally permissive of intervention, and clinical practice norms and patterns of usual care can promote the accumulation of multiple interventions over time. Existing models of medical decision-making in the ICU describe how individual signs, symptoms, or diagnoses automatically lead to intervention, bypassing opportunities to deliberate about the value of an intervention in the context of a patient's likely outcome or treatment preferences. We hypothesize that clinical momentum influences patients, families, and physicians to accept or tolerate ongoing interventions without consideration of likely outcomes, eventually leading to the delivery of unwanted care near the end of life. In the future, a mixed-methods research program could refine the conceptual model of clinical momentum, measure its impact on clinical practice, and interrupt its influence on unwanted care near the end of life.
Brennan, Michael D; Duncan, Alan K; Armbruster, Ryan R; Montori, Victor M; Feyereisn, Wayne L; LaRusso, Nicholas F
Clinical research centers that support hypothesis-driven investigation have long been a feature of academic medical centers but facilities in which clinical care delivery can be systematically assessed and evaluated have heretofore been nonexistent. The Institute of Medicine report "Crossing the Quality Chasm" identified six core attributes of an ideal care delivery system that in turn relied heavily on system redesign. Although manufacturing and service industries have leveraged modern design principles in new product development, healthcare has lagged behind. In this article, we describe a methodology utilized by our facility to study the clinical care delivery system that incorporates modern design principles.
OBJECTIVES--To evaluate integrated care for diabetes in clinical, psychosocial, and economic terms. DESIGN--Pragmatic randomised trial. SETTING--Hospital diabetic clinic and three general practice groups in Grampian. PATIENTS--274 adult diabetic patients attending a hospital clinic and registered with one of three general practices. INTERVENTION--Random allocation to conventional hospital clinic care or integrated care. Integrated care patients seen in general practice every three or four months and in the hospital clinic annually. General practitioners were given written guidelines for integrated care. MAIN OUTCOME MEASURES--Metabolic control, psychosocial status, knowledge of diabetes, beliefs about control of diabetes, satisfaction with treatment, disruption of normal activities, numbers of consultations and admissions, frequency of metabolic monitoring, costs to patients and NHS. RESULTS--A higher proportion of patients defaulted from conventional care (14 (10%)) than from integrated care (4 (3%), 95% confidence interval of difference 2% to 13%). After two years no significant differences were found between the groups in metabolic control, psychosocial status, knowledge, beliefs about control, satisfaction with treatment, unscheduled admissions, or disruption of normal activities. Integrated care was as effective for insulin dependent as non-insulin dependent patients. Patients in integrated care had more visits and higher frequencies of examination. Costs to patients were lower in integrated care (mean 1.70 pounds) than in conventional care (8 pounds). 88% of patients who experienced integrated care wished to continue with it. CONCLUSIONS--This model of integrated care for diabetes was at least as effective as conventional hospital clinic care. PMID:8180540
King, Kevin; Grazette, Luanda P.; Paltoo, Dina N.; McDevitt, John T.; Sia, Samuel K.; Barrett, Paddy M.; Apple, Fred S.; Gurbel, Paul A.; Weissleder, Ralph; Leeds, Hilary; Iturriaga, Erin J.; Rao, Anupama; Adhikari, Bishow; Desvigne-Nickens, Patrice; Galis, Zorina S.; Libby, Peter
Point-of-care technologies (POC or POCT) are enabling innovative cardiovascular diagnostics that promise to improve patient care across diverse clinical settings. The National Heart, Lung, and Blood Institute convened a working group to discuss POCT in cardiovascular medicine. The multidisciplinary working group, which included clinicians, scientists, engineers, device manufacturers, regulatory officials, and program staff, reviewed the state of the POCT field; discussed opportunities for POCT to improve cardiovascular care, realize the promise of precision medicine, and advance the clinical research enterprise; and identified barriers facing translation and integration of POCT with existing clinical systems. A POCT development roadmap emerged to guide multidisciplinary teams of biomarker scientists, technologists, health care providers, and clinical trialists as they: 1) formulate needs assessments; 2) define device design specifications; 3) develop component technologies and integrated systems; 4) perform iterative pilot testing; and 5) conduct rigorous prospective clinical testing to ensure that POCT solutions have substantial effects on cardiovascular care. PMID:26977455
Matney, Susan A; Dolin, Gay; Buhl, Lindy; Sheide, Amy
A care plan provides a patient, family, or community picture and outlines the care to be provided. The Health Level Seven Consolidated Clinical Document Architecture (C-CDA) Release 2 Care Plan Document is used to structure care plan data when sharing the care plan between systems and/or settings. The American Nurses Association has recommended the use of two terminologies, Logical Observation Identifiers Names and Codes (LOINC) for assessments and outcomes and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for problems, procedures (interventions), outcomes, and observation findings within the C-CDA. This article describes C-CDA, introduces LOINC and SNOMED CT, discusses how the C-CDA Care Plan aligns with the nursing process, and illustrates how nursing care data can be structured and encoded within a C-CDA Care Plan.
Ickovics, J R; Meisler, A W
Assessment of adherence within AIDS clinical trials is a critical component of the successful evaluation of therapeutic outcomes. Poor medication adherence can result in the misinterpretation of clinical trial data. Research on factors affecting adherence in AIDS clinical trials has been scarce, and few investigations have evaluated strategies for enhancing patient participation. One reason may be the absence of a conceptual framework to guide research. Consistent with previous research on medical adherence, we propose a framework whereby factors affecting adherence in AIDS clinical trials can be categorized as characteristics of the: (a) individual, (b) treatment regimen, (c) patient-provider relationship, (d) clinical setting, and (e) disease. This framework is used as a heuristic for reviewing studies that examine factors affecting adherence in AIDS clinical trials. Suggestions for future research and clinical intervention are provided. These efforts are timely because adherence is now the center of attention in discourse about the efficacy of the new class of protease inhibitor drugs; non-adherence has been linked to viral resistance and drug failure. Efforts to identify factors that influence adherence to AIDS clinical trials can inform future attempts to improve adherence and retention. Better adherence protects the scientific integrity of AIDS clinical trials, promoting more efficient and accurate evaluations of therapeutic value. Accelerated access to new treatments may follow, ultimately enhancing patient care.
Panko, Walter B.
The purpose of this article is to provide the author's perspective on whether it is likely or feasible that those working in the health care domain will adapt and use lessons learned by those in the industrial domain. This article provides some historical perspective on the changes brought about in the industrial domain through the introduction of new technologies, including information technologies. The author discusses how industrialization catalyzed changes in health care delivery that paralleled but lagged behind those of the broader U.S. economy. The article concludes that there is ample reason for those interested in improving the quality and effectiveness of health informatics to systematically evaluate information technology strategies used in the industrial domain. Finally, it outlines some challenges for health informaticians and a number of factors that should be considered in adapting lessons from industry to the health care domain. PMID:10495094
Lazaridis, Christos; Maas, Andrew I R; Souter, Michael J; Martin, Renee H; Chesnut, Randal M; DeSantis, Stacia M; Sung, Gene; Leroux, Peter D; Suarez, Jose I
Neurocritical care involves the care of highly complex patients with combinations of physiologic derangements in the brain and in extracranial organs. The level of evidence underpinning treatment recommendations remains low due to a multitude of reasons including an incomplete understanding of the involved physiology; lack of good quality, prospective, standardized data; and the limited success of conventional randomized controlled trials. Comparative effectiveness research can provide alternative perspectives and methods to enhance knowledge and evidence within the field of neurocritical care; these include large international collaborations for generation and maintenance of high quality data, statistical methods that incorporate heterogeneity and individualize outcome prediction, and finally advanced bioinformatics that integrate large amounts of variable-source data into patient-specific phenotypes and trajectories.
Bittner, S; Meuth, S G
The treatment of patients with multiple sclerosis (MS) is associated with constantly rising costs for the healthcare system and pharmaceuticals constitute 60 % of the direct medical costs. The Pharmaceutical Market Restructuring Act (Arzneimittelmarkt-Neuordnungsgesetz, AMNOG) came into force on 1 January 2011 with the aim of limiting the costs of pharmaceuticals by obligating newly approved products to be subjected to an early evaluation of the additional benefits by the Federal Joint Committee (FJC, Gemeinsamer Bundesausschuss, G‑BA). The majority of products evaluated up to October 2015 in neurology (5 out of 8) were approved for treatment of MS. Has the AMNOG been able to fulfill the original aims? Analysis of available information on MS therapies evaluated by the FJC between December 2010 and October 2015. For various reasons an additional benefit could be shown in only 2 out of 5 assessment procedures for MS drugs. It is obvious that some methodological shortcomings of the process have to be improved. Additionally requirements for pivotal clinical trials have to be harmonized with AMNOG requirements taking the best available evidence and real-life data into consideration (e.g. non-interventional studies) and a closer collaboration between the FJC, healthcare providers and the neurological societies is necessary. The AMNOG procedure currently only partially fulfills the original aims, which could be the reason why guidelines play a more important role for therapy decision-making than FJC decisions. As the early evaluation procedure is an adaptive process methodological shortcomings might be overcome in the future; however, this requires a much closer collaboration between the FJC and neurological societies.
Burritt, Joan E; Wallace, Patricia; Steckel, Cynthia; Hunter, Anita
Contemporary patient care requires sophisticated clinical judgment and reasoning in all nurses. However, the level of development regarding these abilities varies within a staff. Traditional care models lack the structure and process to close the expertise gap creating potential patient safety risks. In an innovative model, senior, experienced nurses were relieved of direct patient care assignments to oversee nursing care delivery. Evaluation of the model showed significant impact on quality and fiscal outcomes.
Transgender (TG) persons have had historically difficult interactions with health care providers, leading to limited care and risks for a broad spectrum of health problems. This is of particular concern for TG persons with or at risk for HIV infection. This article discusses care providers' roles in establishing TG-friendly clinical care sites; conducting appropriate and thorough physical examinations for TG patients; managing hormones, especially in conjunction with antiretroviral therapy; and engaging TG persons in education about prevention and treatment of HIV.
Smith, Thomas J; Temin, Sarah; Alesi, Erin R; Abernethy, Amy P; Balboni, Tracy A; Basch, Ethan M; Ferrell, Betty R; Loscalzo, Matt; Meier, Diane E; Paice, Judith A; Peppercorn, Jeffrey M; Somerfield, Mark; Stovall, Ellen; Von Roenn, Jamie H
An American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) offers timely clinical direction to ASCO's membership following publication or presentation of potentially practice-changing data from major studies. This PCO addresses the integration of palliative care services into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. Palliative care is frequently misconstrued as synonymous with end-of-life care. Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient's illness. Although the use of hospice and other palliative care services at the end of life has increased, many patients are enrolled in hospice less than 3 weeks before their death, which limits the benefit they may gain from these services. By potentially improving quality of life (QOL), cost of care, and even survival in patients with metastatic cancer, palliative care has increasing relevance for the care of patients with cancer. Until recently, data from randomized controlled trials (RCTs) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care have not been available. Seven published RCTs form the basis of this PCO. Based on strong evidence from a phase III RCT, patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care-when combined with standard cancer care or as the main focus of care-leads to better patient and caregiver outcomes. These include improvement in symptoms, QOL, and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and
Ozolins, Lise-Lotte; Hörberg, Ulrica; Dahlberg, Karin
This study describes the phenomenon of caring touch from the patients' perspective in an anthroposophic clinical context where caring touch is often used to promote health and alleviate suffering. The aim of the study was to explore and phenomenologically describe the phenomenon of caring touch from the patients' perspectives. The study has been carried out with a Reflective Lifeworld Research approach in order to understand and describe human existential phenomena. Ten female patients were interviewed in an anthroposophic clinic in Sweden. The findings show how caring touch has multifaceted meanings and makes the patients' feel present and anchored in a meaningful context. The patients' feel that they are seen, accepted and confirmed. Furthermore, touch creates a caring space where the patients become receptive for care and has the power to alleviate the patients' suffering, as well as to frighten and cause or worsen the suffering. In order to take advantage of the caring potential, the patient needs to be invited to a respectful and sensitive form of touch. An interpersonal flexible space is necessary where the touch can be effective, and where a dynamic interplay can develop. In conclusion, caring touch is an opportunity for carers to support well-being and health. The carers need to approach their patients in both a sensitive and reflective way. A caring science perspective can serve as a help to further understand touch as a unique caring act. © 2015 Nordic College of Caring Science.
Ab Rahman, Norazida; Sivasampu, Sheamini; Mohamad Noh, Kamaliah; Khoo, Ee Ming
The world population has become more globalised with increasing number of people residing in another country for work or other reasons. Little is known about the health profiles of foreign population in Malaysia. The aim of this study was to provide a detailed description of the health problems presented by foreigners attending primary care clinics in Malaysia. Data were derived from the 2012 National Medical Care Survey (NMCS), a cross sectional survey of primary care encounters from public and private primary care clinics sampled from five regions in Malaysia. Patients with foreign nationality were identified and analysed for demographic profiles, reasons for encounter (RFEs), diagnosis, and provision of care. Foreigners accounted for 7.7 % (10,830) of all patient encounters from NMCS. Most encounters were from private clinics (90.2 %). Median age was 28 years (IQR: 24.0, 34.8) and 69.9 % were male. Most visits to the primary care clinics were for symptom-based complaints (69.5 %), followed by procedures (23.0 %) and follow-up visit (7.4 %). The commonest diagnosis in public clinics was antenatal care (21.8 %), followed by high risk pregnancies (7.5 %) and upper respiratory tract infection (URTI) (6.8 %). Private clinics had more cases for general medical examination (13.5 %), URTI (13.1 %) and fever (3.9 %). Medications were prescribed to 76.5 % of these encounters. More foreigners were seeking primary medical care from private clinics and the encounters were for general medical examinations and acute minor ailments. Those who sought care from public clinics were for obstetric problems and chronic diseases. Medications were prescribed to two-thirds of the encounters while other interventions: laboratory investigations, medical procedures and follow-up appointment had lower rates in private clinics. Foreigners are generally of young working group and are expected to have mandatory medical checks. The preponderance of obstetrics seen in public
Szilagyi, I-S; Bornemann-Cimenti, H; Messerer, B; Vittinghoff, M; Sandner-Kiesling, A
Pain clinics provide interdisciplinary therapy to treat chronic pain patients and to increase the return-to-work rate. In recent years and due to increased economic pressure in health care, a change in the management of pain in Austrian health care centers has been observed. For the analysis of the current situation, two surveys addressing all Austrian pain clinics were performed. In total, 133 heads of Austrian Anesthesia Departments were interviewed online and personally. The data from the first interview were confirmed by an additional telephone survey that was performed by one anesthetist per Austrian state (n = 9). Currently, 44 Austrian pain clinics are active. During the last 5 years, 9 pain clinics closed. Adding the current active pain clinics together, they represent a total of 17.5 full-time-operated clinics. The most common reasons for closing the pain clinics were lack of personnel (47%), lack of time resources (26%), lack of space resources (11%), and financial difficulties (11%). A reduction of >50% of operating hours during the last 3 years was reported by 9 hospitals. The reasons for not running a pain clinic were lack of personnel (36%), lack of time (25%) and department too small (16%). Estimates between actual and required clinics indicate that 49.5 full-time-operating pain clinics are lacking in Austria, resulting in 74% of the Austrian chronic pain patients not receiving interdisciplinary pain management. Our survey confirmed the closure of 9 pain clinics during the last 5 years due to lack of personnel and time. Pain clinics appear to provide the simplest economic saving potential. This development is a major concern. Although running a pain clinic seems to be expensive at the first sight, it reduces pain, sick leave, complications, and potential legal issues against health care centers, while simultaneously increasing the hospital's competitiveness. Our results show that 74% of Austrian chronic pain patients do not have access to an
Abrams, Michael N; Cummings, Simone; Hage, Dana
Care paths map the critical actions and decision points across a patient's course of medical treatment; their purpose is to guide physicians in the delivery of high-quality care while reducing care costs by avoiding services that do not contribute meaningfully to positive outcomes. Each care path development initiative should be led by a respected physician champion, whose specialty is in the area of the care episode being mapped, with the support of a clinician project manager. Once the care path has been developed and implemented, the finance leader's role begins in earnest with the tracking of financial and clinical data against care paths.
There is mounting public awareness of an increasing number of adverse clinical incidents within the National Health Service (NHS), but at the same time, large health care projects like the National Programme for IT (NPFIT) are claiming that safer care is one of the benefits of the project and that health software systems in particular have the potential to reduce the likelihood of accidental or unintentional harm to patients. This paper outlines the approach to clinical safety management taken by CSC, a major supplier to NPFIT; discusses acceptable levels of risk and clinical safety as an end-to-end concept; and touches on the future for clinical safety in health systems software.
Bober, Kenneth F.; And Others
A second-year clinical course composed of weekly observation sessions of interactions between patients and health care professionals in a variety of health care settings within a hospital is described. Weekly discussion sessions summarize the observations and introduce such topics as communication skills, patients' rights, patient relationships,…
Scherer, Jennifer S; Wright, Rebecca; Blaum, Caroline S; Wall, Stephen P
A diagnosis of advanced chronic kidney disease (CKD), or end stage renal disease (ESRD) represents a significant life change for patients and families. Individuals often experience high symptom burden, decreased quality of life, increased health care utilization, and end-of-life care discordant with their preferences. Early integration of palliative care with standard nephrology practice in the outpatient setting has the potential to improve quality of life through provision of expert symptom management, emotional support, and facilitation of advance care planning that honors the individual's values and goals. This special report describes application of participatory action research (PAR) methods to develop an outpatient integrated nephrology and palliative care program. Stakeholder concerns were thematically analyzed to inform translation of a known successful model of outpatient kidney palliative care to a practice in a large, urban medical center in the United States. Stakeholder needs and challenges to meeting these needs were identified. We uncovered a shared understanding of the clinical need for palliative care services in nephrology practice, but apprehension towards practice change. Action steps to modify the base model were created in response to stakeholder feedback. The development of a model of care that provides a new approach to clinical practice requires attention to relevant stakeholder concerns. PAR is a useful methodological approach that engages stakeholders and builds partnerships. This creation of shared ownership can facilitate innovation and practice change. We synthesized stakeholder concerns to build a conceptual model for an integrated nephrology and palliative care clinical program. Copyright © 2017. Published by Elsevier Inc.
Heru, Alison M
Although family research supports family-centered care for all medical specialties, the benefit of family-centered care has not been fully realized in outpatient practice. Physicians, including psychiatrists, are not routinely taught how to work with families and may not be aware of the evidence-base for family interventions. However, some medical specialties, such as family medicine and palliative care, have a clinical practice that routinely includes the family. Clinicians working in medical clinics, such as diabetes clinics, know that successful management of chronic illness requires family involvement. Psychiatric clinics, such as The Family Center for Bipolar Disorder at Beth Israel Medical Center in New York City, also have a family-centered practice and show improved patient outcomes. This article provides guidelines, including clinical interview questions, to help psychiatrists practice family-centered care, either in a private office or in a general psychiatric outpatient clinic. The guidelines include questions that identify when to seek an in-depth family assessment or consultation. Family-centered care will become more useful when health care reimbursement focuses on patient outcome.
Lim, Christopher T; Tadmor, Avia; Fujisawa, Daisuke; MacDonald, James J; Gallagher, Emily R; Eusebio, Justin; Jackson, Vicki A; Temel, Jennifer S; Greer, Joseph A; Hagan, Teresa; Park, Elyse R
While vast opportunities for using qualitative methods exist within palliative care research, few studies provide practical advice for researchers and clinicians as a roadmap to identify and utilize such opportunities. To provide palliative care clinicians and researchers descriptions of qualitative methodology applied to innovative research questions relative to palliative care research and define basic concepts in qualitative research. Body: We describe three qualitative projects as exemplars to describe major concepts in qualitative analysis of early palliative care: (1) a descriptive analysis of clinician documentation in the electronic health record, (2) a thematic content analysis of palliative care clinician focus groups, and (3) a framework analysis of audio-recorded encounters between patients and clinicians as part of a clinical trial. This study provides a foundation for undertaking qualitative research within palliative care and serves as a framework for use by other palliative care researchers interested in qualitative methodologies.
Parchman, Michael L.; Von Korff, Michael; Baldwin, Laura-Mae; Stephens, Mark; Ike, Brooke; Cromp, DeAnn; Hsu, Clarissa; Wagner, Ed H.
Background The challenge of responding to prescription opioid overuse within the United States has fallen disproportionately on the primary care clinic setting. Here we describe a framework comprised of 6 Building Blocks to guide efforts within this setting to address the use of opioids for chronic pain. Methods Investigators conducted site visits to thirty primary care clinics across the United States selected for their use of team-based workforce innovations. Site visits included interviews with leadership, clinic tours, observations of clinic processes and team meetings, and interviews with staff and clinicians. Data were reviewed to identify common attributes of clinic system changes around chronic opioid therapy (COT) management. These concepts were reviewed to develop narrative descriptions of key components of changes made to improve COT use. Results Twenty of the thirty sites had addressed improvements in COT prescribing. Across these sites a common set of 6 Building Blocks were identified: 1) providing leadership support; 2) revising and aligning clinic policies, patient agreements (contracts) and workflows; 3) implementing a registry tracking system; 4) conducting planned, patient-centered visits; 5) identifying resources for complex patients; and 6) measuring progress toward achieving clinic objectives. Common components of clinic policies, patient agreements and data tracked in registries to assess progress are described. Conclusions In response to prescription opioid overuse and the resulting epidemic of overdose and addiction, primary care clinics are making improvements driven by a common set of best practices that address complex challenges of managing COT patients in primary care settings. PMID:28062816
Bala, Sidona-Valentina; Samuelson, Karin; Hagell, Peter; Svensson, Björn; Fridlund, Bengt; Hesselgard, Karin
To describe how people with rheumatoid arthritis (RA) experience the care provided by Swedish nurse-led rheumatology outpatient clinics. Eighteen adult people with a diagnosis of RA who had had at least three documented contact sessions with a nurse-led clinic were interviewed. The interviews were analysed with qualitative content analysis. Care was expressed in three categories: social environment, professional approach and value-adding measures. A social environment including a warm encounter, a familial atmosphere and pleasant premises was desired and contributed to a positive experience of care. The nurses' professional approach was experienced as empathy, knowledge and skill, as well as support. The care was described as person centred and competent, as it was based on the individual's unique experience of his/her disease and needs. The nurses' specialist knowledge of rheumatology and rheumatology care was highly valued. The offered care represented added value for the participants, instilling security, trust, hope and confidence. It was perceived as facilitating daily life and creating positive emotions. The nurse-led clinics were reported to be easily accessible and provided continuity of the care. These features were presented as fundamental guarantees for health care safety. The experiences emphasized the need for a holistic approach to care. In this process, the organization of care and the role and skills of the nurse should be focused on the individual's needs and perspectives. The social environment, professional approach and value-adding measures are particularly relevant for optimal care at nurse-led rheumatology outpatient clinics. Copyright © 2012 John Wiley & Sons, Ltd.
Mansdorf, B D
The enormous commitment of resources to ambulatory health care services requires that flexible and easily implementable management techniques be developed to improve the allocation of health manpower and funds. This article develops a feasible model for staffing outpatient clinics and thereby potentially provides an important analytical tool for allocating and monitoring the utilization of the most critical and expensive of ambulatory care resources-professional and nonprofessional clinic personnel. The model is simplistic, extremely flexible, and can be applied to many modes of delivering ambulatory care-from HMOs to traditional hospital outpatient clinics. To employ the model, certain decision variables must be specified so that the model can produce a least-cost staffing configuration to meet the demand for service in accordance with the desired mode and intensity of care. The key decision varables that require input from administrators and medical personnel include standards for physician-patient contact time, a desired ratio of staff time actually spent treating patients to total paid staff time, and the desired mix of various staff categories to achieve program objectives. Specific benefits of using the model include determining staffing for new, expanded, or existing outpatient clinics, determining budget requirements for such staffing needs, and providing quantitative productivity and utilization objectives and measurements. PMID:809787
Chaisson, Nicole; Shore, William B
Adolescence is marked by complex physical, cognitive, social, and emotional development, which can be stressful for families and adolescents. Before the onset of puberty, providers should clearly lay the groundwork for clinical care and office visits during the adolescent years. This article addresses the guidelines and current legal standards for confidentiality in adolescent care, the most frequently used psychosocial screening tools, and current recommendations for preventive health services and immunizations. Through the creation of teen-friendly clinics, primary care providers are well positioned to offer guidance and support to teens and their parents during this time of transition and growth. Copyright © 2014 Elsevier Inc. All rights reserved.
Bender, Miriam; Connelly, Cynthia D; Glaser, Dale; Brown, Caroline
The current fragmented healthcare system, characterized by a lack of collaborative, patient-centered care processes, creates significant barriers to providing quality patient care. The clinical nurse leader (CNL) is theorized to provide clinical leadership at the point-of-practice to maintain cross-disciplinary collaborative processes that lead to integrated quality care. The aim of this study was to assess the impact of CNL integration into an acute care microsystem on care quality, as measured by patient satisfaction with care. A short interrupted time series design was used to measure patient satisfaction with multiple aspects of care 10 months before and 12 months after integration of the CNL role on a progressive care unit, compared with a control unit. Data were obtained from Press Ganey surveys, and analysis was completed using a publicly available program for short time series data streams. Clinical nurse leader implementation was correlated with significantly improved patient satisfaction with admission processes (r = + .63, p = .02) and nursing care (r = +.75, p = .004), including skill level (r = .83, p = .003) and keeping patients informed (r = .70, p = .003). There was no significant correlation with improved patient satisfaction with physician care (r = .31, p = .14) or discharge processes (r = .33, p = .23) postimplementation. Control data showed no significant changes in patient satisfaction measures throughout the study time frame. The positive correlation between CNL-mediated collaborative care processes and improvements in patient satisfaction with care quality provides empirical evidence of outcomes achievable through CNL implementation. Research is needed to explore the full range of achievable outcomes and to determine the specific processes by which these outcomes are realized.
First, Michael B; Bhat, Venkat; Adler, David; Dixon, Lisa; Goldman, Beth; Koh, Steve; Levine, Bruce; Oslin, David; Siris, Sam
The clinical use of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is explicitly stated as a goal for both the DSM Fourth Edition and DSM Fifth Edition (DSM-5) revisions. Many uses assume a relatively faithful application of the DSM diagnostic definitions. However, studies demonstrate significant discrepancies between clinical psychiatric diagnoses with those made using structured interviews suggesting that clinicians do not systematically apply the diagnostic criteria. The limited information regarding how clinicians actually use the DSM raises important questions: a) How can the clinical use be improved without first having a baseline assessment? b) How can potentially significant shifts in practice patterns based on wording changes be assessed without knowing the extent to which the criteria are used as written? Given the American Psychiatric Association's plans for interim revisions to the DSM-5, the value of a detailed exploration of its actual use in clinical practice remains a significant ongoing concern and deserves further study including a number of survey and in vivo studies.
Sroczynski, Maureen; Dunphy, Lynne M
The Institute of Medicine report and the passage of the Patient Protection and Affordable Care Act present significant opportunities for the nursing profession. As the largest group of primary care providers, nurse practitioners are the critical element in the provision of comprehensive primary care, and a critical element to the success of the redesigned health care system. Nurse practitioners can bridge the gap between coverage and access and provide the patient-centered innovative approaches needed. There are, however, significant barriers that need to be addressed. This article presents a framework for creating innovative approaches to the redesign of nurse practitioner clinical education. Copyright © 2012 Elsevier Inc. All rights reserved.
Simpao, Allan F; Ahumada, Luis M; Gálvez, Jorge A; Rehman, Mohamed A
Federal investment in health information technology has incentivized the adoption of electronic health record systems by physicians and health care organizations; the result has been a massive rise in the collection of patient data in electronic form (i.e. "Big Data"). Health care systems have leveraged Big Data for quality and performance improvements using analytics-the systematic use of data combined with quantitative as well as qualitative analysis to make decisions. Analytics have been utilized in various aspects of health care including predictive risk assessment, clinical decision support, home health monitoring, finance, and resource allocation. Visual analytics is one example of an analytics technique with an array of health care and research applications that are well described in the literature. The proliferation of Big Data and analytics in health care has spawned a growing demand for clinical informatics professionals who can bridge the gap between the medical and information sciences.
Audet, M C
It has been well-documented that the clinical experience is one of the most anxiety-producing aspects of nursing education. When feelings of anxiety become severe, they present a clear threat to the student's success in the program. This article explores the role of "caring" in nursing education as a means of reducing student anxiety. Caring, described at length by Jean Watson, has become one of the most popular trends in the education of young nurses. When caring behaviors are demonstrated in a meaningful way by clinical instructors, the student may experience a sense of comfort and belonging, which may in turn be effective in reducing anxiety and enabling the student to successfully complete a clinical rotation. The aim of this article is to inspire nurses, not only those in the educational setting but in all settings and at all levels of their careers, to reconsider the effects and benefits of displaying a caring attitude.
Fernandez, Leonor; Irby, David M.; Harleman, Elizabeth; Fernandez, Alicia
Clinical teachers often observe interactions that may contribute to health care disparities, yet may hesitate to teach about them. A pedagogical model could help faculty structure teaching about health care disparities in the clinical setting, but to our knowledge, none have been adapted for this purpose. In this paper, we adapt an established model, Time-Effective Strategies for Teaching (TEST), to the teaching of health care disparities. We use several case scenarios to illustrate the core components of the model: diagnose the learner, teach rapidly to the learner’s need, and provide feedback. The TEST model is straightforward, easy to use, and enables the incorporation of teaching about health care disparities into routine clinical teaching. PMID:20352501
Ham, Nancy J
Based on the experiences of an electronic information-sharing network, the following tactics can help healthcare organizations gauge the "soft" ROI of potential investments in clinical technology: Start with a needs assessment. Walk before you run. Establish ROI metrics and measure them consistently. Create a feedback loop. Keep innovating and growing.
Hudson, Peter; Quinn, Karen; O'Hanlon, Brendan; Aranda, Sanchia
Background Support for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion. Methods The guidelines were developed via the following methods: (1) A literature review; (2) Conceptual framework; (3) Refinement of the guidelines based on feedback from an expert panel and focus groups with multidisciplinary specialists from three palliative care units and three major teaching hospitals in Melbourne, Australia. Results The literature review revealed that no comprehensive exploration of the conduct and utility of family meetings in the specialist palliative care setting has occurred. Preliminary clinical guidelines were developed by the research team, based on relevant literature and a conceptual framework informed by: single session therapy, principles of therapeutic communication and models of coping and family consultation. A multidisciplinary expert panel refined the content of the guidelines and the applicability of the guidelines was then assessed via two focus groups of multidisciplinary palliative care specialists. The complete version of the guidelines is presented. Conclusion Family meetings provide an opportunity to enhance the quality of care provided to palliative care patients and their family carers. The clinical guidelines developed from this study offer a framework for preparing, conducting and evaluating family meetings. Future research and clinical implications are outlined. PMID:18710576
Lasierra, N.; Oberbichler, S.; Toma, I.; Fensel, A.; Hoerbst, A.
Summary Background Electronic health records (EHRs) play an important role in the treatment of chronic diseases such as diabetes mellitus. Although the interoperability and selected functionality of EHRs are already addressed by a number of standards and best practices, such as IHE or HL7, the majority of these systems are still monolithic from a user-functionality perspective. The purpose of the OntoHealth project is to foster a functionally flexible, standards-based use of EHRs to support clinical routine task execution by means of workflow patterns and to shift the present EHR usage to a more comprehensive integration concerning complete clinical workflows. Objectives The goal of this paper is, first, to introduce the basic architecture of the proposed OntoHealth project and, second, to present selected functional needs and a functional categorization regarding workflow-based interactions with EHRs in the domain of diabetes. Methods A systematic literature review regarding attributes of workflows in the domain of diabetes was conducted. Eligible references were gathered and analyzed using a qualitative content analysis. Subsequently, a functional workflow categorization was derived from diabetes-specific raw data together with existing general workflow patterns. Results This paper presents the design of the architecture as well as a categorization model which makes it possible to describe the components or building blocks within clinical workflows. The results of our study lead us to identify basic building blocks, named as actions, decisions, and data elements, which allow the composition of clinical workflows within five identified contexts. Conclusions The categorization model allows for a description of the components or building blocks of clinical workflows from a functional view. PMID:25024765
Centeno, Carlos; Rodríguez-Núñez, Alfredo
The aim of this 2-year systematic review is to understand how learner assessment and curriculum evaluation of education in palliative care is being undertaken and to examine whether current undergraduate education influences the clinical patient's care. Almost half of the 30 studies reviewed used a qualitative approach to evaluate learning experiences. Only three of them were controlled studies and a further one was a cohort study.When students openly express themselves, they agree that there is 'something' deep as regards the core or the essence of medical practice or nursing. They feel that they become better professionals and better prepared for the patients, not only in terms of end of life care, but also as regards care, irrespective of the phase of the disease.The inclusion of palliative care in undergraduate education is a way of providing knowledge, skill, and competences about palliative care (especially communication) and also improving attitudes toward caring in advanced disease and at the end of life. Different methods of experiential learning, even brief experiences, which bring students into close contact with palliative care clinical cases or patients, are providing better results. From research studies, there is only indirect evidence that palliative care training at university leads to better clinical care of patients. In the future, long-term cohort or controlled studies might answer that question.
Richards, David A; Hill, Jacqueline J; Gask, Linda; Lovell, Karina; Chew-Graham, Carolyn; Bower, Peter; Cape, John; Pilling, Stephen; Araya, Ricardo; Kessler, David; Bland, J Martin; Green, Colin; Gilbody, Simon; Lewis, Glyn; Manning, Chris; Hughes-Morley, Adwoa; Barkham, Michael
To compare the clinical effectiveness of collaborative care with usual care in the management of patients with moderate to severe depression. Cluster randomised controlled trial. 51 primary care practices in three primary care districts in the United Kingdom. 581 adults aged 18 years and older who met ICD-10 (international classification of diseases, 10th revision) criteria for a depressive episode on the revised Clinical Interview Schedule. We excluded acutely suicidal patients and those with psychosis, or with type I or type II bipolar disorder; patients whose low mood was associated with bereavement or whose primary presenting problem was alcohol or drug abuse; and patients receiving psychological treatment for their depression by specialist mental health services. We identified potentially eligible participants by searching computerised case records in general practices for patients with depression. Collaborative care, including depression education, drug management, behavioural activation, relapse prevention, and primary care liaison, was delivered by care managers. Collaborative care involved six to 12 contacts with participants over 14 weeks, supervised by mental health specialists. Usual care was family doctors' standard clinical practice. Depression symptoms (patient health questionnaire 9; PHQ-9), anxiety (generalised anxiety disorder 7; GAD-7), and quality of life (short form 36 questionnaire; SF-36) at four and 12 months; satisfaction with service quality (client satisfaction questionnaire; CSQ-8) at four months. 276 participants were allocated to collaborative care and 305 allocated to usual care. At four months, mean depression score was 11.1 (standard deviation 7.3) for the collaborative care group and 12.7 (6.8) for the usual care group. After adjustment for baseline depression, mean depression score was 1.33 PHQ-9 points lower (95% confidence interval 0.35 to 2.31, P=0.009) in participants receiving collaborative care than in those receiving usual
Whittenburg, Luann; Meetim, Aunchisa
An innovative nursing documentation project conducted at Bumrungrad International Hospital in Bangkok, Thailand demonstrated patient care continuity between nursing patient assessments and nursing Plans of Care using the Clinical Care Classification System (CCC). The project developed a new generation of interactive nursing Plans of Care using the six steps of the American Nurses Association (ANA) Nursing process and the MEDCIN® clinical knowledgebase to present CCC coded concepts as a natural by-product of a nurse's documentation process. The MEDCIN® clinical knowledgebase is a standardized point-of-care terminology intended for use in electronic health record systems. The CCC is an ANA recognized nursing terminology.
Preissig, Catherine M; Rigby, Mark R
Hyperglycemia is common in critically ill patients and is associated with increased morbidity and mortality. Strict glycemic control improves outcomes in some adult populations and may have similar effects in children. While glycemic control has become standard care in adults, little is known regarding hyperglycemia management strategies used by pediatric critical care practitioners. We sought to assess both the beliefs and practice habits regarding glycemic control in pediatric intensive care units (ICUs) in the United States (US). We surveyed 30 US pediatric ICUs from January to May 2009. Surveys were conducted by phone between the investigators and participating centers and consisted of a 22-point questionnaire devised to assess physician perceptions and center-specific management strategies regarding glycemic control. ICUs included a cross section of centers throughout the US. Fourteen out of 30 centers believe all critically ill hyperglycemic adults should be treated, while 3/30 believe all critically ill children should be treated. Twenty-nine of 30 believe some subsets of adults with hyperglycemia should be treated, while 20/30 believe some subsets of children should receive glycemic control. A total of 70%, 73%, 80%, 27%, and 40% of centers believe hyperglycemia adversely affects outcomes in cardiac, trauma, traumatic brain injury, general medical, and general surgical pediatric patients, respectively. However, only six centers use a standard, uniform approach to treat hyperglycemia at their institution. Sixty percent of centers believe hypoglycemia is more dangerous than hyperglycemia. Seventy percent listed fear of management-induced hypoglycemia as a barrier to glycemic control at their center. Considerable disparity exists between physician beliefs and actual practice habits regarding glycemic control among pediatric practitioners, with few centers reporting the use of any consistent standard approach to screening and management. Physicians wishing to
pathogenesis of coronary artery, peripheral vascular , and cerebrovascular disease . Impairment of endothelial function has been demonstrated after high...cardio’Va~ ct•b.r disease , Subsequently, ultrnlow-fat diets (:;;1.0% of totlll caloric intake as fat), emphasi?.in,g the amount ra.thcr th<•.o the...cardiovascular disease at the molecular disease stage and identify biomarkers predictive of sub- clinical CVD; and 3) Relate genomic/proteomic changes to the
D'Amico, Jessica B; Nelson, Joan
(1) Describe the nurse care manager role at a shelter-based clinic for women and children who have experienced domestic violence (DV). (2) Develop an innovative model for nursing care management in this unique setting and discuss implications for its implementation in other shelter-based clinics. (3) Provide historical benchmarking data on the use of health-related community resources and common barriers to obtaining these services among women and children following a nurse care management intervention. A clinic-based, nurse care management model was developed and implemented at a not-for-profit emergency residential shelter for women and children who have experienced DV. However, DV victims do not just appear in the community: nurse case managers encounter DV in every healthcare setting from hospitals to physician offices/clinics. A shelter-based clinic is a safe, confidential, and easily accessible place for women and children victimized by DV to receive immediate care and ongoing assistance for health-related needs. The nurse care manager, who practices in this setting and utilizes motivational interviewing techniques, has a unique opportunity to empower and support women to make informed decisions regarding the health and well-being of themselves and their children. Provision of nursing care management services in a shelter-based clinic is an innovative approach to improving outcomes and reducing the burden of suffering among women and children who leave abusive situations. The nurse care manager role and, specifically, the model of care described in this project, which includes motivational interviewing techniques, may be generalized to other shelter-type settings to promote sustained, healthy lifestyle practices for victims of DV. Benchmarks developed in this study serve as an initial approach to evaluating outcomes when applying this nursing care management model in practice. Future studies on the effectiveness of this approach among victims of DV are
required application of innovative and creative strategies to improve self-management. The cases are representative of some common themes within the patient with type 2 diabetes in a military primary care clinic.
Ferrell, Betty R; Temel, Jennifer S; Temin, Sarah; Alesi, Erin R; Balboni, Tracy A; Basch, Ethan M; Firn, Janice I; Paice, Judith A; Peppercorn, Jeffrey M; Phillips, Tanyanika; Stovall, Ellen L; Zimmermann, Camilla; Smith, Thomas J
Purpose To provide evidence-based recommendations to oncology clinicians, patients, family and friend caregivers, and palliative care specialists to update the 2012 American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) on the integration of palliative care into standard oncology care for all patients diagnosed with cancer. Methods ASCO convened an Expert Panel of members of the ASCO Ad Hoc Palliative Care Expert Panel to develop an update. The 2012 PCO was based on a review of a randomized controlled trial (RCT) by the National Cancer Institute Physicians Data Query and additional trials. The panel conducted an updated systematic review seeking randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of RCTs in the 2012 PCO, published from March 2010 to January 2016. Results The guideline update reflects changes in evidence since the previous guideline. Nine RCTs, one quasiexperimental trial, and five secondary analyses from RCTs in the 2012 PCO on providing palliative care services to patients with cancer and/or their caregivers, including family caregivers, were found to inform the update. Recommendations Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer family and friend caregivers of patients with early or advanced cancer to palliative care services.
Bozic, Kevin J; Pierce, Read G; Herndon, James H
Health care technology (defined as all drugs, devices, and medical and surgical procedures used in medical care as well as the organizational and supportive systems within which such care is provided) is widely regarded as an important driver of escalating health care spending in the United States. Many new health care technologies are adopted and used in clinical practice with little or no evidence that their use is associated with improved patient outcomes. Orthopaedic surgeons are facing increasing scrutiny from hospitals and payers regarding the adoption and use of new technology for the treatment of patients with musculoskeletal disease. Health care technology assessment is a growing field that is concerned with the multidisciplinary evaluation of clinical data on the basis of safety and efficacy as well as economic aspects of technology acquisition. Through an understanding of the relevant literature and the concepts of health care technology assessment, orthopaedic surgeons have an opportunity to participate in the assessment process and thus influence clinical and health policy decisions regarding the adoption and use of new and existing technologies in the field of orthopaedic surgery.
Fitzgerald, Ruth P
Doctor flight from rural areas is an international phenomenon that places great pressure on primary health care delivery. In New Zealand, the response to these empty doctors' surgeries has been the introduction of nurse-led rural health clinics that have attracted controversy both in the media and from urban-based doctors over whether such nurse-led care is a direct substitution of medical care. This article analyzes the reflections of nurses working in some of these clinics who suggest that their situation is more complex than a direct substitution of labor. Although the nurses indicate some significant pressures moving them closer to the work of doctoring, they actively police this cross-boundary work and labor simultaneously to shore up their nursing identities. My own conclusions support their assertions. I argue that it is the maintenance of a holistic professional habitus that best secures their professional identity as nurses while they undertake the cross-boundary tasks of primary rural health care. There are clear professional benefits and disadvantages for the nurses in these situations, which make the positions highly politicized. These recurring divisions of labor within medical care giving and the elaboration of new types of care worker form an appropriate although neglected topic of study for anthropologists. The study of the social organization of clinical medicine is much enriched by paying closer attention to its interaction with allied health professions and their associated understandings of "good" care.
Radix, Asa; Deutsch, Madeline B.
Abstract: Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested “best practices” for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment). PMID:27429189
The paper argues that a particular version of moral realism constitutes an important basis for ethics in medicine and health care. Moral realism is the position that moral value is a part of the fabric of relational and interpersonal reality. But even though moral values are subject to human interpretations, they are not themselves the sole product of these interpretations. Moral values are not invented but discovered by the subject. Moral realism argues that values are open to perception and experience and that moral subjectivity must be portrayed in how moral values are discovered and perceived by the human subject. Moral values may exist independent of the particular subject's interpretative evaluations as a part of reality. This epistemological point about normativity is particularly significant in medical care and in health care. The clinician perceives moral value in the clinical encounter in a way that is important for competent clinical understanding. Clinical understanding in medical care and health care bears on the encounter with moral values in the direct and embodied relations to patients, with their experiences of illness and their vulnerabilities. Good clinical care is then partly conditioned upon adequate understanding of such moral realities.
Xue, Ying; Tuttle, Jane
Nurse practitioners are increasingly being integrated into primary care delivery to help meet the growing demand for primary care. It is therefore important to understand nurse practitioners' productivity in primary care practice. We examined nurse practitioners' clinical productivity in regard to number of patients seen per week, whether they had a patient panel, and patient panel size. We further investigated practice characteristics associated with their clinical productivity. We conducted cross-sectional analysis of the 2012 National Sample Survey of Nurse Practitioners. The sample included full-time primary care nurse practitioners in ambulatory settings. Multivariable survey regression analyses were performed to examine the relationship between practice characteristics and nurse practitioners' clinical productivity. Primary care nurse practitioners in ambulatory settings saw an average of 80 patients per week (95% confidence interval [CI]: 79-82), and 64% of them had their own patient panel. The average patient panel size was 567 (95% CI: 522-612). Nurse practitioners who had their own patient panel spent a similar percent of time on patient care and documentation as those who did not. However, those with a patient panel were more likely to provide a range of clinical services to most patients. Nurse practitioners' clinical productivity was associated with several modifiable practice characteristics such as practice autonomy and billing and payment policies. The estimated number of patients seen in a typical week by nurse practitioners is comparable to that by primary care physicians reported in the literature. However, they had a significantly smaller patient panel. Nurse practitioners' clinical productivity can be further improved. Copyright © 2016 Elsevier Inc. All rights reserved.
Yu Hong; Han Shensheng; Ding Jianhui; Jiang Zhaoxia; Peng Weijun
A hybrid model combining Monte Carlo method with diffraction theory of wave optics has been developed and applied to quantitatively simulate the in-line diffractive phase-contrast x-ray imaging of three dimensional tissue samples under actual clinic imaging parameters. The primary microcosmic interactions of medical-energy x-ray within matter including photoabsorption, Compton scattering, and coherent scattering, have been taken into account in the Monte Carlo simulation. A diffraction processing based on Fresnel diffraction theory is carried out to simulate the macroscopic diffraction effect. A comparison with experiment results has also been performed.
González-de Paz, L
The clinical decision making process with ethical implications in the area of primary healthcare differs from other healthcare areas. From the ethical perspective it is important to include these issues in the decision making model. This dissertation explains the need for a process of bioethical deliberation for Primary Healthcare, as well as proposing a method for doing so. The decision process method, adapted to this healthcare area, is flexible and requires a more participative Healthcare System. This proposal involves professionals and the patient population equally, is intended to facilitate the acquisition of responsibility for personal and community health.
Background For the treatment of chronic back pain, it has been theorized that integrative care plans can lead to better outcomes than those achieved by monodisciplinary care alone, especially when using a collaborative, interdisciplinary, and non-hierarchical team approach. This paper describes the use of a care pathway designed to guide treatment by an integrative group of providers within a randomized controlled trial. Methods A clinical care pathway was used by a multidisciplinary group of providers, which included acupuncturists, chiropractors, cognitive behavioral therapists, exercise therapists, massage therapists and primary care physicians. Treatment recommendations were based on an evidence-informed practice model, and reached by group consensus. Research study participants were empowered to select one of the treatment recommendations proposed by the integrative group. Common principles and benchmarks were established to guide treatment management throughout the study. Results Thirteen providers representing 5 healthcare professions collaborated to provide integrative care to study participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into treatment plans. Conclusion This clinical care pathway was a useful tool for the consistent application of evidence-based care for low back pain in the context of an integrative setting. Trial registration ClinicalTrials.gov NCT00567333 PMID:21034483
Shrank, William H; Krumme, Alexis A; Tong, Angela Y; Spettell, Claire M; Matlin, Olga S; Sussman, Andrew; Brennan, Troyen A; Choudhry, Niteesh K
Evaluation of quality of care across retail clinics in a geographically diverse population has not been undertaken to date. We sought to evaluate and compare the quality of care for otitis media, pharyngitis, and urinary tract infection received in retail medical clinics in CVS pharmacies ("MinuteClinics" [MCs]), ambulatory care facilities (ACFs), and emergency departments (EDs). We used 14 measures constructed from RAND Corporation's Quality Assurance Tools and guidelines from the American Academy of Pediatrics, the American Academy of Family Physicians, and the Infectious Diseases Society of America. Our cohort was drawn from Aetna medical and prescription claims, 2009-2012. Members were matched on visit date, condition, and propensity score. Generalized estimating equations were used to compare quality across clinic type, overall, and by index condition. We matched 75,886 episodes of care, of which 20,153 were eligible for at least 1 quality measure. MCs performed better than EDs and ACFs in 7 measures. In a multivariable model, MCs performed better than ACFs and EDs across all quality measures ([OR 0.42; 95% CI, 0.40-0.45; P < .0001; ACF vs MC] [OR 0.29; 95% CI, 0.27-0.31; P < .0001; ED vs MC]). Results for each condition were significant at P < .0001. Quality of care for these conditions based on widely accepted objective measures was superior in MinuteClinics compared with ACFs and EDs.
Bowling, A; Bond, M
Encouraged by the increased purchasing power of general practitioners (GPs), specialist-run clinics in general practice and community health care settings (known as specialist outreach clinics) have increased rapidly across England. The activities of local commissioning schemes within primary care groups are likely to accelerate this trend. To evaluate the costs, processes, and benefits of specialists' outreach clinics held in GPs' surgeries, compared with hospital outpatient clinics. A case-referent (comparative) study comparing the characteristics of outreach clinics (cases) with matched outpatient control clinics. Thirty-eight outreach clinics, compared with 38 matched outpatient clinics as controls, covering 14 hospital trust areas across England. Self-administered questionnaires were given to patients in both clinic settings. These covered processes, satisfaction, personal costs, and health status, with postal follow-up at six months to assess health outcomes. Self-administered questionnaires were also given to the specialists and GPs whose clinics were included in the study (individual patient clinical sheet and an attitude questionnaire), practice managers, and trust accountants (process and costs questionnaire). Evaluation of the costs, processes, and benefits of specialist outreach clinics versus hospital outpatient clinics was carried out by comparing questionnaire responses. In comparison with outpatients, outreach clinic patients spent less time on the waiting lists for appointments to see the specialist, they had shorter waiting times in clinics, fewer follow-up appointments, and were more likely to be completely discharged after the sampled attendance. Outreach patients were more satisfied than outpatients with the range of clinic process items asked about. Most doctors felt that the outreach clinic was 'worthwhile'. While patients' personal costs were lower in outreach than in outpatients clinics, NHS costs were more expensive per patient in outreach
Bowling, A; Bond, M
BACKGROUND: Encouraged by the increased purchasing power of general practitioners (GPs), specialist-run clinics in general practice and community health care settings (known as specialist outreach clinics) have increased rapidly across England. The activities of local commissioning schemes within primary care groups are likely to accelerate this trend. AIM: To evaluate the costs, processes, and benefits of specialists' outreach clinics held in GPs' surgeries, compared with hospital outpatient clinics. DESIGN OF STUDY: A case-referent (comparative) study comparing the characteristics of outreach clinics (cases) with matched outpatient control clinics. SETTING: Thirty-eight outreach clinics, compared with 38 matched outpatient clinics as controls, covering 14 hospital trust areas across England. METHOD: Self-administered questionnaires were given to patients in both clinic settings. These covered processes, satisfaction, personal costs, and health status, with postal follow-up at six months to assess health outcomes. Self-administered questionnaires were also given to the specialists and GPs whose clinics were included in the study (individual patient clinical sheet and an attitude questionnaire), practice managers, and trust accountants (process and costs questionnaire). Evaluation of the costs, processes, and benefits of specialist outreach clinics versus hospital outpatient clinics was carried out by comparing questionnaire responses. RESULTS: In comparison with outpatients, outreach clinic patients spent less time on the waiting lists for appointments to see the specialist, they had shorter waiting times in clinics, fewer follow-up appointments, and were more likely to be completely discharged after the sampled attendance. Outreach patients were more satisfied than outpatients with the range of clinic process items asked about. Most doctors felt that the outreach clinic was 'worthwhile'. While patients' personal costs were lower in outreach than in outpatients
Van de Kerkhof, Noortje WA; Feenstra, Ilse; van der Heijden, Frank MMA; de Leeuw, Nicole; Pfundt, Rolph; Stöber, Gerald; Egger, Jos IM; Verhoeven, Willem MA
With the introduction of new genetic techniques such as genome-wide array comparative genomic hybridization, studies on the putative genetic etiology of schizophrenia have focused on the detection of copy number variants (CNVs), ie, microdeletions and/or microduplications, that are estimated to be present in up to 3% of patients with schizophrenia. In this study, out of a sample of 100 patients with psychotic disorders, 80 were investigated by array for the presence of CNVs. The assessment of the severity of psychiatric symptoms was performed using standardized instruments and ICD-10 was applied for diagnostic classification. In three patients, a submicroscopic CNV was demonstrated, one with a loss in 1q21.1 and two with a gain in 1p13.3 and 7q11.2, respectively. The association between these or other CNVs and schizophrenia or schizophrenia-like psychoses and their clinical implications still remain equivocal. While the CNV affected genes may enhance the vulnerability for psychiatric disorders via effects on neuronal architecture, these insights have not resulted in major changes in clinical practice as yet. Therefore, genome-wide array analysis should presently be restricted to those patients in whom psychotic symptoms are paired with other signs, particularly dysmorphisms and intellectual impairment. PMID:22848183
Long, Stacey; Meyer, Caroline; Leung, Newman; Wallis, Deborah J
The aim of this study was to determine the effects of distraction and focused attention on both food intake and accuracy of perceived intake in women with non-clinical levels of disordered eating. In a laboratory study, twenty-seven young women consumed three identical pasta meals once a week for three consecutive weeks. Meals were eaten ad libitum during a control and two test conditions, in which attention was either diverted away from (distraction condition) or directed towards food-related stimuli (focused attention condition). They also completed the drive for thinness, bulimia and body dissatisfaction subscales of the Eating Disorders Inventory-2. Intake was significantly higher in the distraction than in the control or focused attention conditions, but was not related to eating psychopathology. A measure of accuracy of perceived intake indicated that drive for thinness was associated with overestimation of food intake in the focused attention condition. This study suggests that distraction could promote food intake in all non-clinical consumers, irrespective of individual differences in eating behaviours. Furthermore, it suggests that those with a high drive for thinness may overestimate intake when required to focus on their food. These findings could have implications for mealtime interventions in the treatment of eating disorders. Copyright © 2010 Elsevier Ltd. All rights reserved.
Abrams, D I
Cannabis species have been used as medicine for thousands of years; only since the 1940s has the plant not been widely available for medical use. However, an increasing number of jurisdictions are making it possible for patients to obtain the botanical for medicinal use. For the cancer patient, cannabis has a number of potential benefits, especially in the management of symptoms. Cannabis is useful in combatting anorexia, chemotherapy-induced nausea and vomiting, pain, insomnia, and depression. Cannabis might be less potent than other available antiemetics, but for some patients, it is the only agent that works, and it is the only antiemetic that also increases appetite. Inhaled cannabis is more effective than placebo in ameliorating peripheral neuropathy in a number of conditions, and it could prove useful in chemotherapy-induced neuropathy. A pharmacokinetic interaction study of vaporized cannabis in patients with chronic pain on stable doses of sustained-release opioids demonstrated no clinically significant change in plasma opiates, while suggesting the possibility of synergistic analgesia. Aside from symptom management, an increasing body of in vitro and animal-model studies supports a possible direct anticancer effect of cannabinoids by way of a number of different mechanisms involving apoptosis, angiogenesis, and inhibition of metastasis. Despite an absence of clinical trials, abundant anecdotal reports that describe patients having remarkable responses to cannabis as an anticancer agent, especially when taken as a high-potency orally ingested concentrate, are circulating. Human studies should be conducted to address critical questions related to the foregoing effects.
Ruben, Mollie A; Shipherd, Jillian C; Topor, David; AhnAllen, Christopher G; Sloan, Colleen A; Walton, Heather M; Matza, Alexis R; Trezza, Glenn R
Culturally competent health care is especially important among sexual and gender minority patients because poor cultural competence contributes to health disparities. There is a need to understand how to improve health care quality and delivery for lesbian, gay, bisexual, and transgender (LGBT) veterans in particular, because they have unique physical and mental health needs as both LGBT individuals and veterans. The following article is a case study that focuses on the policy and clinical care practices related to LGBT clinical competency, professional training, and ethical provision of care for veteran patients in the VA Boston Healthcare System. We apply Betancourt et al.'s (2003) cultural competence framework to outline the steps that VA Boston Healthcare System took to increase cultural competency at the organizational, structural, and clinical level. By sharing our experiences, we aim to provide a model and steps for other health care systems and programs, including other VA health care systems, large academic health care systems, community health care systems, and mental health care systems, interested in developing LGBT health initiatives.
Link, Denise G; Perry, Diane; Cesarotti, Evelyn L
Beginning in January 2014, millions of Americans will enroll in health insurance plans under the Affordable Care Act. Some of these individuals were obtaining health care in safety net health clinics, emergency departments, or urgent care centers; many were going without needed care and will be new to the health care system. In addition to these newly insured, the ranks of older Americans and persons in need of chronic disease management will be on the rise. The way in which health care is delivered will have to change in order for the health care workforce to meet the demand for their services without sacrificing quality or access. Nurse practitioners and registered nurses have the education and skills to provide health promotion, disease prevention, and chronic disease management services that will make up a sizable portion of the demand. Amending state practice acts so that the authority to practice matches the ability to practice and opening provider panels to advanced practice nurses will provide opportunities to establish or expand sustainable nurse-led primary care practices in health care shortage areas. Along with these changes, models of health care delivery that incorporate differentiated practice roles and shared interprofessional responsibility for providing care will maximize the capacity of the system to provide the health care that people need.
Crespin, Daniel J; Christianson, Jon B; McCullough, Jeffrey S; Finch, Michael D
We addressed two questions regarding health system consolidation through the acquisition of ambulatory clinics: (1) Was increasing health system size associated with improved diabetes care performance and (2) Did the diabetes care performance of acquired clinics improve postacquisition? Six hundred sixty-one ambulatory clinics in Minnesota and bordering states that reported performance data from 2007 to 2013. We employed fixed effects regression to determine if increased health system size and being acquired improved clinics' performance. Using our regression results, we estimated the average effect of consolidation on the performance of clinics that were acquired during our study. Publicly reported performance data obtained from Minnesota Community Measurement. Acquired clinics experienced performance improvements starting in their third year postacquisition. By their fifth year postacquisition, acquired clinics had 3.6 percentage points (95 percent confidence interval: 2.0, 5.1) higher performance than if they had never been acquired. Increasing health system size was associated with slight performance improvements at the end of the study. Health systems modestly improved the diabetes care performance of their acquired clinics; however, we found little evidence that systems experienced large, system-wide performance gains by increasing their size. © Health Research and Educational Trust.
de Mul, Marleen; Alons, Peter; van der Velde, Peter; Konings, Ilse; Bakker, Jan; Hazelzet, Jan
There are relatively few institutions that have developed clinical data warehouses, containing patient data from the point of care. Because of the various care practices, data types and definitions, and the perceived incompleteness of clinical information systems, the development of a clinical data warehouse is a challenge. In order to deal with managerial and clinical information needs, as well as educational and research aims that are important in the setting of a university hospital, Erasmus Medical Center Rotterdam, The Netherlands, developed a data warehouse incrementally. In this paper we report on the in-house development of an integral part of the data warehouse specifically for the intensive care units (ICU-DWH). It was modeled using Atos Origin Metadata Frame method. The paper describes the methodology, the development process and the content of the ICU-DWH, and discusses the need for (clinical) data warehouses in intensive care.
Gonçalves, Giulliano Peixoto; Barbosa, Fabiano Timbó; Barbosa, Luciano Timbó; Duarte, José Lira
A randomized clinical trial is a prospective study that compares the effect and value of interventions in human beings, of one or more groups vs. a control group. The objective of this study was to evaluate the quality of published randomized clinical trials in Intensive care in Brazil. All randomized clinical trials in intensive care found by manual search in Revista Brasileira de Terapia Intensiva from January 2001 to March 2008 were assessed to evaluate their description by the quality scale. Descriptive statistics and a 95 % confidence interval were used for the primary outcome. Our primary outcome was the randomized clinical trial quality. Our search found 185 original articles, of which 14 were randomized clinical trials. Only one original article (7.1%) showed good quality. There was no statistical significance between the collected data and the data shown in the hypothesis of this search. It can be concluded that in the sample of assessed articles 7% of the randomized clinical trials in intensive care published in a single intensive care journal in Brazil, present good methodological quality.
Lewis, Roger J
A learning health care system ideally incorporates the ability to adapt to the pace of change, the incorporation of new clinical research paradigms, and leverages electronic health record systems and clinical decision support systems to narrow the divide between research and clinical practice. An adaptive clinical trial can be embedded into the sites and practice of clinical care in a highly pragmatic way to simultaneously generate high-quality data on treatment efficacy and improve the care of patients. This approach can be expanded into a pragmatic platform trial, meaning a trial that is intended to evaluate multiple treatments for a disease or diseases, possibly in combination, and with the available treatments potentially changing over time. This strategy is illustrated using a trial currently being implemented in Europe and funded by the European Union, evaluating three different "domains" of treatments for patients with severe community-acquired pneumonia requiring intensive care. Simulation studies demonstrate that this approach has the potential to save lives while identifying the best treatment strategies for this critically ill population. Patients are likely to benefit if we can merge clinical trials and decision support into a single continuous learning process. © The Author(s) 2016.
Cannabis species have been used as medicine for thousands of years; only since the 1940s has the plant not been widely available for medical use. However, an increasing number of jurisdictions are making it possible for patients to obtain the botanical for medicinal use. For the cancer patient, cannabis has a number of potential benefits, especially in the management of symptoms. Cannabis is useful in combatting anorexia, chemotherapy-induced nausea and vomiting, pain, insomnia, and depression. Cannabis might be less potent than other available antiemetics, but for some patients, it is the only agent that works, and it is the only antiemetic that also increases appetite. Inhaled cannabis is more effective than placebo in ameliorating peripheral neuropathy in a number of conditions, and it could prove useful in chemotherapy-induced neuropathy. A pharmacokinetic interaction study of vaporized cannabis in patients with chronic pain on stable doses of sustained-release opioids demonstrated no clinically significant change in plasma opiates, while suggesting the possibility of synergistic analgesia. Aside from symptom management, an increasing body of in vitro and animal-model studies supports a possible direct anticancer effect of cannabinoids by way of a number of different mechanisms involving apoptosis, angiogenesis, and inhibition of metastasis. Despite an absence of clinical trials, abundant anecdotal reports that describe patients having remarkable responses to cannabis as an anticancer agent, especially when taken as a high-potency orally ingested concentrate, are circulating. Human studies should be conducted to address critical questions related to the foregoing effects. PMID:27022315
Passos, Talita Rocha; Santos, Fabiana Silva; Martins, Maria Cleusa; Pinto, Vanusa Barbosa; Carrilho, Flair José; Ono, Suzane Kioko
Since 2010, the Clinical Gastroenterology and Hepatology Division of the Central Institute of Hospital das Clínicas of the University of São Paulo Medical School (HC-FMUSP, in the Portuguese acronym) has been developing specialized electives assistance activities in the Outpatient Specialty Clinic, Secondary Level, in São Paulo NGA-63 Várzea do Carmo. The objective of this study was to analyze the pharmacotherapeutic profile of patients. This is a cross-sectional and retrospective study in which patients were seen at the Hepatology sector and the results were submitted to descriptive statistics. During the study period, 492 patients were treated at the clinic, with a mean age of 58.9 years and frequency of 61.2% female and 74.8% living in São Paulo. This population was served by various other medical specialties (cardiology and endocrine among others) and the major liver diagnoses were: chronic hepatitis B and C and fatty liver. Comorbidities were also identified, such as diabetes, hypertension and dyslipidemia. Most patients took their medication in the Basic Health Units. We found that 30% of patients use of more than five medications and the most prescribed were omeprazole 208 (42.3%), metformin 132 (26.8%) and losartan 80 (16.3%). Because it is an adult/elderly population, with several comorbidities and polymedication, it is important to be aware of the rational use of medication. The multidisciplinary team is important in applying correct conducts for the safe use of medicines, to reduce the burden on health spending and improving the quality of life of patients.
Gonçalves, Evelise Ribeiro; Verdi, Marta Inez Machado
An exploratory, descriptive and qualitative survey was conducted at the Dentistry School, Santa Catarina State Federal University, Brazil, in order to identify and analyze the ethical problems involved in patient care at this teaching clinic. Data were collected through semi-structured interviews with professors of clinical disciplines and assessed through the Analysis of Content technique, using the bioethical principles of the autonomy of the patient and the confidentiality of the information as references. Some analysis categories were identified, pointing to the existence of several ethical problems in the daily patient care routines at this teaching clinic. They include scheduling stand-by patients, favored care for the friends of lecturers and employees, a lack of information offered to patients on treatment and imaging procedures, distortions in the use of deed of informed consent, etc. The constantly vulnerable situation of the patients became quite clear, together with the importance and responsibility of the professors in building up the ethical competence of future dentists.
Moreno, Gerardo; Lonowski, Sarah; Fu, Jeffrey; Chon, Janet S; Whitmire, Natalie; Vasquez, Carolina; Skootsky, Samuel A; Bell, Douglas S; Maranon, Richard; Mangione, Carol M
Improving medication management is an important component of comprehensive care coordination for health systems. The Managing Your Medication for Education and Daily Support (MyMeds) medication management program at the University of California Los Angeles addresses medication management issues by embedding trained clinical pharmacists in primary care practice teams. The aim of this work was to examine and explore physician opinions about the clinical pharmacist program and identify common themes among physician experiences as well as barriers to integration of clinical pharmacists into primary care practice teams. We conducted a mixed quantitative-qualitative methods study consisting of a cross-sectional physician survey (n = 69) as well as semistructured one-on-one physician interviews (n = 13). Descriptive statistics were used to summarize survey responses, and standard qualitative content-analysis methods were used to identify major themes from the interviews. The survey response rate was 61%; 13 interviews were conducted. Ninety percent of survey respondents agreed or strongly agreed that having the pharmacist in the office makes management of the patient's medication more efficient, 93% agreed or strongly agreed that pharmacist recommendations are clinically helpful, 71% agreed or strongly agreed that having access to a pharmacist has increased their knowledge about medications they prescribe, and 75% agreed or strongly agreed that having a pharmacist as part of the primary care team has made their job easier. Qualitative interviews corroborated survey findings, and physicians highlighted the value of the clinical pharmacist's communication, team care and expanded roles, and medication management. Primary care physicians valued the integrated pharmacy program highly, particularly its features of strong communication, expanded roles, and medication management. Pharmacists were viewed as integral members of the health care team. Copyright © 2017 American
Sattin, Davide; Morganti, Laura; De Torres, Laura; Dolce, Giuliano; Arcuri, Francesco; Estraneo, Anna; Cardinale, Viviana; Piperno, Roberto; Zavatta, Elena; Formisano, Rita; D'Ippolito, Mariagrazia; Vassallo, Claudio; Dessi, Barbara; Lamberti, Gianfranco; Antoniono, Elena; Lanzillotti, Crocifissa; Navarro, Jorge; Bramanti, Placido; Corallo, Francesco; Zampolini, Mauro; Scarponi, Federico; Avesani, Renato; Salvi, Luca; Ferro, Salvatore; Mazza, Luigi; Fogar, Paolo; Feller, Sandro; De Nigris, Fulvio; Martinuzzi, Andrea; Buffoni, Mara; Pessina, Adriano; Corsico, Paolo; Leonardi, Matilde
Patients with Disorders of consciousness, are persons with extremely low functioning levels and represent a challenge for health care systems due to their high needs of facilitating environmental factors. Despite a common Italian health care pathway for these patients, no studies have analyzed information on how each region have implemented it in its welfare system correlating data with patients' clinical outcomes. A multicenter observational pilot study was realized. Clinicians collected data on the care pathways of patients with Disorder of consciousness by asking 90 patients' caregivers to complete an ad hoc questionnaire through a structured phone interview. Questionnaire consisted of three sections: sociodemographic data, description of the care pathway done by the patient, and caregiver evaluation of health services and information received. Seventy-three patients were analyzed. Length of hospital stay was different across the health care models and it was associated with improvement in clinical diagnosis. In long-term care units, the diagnosis at admission and the number of caregivers available for each patient (median value = 3) showed an indirect relationship with worsening probability in clinical outcome. Caregivers reported that communication with professionals (42%) and the answer to the need of information were the most critical points in the acute phase, whereas presence of Non-Governmental Organizations (25%) and availability of psychologists for caregivers (21%) were often missing during long-term care. The 65% of caregivers reported they did not know the UN Convention on the Rights of Persons with Disabilities. This study highlights relevant differences in analyzed models, despite a recommended national pathway of care. Future public health considerations and actions are needed to guarantee equity and standardization of the care process in all European countries.
Furler, John; Cleland, Jennifer; Del Mar, Chris; Hanratty, Barbara; Kadam, Umesh; Lasserson, Daniel; McCowan, Colin; Magin, Parker; Mitchell, Caroline; Qureshi, Nadeem; Rait, Greta; Steel, Nick; van Driel, Mieke; Ward, Alison
Background A strong and self confident primary care workforce can deliver the highest quality care and outcomes equitably and cost effectively. To meet the increasing demands being made of it, primary care needs its own thriving research culture and knowledge base. Methods Review of recent developments supporting primary care clinical research. Results Primary care research has benefited from a small group of passionate leaders and significant investment in recent decades in some countries. Emerging from this has been innovation in research design and focus, although less is known of the effect on research output. Conclusion Primary care research is now well placed to lead a broad re-vitalisation of academic medicine, answering questions of relevance to practitioners, patients, communities and Government. Key areas for future primary care research leaders to focus on include exposing undergraduates early to primary care research, integrating this early exposure with doctoral and postdoctoral research career support, further expanding cross disciplinary approaches, and developing useful measures of output for future primary care research investment. PMID:18822178
Solvoll, Betty-Ann; Heggen, Kristin M
Care has always been a key element of nursing. This paper presents findings from research on the following issue: What opportunities and limitations do nursing students encounter when learning nursing care? The study has a qualitative design with field methodology and the study of documents. Six nursing students have been closely monitored during their clinical studies in hospitals, nursing homes and home-based nursing. The study shows that nursing students are likely to possess the potential to provide care for sick and unknown people. The motivation for their commitment to patients may contain an egoistical orientation and runs contrary to former ideals of the nurse's self-sacrificing altruism. Moreover the study shows that there is a potential in the clinical field and in the university college to reflective considerations on experience of care. While clinical practice often has focus on practical problem-solving and procedures, the college tends to focus on abstract theory. Both of these promote the privatisation and neglect of the students' experience of care. The paper concludes with a call for teaching and learning strategies targeting the use of nursing students' personal experience of care.
Valdez-Martínez, Edith; Lavielle, Pilar; Bedolla, Miguel; Squires, Allison
The objective of this study was to describe the cultural domain of ethical behaviours in clinical practice as defined by health care providers in Mexico. Structured interviews were carried out with 500 health professionals employed at the Mexican Institute of Social Security in Mexico City. The Smith Salience Index was used to evaluate the relevance of concepts gathered from the free listings of the interviewees. Cluster analysis and factor analysis facilitated construction of the conceptual categories, which the authors refer to as ;dimensions of ethical practice'. Six dimensions emerged from the analysis to define the qualities that comprise ethical clinical practice for Mexican health care providers: overall quality of clinical performance; working conditions that favour quality of care; use of ethical considerations as prerequisites for any health care intervention; values favouring teamwork in the health professional-patient relationship; patient satisfaction scores; and communication between health care providers and patients. The findings suggest that improved working conditions and management practices that promote the values identified by the study's participants would help to improve quality of care.
Valdez-Martínez, Edith; Lavielle, Pilar; Bedolla, Miguel; Squires, Allison
The objective of this study was to describe the cultural domain of ethical behaviours in clinical practice as defined by health care providers in Mexico. Structured interviews were carried out with 500 health professionals employed at the Mexican Institute of Social Security in Mexico City. The Smith Salience Index was used to evaluate the relevance of concepts gathered from the free listings of the interviewees. Cluster analysis and factor analysis facilitated construction of the conceptual categories, which the authors refer to as ‘dimensions of ethical practice’. Six dimensions emerged from the analysis to define the qualities that comprise ethical clinical practice for Mexican health care providers: overall quality of clinical performance; working conditions that favour quality of care; use of ethical considerations as prerequisites for any health care intervention; values favouring teamwork in the health professional–patient relationship; patient satisfaction scores; and communication between health care providers and patients. The findings suggest that improved working conditions and management practices that promote the values identified by the study’s participants would help to improve quality of care. PMID:18849364
Kost, G J
The goal of improving medical and economic outcomes calls for leadership based on fundamental principles. The manager of clinical systems works collaboratively within the acute care center to optimize point-of-care testing through systematic approaches such as integrative strategies, algorithms, and performance maps. These approaches are effective and efficacious for critically ill patients. Optimizing point-of-care testing throughout the entire health-care system is inherently more difficult. There is potential to achieve high-quality testing, integrated disease management, and equitable health-care delivery. Despite rapid change and economic uncertainty, a macro-strategic, information-integrated, feedback-systems, outcomes-oriented approach is timely, challenging, effective, and uplifting to the creative human spirit.
Lamper-Linden, C; Goetz-Kulas, J; Lake, R
While hospitals evaluate ambulatory clinics as a revenue-generating service alternative, nursing executives develop new areas for nursing practice in nurse-managed clinics. The authors describe the five-year growth of a nurse-managed ambulatory clinic providing primary health care to those aged 55 and older. The discussion explains nurse practitioner leadership and practice, and accountability between professions. The concept and structure of services and marketing strategies are elated to the people served. Financial feasibility, cost containment, and other factors demonstrate the clinic's contribution to its sponsoring hospital.
Brölmann, Fleur E; Eskes, Anne M; Sumpio, Bauer E; Mayer, Dieter O; Moore, Zena; Agren, Magnus S; Hermans, Michel; Cutting, Keith; Legemate, Dink A; Vermeulen, Hester; Ubbink, Dirk T
In wound care research, available high-level evidence according to the evidence pyramid is rare, and is threatened by a poor study design and reporting. Without comprehensive and transparent reporting, readers will not be able to assess the strengths and limitations of the research performed. Randomized clinical trials (RCTs) are universally acknowledged as the study design of choice for comparing treatment effects. To give high-level evidence the appreciation it deserves in wound care, we propose a step-by-step reporting standard for comprehensive and transparent reporting of RCTs in wound care. Critical reporting issues (e.g., wound care terminology, blinding, predefined outcome measures, and a priori sample size calculation) and wound-specific barriers (e.g., large diversity of etiologies and comorbidities of patients with wounds) that may prevent uniform implementation of reporting standards in wound care research are addressed in this article. The proposed reporting standards can be used as guidance for authors who write their RCT, as well as for peer reviewers of journals. Endorsement and application of these reporting standards may help achieve a higher standard of evidence and allow meta-analysis of reported wound care data. The ultimate goal is to help wound care professionals make better decisions for their patients in clinical practice. © 2013 by the Wound Healing Society.
Lin, Chia-Huei; Tzeng, Wen-Chii; Chiang, Shang-Lin; Chiang, Li-Chi
nursing research and clinical care professionals responsible to improve and integrate medical care quality.
Parchman, Michael L; Von Korff, Michael; Baldwin, Laura-Mae; Stephens, Mark; Ike, Brooke; Cromp, DeAnn; Hsu, Clarissa; Wagner, Ed H
The challenge of responding to prescription opioid overuse within the United States has fallen disproportionately on the primary care clinic setting. Here we describe a framework comprised of 6 Building Blocks to guide efforts within this setting to address the use of opioids for chronic pain. Investigators conducted site visits to thirty primary care clinics across the United States selected for their use of team-based workforce innovations. Site visits included interviews with leadership, clinic tours, observations of clinic processes and team meetings, and interviews with staff and clinicians. Data were reviewed to identify common attributes of clinic system changes around chronic opioid therapy (COT) management. These concepts were reviewed to develop narrative descriptions of key components of changes made to improve COT use. Twenty of the thirty sites had addressed improvements in COT prescribing. Across these sites a common set of 6 Building Blocks were identified: 1) providing leadership support; 2) revising and aligning clinic policies, patient agreements (contracts) and workflows; 3) implementing a registry tracking system; 4) conducting planned, patient-centered visits; 5) identifying resources for complex patients; and 6) measuring progress toward achieving clinic objectives. Common components of clinic policies, patient agreements and data tracked in registries to assess progress are described. In response to prescription opioid overuse and the resulting epidemic of overdose and addiction, primary care clinics are making improvements driven by a common set of best practices that address complex challenges of managing COT patients in primary care settings. © Copyright 2017 by the American Board of Family Medicine.
Comer, Shirley K
Role-play techniques can serve as an effective substitute for, and supplement to, simulation technology when teaching clinical nursing skills. They provide risk-free opportunities to practice clinical skills and develop clinical judgment. A two-phase patient care simulation, performed in real time, is described. Students are presented with a scenario and work cooperatively in role-playing appropriate care, with one student using a prepared script to assume the role of patient. The class functions as a resource for four students who assume the nursing role. Students reported increased understanding of course material as a result of participation in the clinical simulation scenario. Faculty observed a decreased failure rate on the corresponding course examination.
Creasy, Kerry Rae; Lutz, Barbara J; Young, Mary Ellen; Stacciarini, Jeanne-Marie R
Most stroke survivors will be cared for at home by family caregivers with limited training. Families actively involved in rehabilitation feel more prepared for the new responsibilities of caring for the stroke survivor. The focus of this article is to highlight the relevant concepts of a family-centered model of care and provide general guidance on how integrating a family-centered mindset may be clinically applicable. Concept Analysis. Synthesis of literature on family-centered care and its application in for rehabilitation nurses. Family-centered care is a model of collaborative healthcare that encourages collaboration and partnership among patients, families, and providers with respect to the planning, delivery, and evaluation of health care. Care provided within such a model can expand providers' knowledge of the impact of illness and any issues that may affect eventual transition back home. Rehabilitation nurses should view stroke patients and family caregivers as a unit. Using family-centered strategies can help nurses provide appropriate, individualized care during rehabilitation. © 2015 Association of Rehabilitation Nurses.
Pedersen, Birgith; Sivonen, Kerstin
The aim of this study was to get a deeper understanding of student nurses' experiences of personal caring ethics by reflection on caring encounters with patients in clinical practice, ethical caring ideals, ethical problems, and sources for inner strength that give courage to practice good caring. In all, 24 Scandinavian student nurses participated voluntarily in an interview study. The interviews were analyzed within a phenomenological-hermeneutical approach and revealed three themes. The students found themselves in two different states of vulnerability: one in which they were overwhelmed by their vulnerability and began to suffer themselves and the other where their vulnerability became a source of development with focus on the patient. The students' ethical caring ideals served as fixed reference points in their ethical development, but their ideals were at risk of decline. The students reflected on the barriers for performing ethical care and nurtured their ethical ideals by providing ethical care in secret. Caring in secret occurred also when student nurses did not experience a shared ethos.
Anderson, H. Vernon; Weintraub, William S.; Radford, Martha J.; Kremers, Mark S.; Roe, Matthew T.; Shaw, Richard E.; Pinchotti, Dana M.; Tcheng, James E.
Relatively little attention has been focused on standardization of data exchange in clinical research studies and patient care activities. Both are usually managed locally using separate and generally incompatible data systems at individual hospitals or clinics. In the past decade there have been nascent efforts to create data standards for clinical research and patient care data, and to some extent these are helpful in providing a degree of uniformity. Nevertheless these data standards generally have not been converted into accepted computer-based language structures that could permit reliable data exchange across computer networks. The National Cardiovascular Research Infrastructure (NCRI) project was initiated with a major objective of creating a model framework for standard data exchange in all clinical research, clinical registry, and patient care environments, including all electronic health records. The goal is complete syntactic and semantic interoperability. A Data Standards Workgroup was established to create or identify and then harmonize clinical definitions for a base set of standardized cardiovascular data elements that could be used in this network infrastructure. Recognizing the need for continuity with prior efforts, the Workgroup examined existing data standards sources. A basic set of 353 elements was selected. The NCRI staff then collaborated with the two major technical standards organizations in healthcare, the Clinical Data Interchange Standards Consortium and Health Level 7 International, as well as with staff from the National Cancer Institute Enterprise Vocabulary Services. Modeling and mapping were performed to represent (instantiate) the data elements in appropriate technical computer language structures for endorsement as an accepted data standard for public access and use. Fully implemented, these elements will facilitate clinical research, registry reporting, administrative reporting and regulatory compliance, and patient care. PMID
Choi, In Young; Kim, Tae-Min; Kim, Myung Shin; Mun, Seong K.
The advances in electronic medical records (EMRs) and bioinformatics (BI) represent two significant trends in healthcare. The widespread adoption of EMR systems and the completion of the Human Genome Project developed the technologies for data acquisition, analysis, and visualization in two different domains. The massive amount of data from both clinical and biology domains is expected to provide personalized, preventive, and predictive healthcare services in the near future. The integrated use of EMR and BI data needs to consider four key informatics areas: data modeling, analytics, standardization, and privacy. Bioclinical data warehouses integrating heterogeneous patient-related clinical or omics data should be considered. The representative standardization effort by the Clinical Bioinformatics Ontology (CBO) aims to provide uniquely identified concepts to include molecular pathology terminologies. Since individual genome data are easily used to predict current and future health status, different safeguards to ensure confidentiality should be considered. In this paper, we focused on the informatics aspects of integrating the EMR community and BI community by identifying opportunities, challenges, and approaches to provide the best possible care service for our patients and the population. PMID:24465229
Choi, In Young; Kim, Tae-Min; Kim, Myung Shin; Mun, Seong K; Chung, Yeun-Jun
The advances in electronic medical records (EMRs) and bioinformatics (BI) represent two significant trends in healthcare. The widespread adoption of EMR systems and the completion of the Human Genome Project developed the technologies for data acquisition, analysis, and visualization in two different domains. The massive amount of data from both clinical and biology domains is expected to provide personalized, preventive, and predictive healthcare services in the near future. The integrated use of EMR and BI data needs to consider four key informatics areas: data modeling, analytics, standardization, and privacy. Bioclinical data warehouses integrating heterogeneous patient-related clinical or omics data should be considered. The representative standardization effort by the Clinical Bioinformatics Ontology (CBO) aims to provide uniquely identified concepts to include molecular pathology terminologies. Since individual genome data are easily used to predict current and future health status, different safeguards to ensure confidentiality should be considered. In this paper, we focused on the informatics aspects of integrating the EMR community and BI community by identifying opportunities, challenges, and approaches to provide the best possible care service for our patients and the population.
Zweig, Richard A.; Siegel, Lawrence; Hahn, Steven; Kuslansky, Gail; Byrne, Kathy; Fyffe, Denise; Passman, Vicki; Stewart, Douglas; Hinrichsen, Gregory
Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica,…
Zweig, Richard A.; Siegel, Lawrence; Hahn, Steven; Kuslansky, Gail; Byrne, Kathy; Fyffe, Denise; Passman, Vicki; Stewart, Douglas; Hinrichsen, Gregory
Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica,…
Zargham-Boroujeni, Ali; Zoafa, Aniyehsadat; Marofi, Maryam; Badiee, Zohreh
Clinical guidelines are important instruments for increasing the quality of clinical practice in the treatment team. Compilation of clinical guidelines is important due to special condition of the neonates and the nurses facing critical conditions in the neonatal intensive care unit (NICU). With 98% of neonatal deaths occurring in NICUs in the hospitals, it is important to pay attention to this issue. This study aimed at compilation of the neonatal palliative care clinical guidelines in NICU. This study was conducted with multistage comparative strategies with localization in Isfahan in 2013. In the first step, the components of the neonatal palliative care clinical guidelines were determined by searching in different databases. In the second stage, the level of expert group's consensus with each component of neonatal palliative care in the nominal group and focus group was investigated, and the clinical guideline was written based on that. In the third stage, the quality and applicability were determined with the positive viewpoints of medical experts, nurses, and members of the science board of five cities in Iran. Data were analyzed by descriptive statistics through SPSS. In the first stage, the draft of neonatal palliative care was designed based on neonates', their parents', and the related staff's requirements. In the second stage, its rank and applicability were determined and after analyzing the responses, with agreement of the focus group, the clinical guideline was written. In the third stage, the means of indication scores obtained were 75%, 69%, 72%, 72%, and 68% by Appraisal of Guidelines for Research and Evaluation (AGREE) instrument. The compilation of the guideline can play an effective role in provision of neonatal care in nursing.
MacLeod, R D; Parkin, C; Pullon, S; Robertson, G
The nature of medical care at the end of life and, in particular, the way in which caring is learned remain problematic for medical educators and the profession. Recent work has indicated that doctors learn to care, in an emotional and intimate way, from people who are dying. This paper reports on the development of a programme designed for medical students in their first clinical year who spend time with a person who is dying and their family. The students are required to produce a portfolio assignment that includes a personal reflection of the experience. The findings from a phenomenological study undertaken using these personal reflections are reported. These reflections and comments are interpreted as being embedded in five key themes. The actual encounters differed from the medical students' anticipation of them. Students identified an emotional component to the experience; they explored their own and the patient's understandings of spirituality; they reflected on personal meanings of the encounter and they suggested ways in which they might learn to care more effectively for people who are dying. The way in which many of these students approach end-of-life care has been altered through a transformative educational experience that encouraged them to draw on their own experiences and skills. Their learning was facilitated by the writing of accounts and the discussion that each group held with teaching staff at the conclusion of the programme.
LeBlanc, Thomas W.; Lodato, Jordan E.; Currow, David C.; Abernethy, Amy P.
Purpose: Palliative care is increasingly viewed as a necessary component of cancer care, especially for patients with advanced disease. Rigorous clinical trials are thus needed to build the palliative care evidence base, but clinical research—especially participant recruitment—is difficult. Major barriers include (1) patient factors, (2) “gatekeeping,” and (3) ethical concerns. Here we discuss an approach to overcoming these barriers, using the Palliative Care Trial (PCT) as a case study. Patients and Methods: The PCT was a 2 × 2 × 2 factorial randomized controlled trial (RCT) of different service delivery models to improve pain control in the palliative setting. It used a recruitment protocol that fused evidence-based strategies with principles of “social marketing,” an approach involving the systematic application of marketing techniques. Main components included (1) an inclusive triage algorithm, (2) information booklets targeting particular stakeholders, (3) a specialized recruitment nurse, and (4) standardization of wording across all study communications. Results: From an eligible pool of 607 patients, the PCT enrolled 461 patients over 26 months. Twenty percent of patients referred to the palliative care service were enrolled (76% of those eligible after screening). Several common barriers were minimized; among those who declined participation, family disinterest was uncommon (5%), as was the perception of burden imposed (4%). Conclusion: Challenges to clinical trial recruitment in palliative care are significant but not insurmountable. A carefully crafted recruitment and retention protocol can be effective. Our experience with designing and deploying a social-marketing–based protocol shows the benefits of such an approach. PMID:24130254
Peters, Mark J; Argent, Andrew; Festa, Marino; Leteurtre, Stéphane; Piva, Jefferson; Thompson, Ann; Willson, Douglas; Tissières, Pierre; Tucci, Marisa; Lacroix, Jacques
Intensive Care Medicine set us the task of outlining a global clinical research agenda for paediatric intensive care (PIC). In line with the clinical focus of this journal, we have limited this to research that may directly influence patient care. Clinician researchers from PIC research networks of varying degrees of formality from around the world were invited to answer two main questions: (1) What have been the major recent advances in paediatric critical care research? (2) What are the top 10 studies for the next 10 years? (1) Inclusive databases are well established in many countries. These registries allow detailed observational studies and feasibility testing of clinical trial protocols. Recent trials are larger and more valuable, and (2) most common interventions in PIC are not evidenced-based. Clinical studies for the next 10 years should address this deficit, including: ventilation techniques and interfaces; fluid, transfusion and feeding strategies; optimal targets for vital signs; multiple organ failure definitions, mechanisms and treatments; trauma, prevention and treatment; improving safety; comfort of the patient and their family; appropriate care in the face of medical complexity; defining post-PICU outcomes; and improving knowledge generation and adoption, with novel trial design and implementation strategies. The group specifically highlighted the need for research in resource-limited environments wherein mortality remains often tenfold higher than in well-resourced settings. Paediatric intensive care research has never been healthier, but many gaps in knowledge remain. We need to close these urgently. The impact of new knowledge will be greatest in resource-limited environments.
Hu, Amanda; Sibert, Thomas; Zhao, Wei; Zarro, Vincent
To determine the otolaryngology needs in a free clinic providing care to medically indigent patients, as perceived by the patients and health care providers. Cross-sectional survey. A survey was administered to patients and health care providers of a free clinic from September 2014 through January 2015 in an urban, inner-city location. One hundred and thirty-seven patients (35.8% male, age 50.8 ± 13.0 years) completed the survey. Mean household income was $29,838 ± $10,425; 32.1% spoke English; 54.7% were employed; 10.2% had health insurance; and 37.2% had seen a primary care provider outside of the free clinic. The top three otolaryngology symptoms among patients were sleep apnea/snoring (39.4%), heartburn/reflux (30.7%), and dizziness (29.9%). Eleven health care providers (45% male, age 50.5 ± 15.3 years, 63.6% physician, 36% nurse) completed the survey. Providers perceived the following otolaryngology complaints as the most prevalent, in descending order: cough, nasal congestion, reflux/heartburn, sore throat, and ear infection/otalgia. Providers felt that sleep apnea and hearing loss were the less common otolaryngology complaints, whereas surveyed patients indicated these symptoms with high frequency. The most requested diagnostic tool among patients and providers was chest X-rays. There are unmet otolaryngology needs in a free clinic. Medically indigent patients have significant barriers to accessing health care. Patient and provider perceptions of top otolaryngology complaints differed, but both identified access to chest X-rays as a major unmet need. Knowledge of patient perceptions may help providers elicit the breadth of otolaryngology complaints. 4. Laryngoscope, 126:1321-1326, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.
Sittig, Dean F.
Acute Respiratory Distress Syndrome (ARDS) is often not responsive to conventional supportive therapy and the mortality rate may exceed 90%. A new form of supportive care, Extracorporeal Carbon Dioxide Removal (ECCO2R), has shown a dramatic increase in survival (48%). A controlled clinical trial of the new ECCO2R therapy versus conventional Continuous Positive Pressure Ventilation (CPPV) is being initiated. Detailed care protocols have been developed by “expert” critical care physicians for the management of patients. Using a blackboard control architecture, the protocols have been implemented on an existing hospital information system and will direct patient care and help manage the controlled clinical trial. Therapeutic instructions are automatically generated by the computer from data input by physicians, nurses, respiratory therapists, and the laboratory. Preliminary results show that the computerized protocol system can direct therapy for acutely ill patients.
Oral health care products generally require laboratory or clinical testing prior to being introduced to the market. Companies that develop such products have three options for such testing--their own facilities, dental schools, or clinical research organizations (CROs). Laboratory or clinical trials involving subjects can be conducted to test claims of safety and efficacy as well as cosmetic and therapeutic claims. CROs, which conduct such research on a fee-for-service basis in an independent environment, are an attractive alternative in many cases.
Lundqvist, M; Davidson, T; Ordell, S; Sjöström, O; Zimmerman, M; Sjögren, P
Dental care for elderly nursing home residents is traditionally provided at fixed dental clinics, but domiciliary dental care is an emerging alternative. Longer life expectancy accompanied with increased morbidity, and hospitalisation or dependence on the care of others will contribute to a risk for rapid deterioration of oral health so alternative methods for delivering oral health care to vulnerable individuals for whom access to fixed dental clinics is an obstacle should be considered. The aim was to analyse health economic consequences of domiciliary dental care for elderly nursing home residents in Sweden, compared to dentistry at a fixed clinic. A review of relevant literature was undertaken complemented by interviews with nursing home staff, officials at county councils, and academic experts in geriatric dentistry. Domiciliary dental care and fixed clinic care were compared in cost analyses and cost-effectiveness analyses. The mean societal cost of domiciliary dental care for elderly nursing home residents was lower than dental care at a fixed clinic, and it was also considered cost-effective. Lower cost of dental care at a fixed dental clinic was only achieved in a scenario where dental care could not be completed in a domiciliary setting. Domiciliary dental care for elderly nursing home residents has a lower societal cost and is cost-effective compared to dental care at fixed clinics. To meet current and predicted need for oral health care in the ageing population alternative methods to deliver dental care should be available.
Mangal, Jed P; Rimland, David; Marconi, Vincent C
The cascade of HIV care in the United States has become a focus for interventions aimed at improving the success of HIV treatment. The Atlanta VA Medical Center (AVAMC) Infectious Disease Clinic (IDC) is an urban clinic that provides care for over 1,400 people living with HIV (PLHIV) annually. Using data from the HIV Atlanta VA Cohort Study (HAVACS), we modeled the continuum of care in the AVAMC IDC and explored similarities and differences with national models. We conducted a cross-sectional analysis of 1,474 individuals receiving care in the AVAMC IDC. We estimated total PLHIV and defined several categories within the spectrum of HIV care. We then developed the continuum of care using two methodologies. The first required each stage to be a dependent subset of the immediate upstream stage. The second allowed each stage to be independent of upstream stages. Dependent stage categorization estimated that 95.3% of individuals were diagnosed with HIV, 89.8% of individuals were linked to care, 73.0% of individuals were retained in care, 65.9% of individuals were eligible for antiretroviral treatment (ART), 62.8% were prescribed ART, and 52.4% had a suppressed viral load (VL). Independent stage categorization estimated that 83.9% of individuals were prescribed ART and 61.5% had a suppressed VL. Our analyses showed that the AVAMC IDC estimates were significantly better than national estimates at every stage. This may reflect the benefits of a universal healthcare system. We propose the use of independent stages for the continuum as this more accurately represents healthcare utilization.
Chong, L A; Khalid, F; Khoo, T B; Teh, S H; Kuan, G L; Aina Mariana, A M; Alias, E; Chieng, C H; Razali, H; Ong, G B; Zainah, S H; Shukor, I N C; Wong, J J
Awareness for paediatric palliative care has resulted in the impetus for paediatrician-led palliative care services across Malaysia. However, there is paucity of local data on patients receiving hospital-based paediatric palliative care. We aim to review the clinical spectrum of patients referred to these services. An observational study of children aged between 0-18 years receiving palliative care at 13 hospitals between 1st January and 31st December 2014 was carried out. There were 315 patients analysed, 90 (28.6%) and 46 (14.6%) were neonates and adolescents respectively. The main ICD-10 diagnostic categories for all patients were identified to be 'Congenital malformations, deformations and chromosomal abnormalities' 117 (37.1%), 'Diseases of nervous system' 76 (24.1%) and 'Neoplasms' 60 (19.0%). At referral 156 (50%) patients had holistic needs assessments. Patients with 'Diseases of nervous system' were assessed to have significantly more physical needs than the other two diagnostic categories. Majority of patients who knew of their diagnosis and prognosis were those with malignancy. Over a fifth of referrals were at their terminal admission. Of 144 who died, 111 (77.1%) had advanced care plans. There was bereavement follow-up in 98 (68.1%) patients. Patients referred for palliative care have varied diagnoses and needs. To ensure all paediatricians are competent to deliver quality care to all children, further education and training initiatives is imperative.
Vallejos, Quirina M.; Quandt, Sara A.; Feldman, Steven R.; Fleischer, Alan B.; Brooks, Thanh; Cabral, Gonzalo; Heck, Judy; Schulz, Mark R.; Verma, Amit; Whalley, Lara E.; Arcury, Thomas A.
Context: Rural patients have limited access to dermatologic care. Farmworkers have high rates of skin disease and limited access to care. Purpose: This exploratory study assessed whether teledermatology consultations could help meet the needs of healthcare providers for farmworkers in rural clinics. Methods: Dermatologists provided 79 consultations, using store-and-forward teledermatology, to farmworkers who presented with a skin disease to rural North Carolina clinics. Clinic providers rated the value of the consultation. Findings: Most requests for consultations (94%) came from family nurse practitioners or physician assistants. 12% of consultations were rated somewhat helpful, and the remainder helpful or very helpful. After receiving the consultation, providers changed the diagnosis in 13% of cases. The consultation led providers to contact or attempt to contact 21% of patients to change treatment recommendations. Conclusions: Access to expert dermatologic services is needed by rural healthcare providers. Teledermatology consultations may be a helpful tool to meet this need. PMID:19785587
Schultz, Jordan L; Horner, Kathleen E; McDanel, Deanna L; Miller, Michelle L; Beranek, Randi L; Jacobsen, Ryan B; Sly, Nichole J; Miller, Aaron C; Mascardo, Lisa A
This study analyzed the impact of a pharmacist-managed diabetes clinic on clinical outcomes compared to usual care received from primary care providers (PCPs). This comparison may more definitively demonstrate the value of pharmacist management of chronic disease states. Retrospective observational cohort study conducted in patients referred to a pharmacist-managed pharmacotherapy (PT) clinic from July 2009 to October 2014. For the primary outcome, the absolute change in A1c during the usual care phase was +1.53% (95% confidence interval [CI]: 1.10-1.96, P < .0001) versus an absolute change of -1.63% (95% CI: -1.28 to -1.97, P < .0001) in the intervention phase. For secondary outcomes, diabetes-related hospitalizations (10 vs 6, P = .104) and emergency room (ER) visits (27 vs 8, P = .049) decreased in the intervention phase compared to the usual care phase. The rate of diabetes-related interventions made per patient per year in the usual care phase was 2.7 versus 11.1 in the intervention phase ( P < .0001). Patients referred to the PT clinic had worsening blood glucose control prior to referral, and their control improved after referral to the clinic. Furthermore, there was an improvement in all diabetes-related outcomes in the intervention phase compared to the usual care phase.
Matumoto, Silvia; Fortuna, Cinira Magali; Kawata, Lauren Suemi; Mishima, Silvana Martins; Pereira, Maria José Bistafa
This study aims to present the re-signification process of the meanings of nurses' clinical practice in primary care from the perspective of extended clinic and permanent education. An intervention research was carried out with the approval of an ethics committee. Nine nurses participated in reflection groups from September to December 2008 in Ribeirão Preto-SP-Brazil. The redefinition process of the meanings proposed by the institutional analysis was mapped. The results point out that the nurses perceive differences in clinical work, by acknowledging the sense of user-centered clinical practice; daily limits and tensions and the need for support from managers and the team to deal with users' problems and situations. They identify the necessity to open space in the schedule to do that. It was concluded that nurses' clinical practice is being consolidated, and that collective analysis processes permit learning and the reconstruction of practices.
Hill, J; Bird, H A; Hopkins, R; Lawton, C; Wright, V
Consumer satisfaction is increasingly recognised by hospital administrators and health care providers as an important aspect of health care. A study was undertaken to investigate the satisfaction with care among patients with rheumatoid arthritis (RA) attending a rheumatology outpatient clinic at Leeds General Infirmary. The Leeds satisfaction questionnaire was developed and rigorously tested for reliability (Cronbachs alpha) and stability (test/retest). The Leeds satisfaction questionnaire was then completed by 70 patients with RA who had attended the Leeds General Infirmary on at least three previous occasions. The results showed that patients were, in general, satisfied with the care they received. The highest satisfaction scores were obtained on the scale for technical quality and competence of health professionals. The least satisfaction was accredited to the difficulty of unscheduled access to the clinic and the lack of continuity with the providers of care. The time spent in the waiting area before consultation was highlighted as the one aspect which caused the greatest dissatisfaction. PMID:1550403
Lelli, Vanessa R; Hickman, Ronald L; Savrin, Carol L; Peterson, Rachel A
To examine if differences exist in the levels of autonomy and job satisfaction among primary care nurse practitioners (NPs) employed in retail clinics versus traditional primary care settings. Data were collected from 310 primary care NPs who attended the American Association of NP's 28th Annual Conference in June 2013. Participants completed a demographic form, the Misener NP Job Satisfaction Scale, and the Dempster Practice Behavior Scale. Overall, there were no differences in job satisfaction or autonomy among NPs by practice setting. Retail NPs felt less valued and were less satisfied with social interaction, but more satisfied with benefits compared to NPs in traditional settings. NPs working in retail clinics were less likely to have intentions to leave current position compared to NPs in traditional practice settings. The results of this study enhance our current understanding of the linkages between levels of autonomy, job satisfaction, and practice setting among primary care NPs. The findings of this descriptive study offer valuable insights for stakeholders devoted to the development of the primary care workforce and identify modifiable factors that may influence retention and turnover rates among NPs. ©2015 American Association of Nurse Practitioners.
Jordan, Desmond; Rose, Sydney E
Medical errors from communication failures are enormous during the perioperative period of cardiac surgical patients. As caregivers change shifts or surgical patients change location within the hospital, key information is lost or misconstrued. After a baseline cognitive study of information need and caregiver workflow, we implemented an advanced clinical decision support tool of intelligent agents, medical logic modules, and text generators called the "Inference Engine" to summarize individual patient's raw medical data elements into procedural milestones, illness severity, and care therapies. The system generates two displays: 1) the continuum of care, multimedia abstract generation of intensive care data (MAGIC)-an expert system that would automatically generate a physician briefing of a cardiac patient's operative course in a multimodal format; and 2) the isolated point in time, "Inference Engine"-a system that provides a real-time, high-level, summarized depiction of a patient's clinical status. In our studies, system accuracy and efficacy was judged against clinician performance in the workplace. To test the automated physician briefing, "MAGIC," the patient's intraoperative course, was reviewed in the intensive care unit before patient arrival. It was then judged against the actual physician briefing and that given in a cohort of patients where the system was not used. To test the real-time representation of the patient's clinical status, system inferences were judged against clinician decisions. Changes in workflow and situational awareness were assessed by questionnaires and process evaluation. MAGIC provides 200% more information, twice the accuracy, and enhances situational awareness. This study demonstrates that the automation of clinical processes through AI methodologies yields positive results.
The discipline of pediatric nephrology addresses a wide range of conditions of varying severity. The most benign conditions include orthostatic proteinuria, and thin basement nephropathy. The most challenging diagnosis in the field is chronic renal failure, particularly if the patient is an infant. Nurses trained in pediatric nephrology provide care to this entire spectrum of patients within the context of their family. The varied responsibilities and specialized training of the pediatric nephrology nurse as described in this article can serve as a prototype for the independent role of clinical care coordinator.
In the field of Intensive Care Medicine, improved survival has resulted from better patient care, the early detection of clinical deterioration, and the prevention of iatrogenic complications, while research on new treatments has been followed by an overwhelming number of disappointments. The origins of these fiascos must be sought in the conjunction of methodological problems - common to other disciplines - and the particularities of critically ill patients. The present article discusses both aspects and suggests some options for progress. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
Chung, Kyusuk; Bell, Ralph; Lee, Dennis
This article identifies two areas of hospice care that may benefit the most from a point-of-care (POC) clinical documentation system: documentation for recertification and symptom/pain management. Applications as solutions for the hospice POC clinical documentation system need two documentation support tools: (1) knowledge-based external or internal reference data available to physicians or medical staff right at the bedside and (2) assisting medical staff in filling out electronic forms for clinical measurements by providing real-time prompts, clues, alerts, or other types of feedback, along with the common features such as pre-defined values in specific fields. Our study may encourage more software vendors to include clinical documentation support tools in their solutions.
Krist, Alex H.; Shenson, Douglas; Woolf, Steven H.; Bradley, Cathy; Liaw, Winston R.; Rothemich, Stephen F.; Slonim, Amy; Benson, William; Anderson, Lynda A.
Although clinical preventive services (CPS)—screening tests, immunizations, health behavior counseling, and preventive medications—can save lives, Americans receive only half of recommended services. This "prevention gap," if closed, could substantially reduce morbidity and mortality. Opportunities to improve delivery of CPS exist in both clinical and community settings, but these activities are rarely coordinated across these settings, resulting in inefficiencies and attenuated benefits. Through a literature review, semi-structured interviews with 50 national experts, field observations of 53 successful programs, and a national stakeholder meeting, a framework to fully integrate CPS delivery across clinical and community care delivery systems was developed. The framework identifies the necessary participants, their role in care delivery, and the infrastructure, support, and policies necessary to ensure success. Essential stakeholders in integration include clinicians; community members and organizations; spanning personnel and infrastructure; national, state, and local leadership; and funders and purchasers. Spanning personnel and infrastructure are essential to bring clinicians and communities together and to help patients navigate across care settings. The specifics of clinical–community integrations vary depending on the services addressed and the local context. Although broad establishment of effective clinical–community integrations will require substantial changes, existing clinical and community models provide an important starting point. The key policies and elements of the framework are often already in place or easily identified. The larger challenge is for stakeholders to recognize how integration serves their mutual interests and how it can be financed and sustained over time. PMID:24050428
It is clear that current government policy places increasing emphasis on the need for flexible team working. This requires a shared understanding of roles and working practices. However, review of the current literature reveals that such a collaborative working environment has not as yet, been fully achieved. Role definitions and power bases based on traditional and historical boundaries continue to exist. This ethnographic study explores decision making between doctors and nurses in the intensive care environment in order to examine contemporary clinical roles in this clinical specialty. Three intensive care units were selected as field sites and data was collected through participant observation, ethnographic interviews and documentation. A key issue arising in this study is that whilst the nursing role in intensive care has changed, this has had little impact on how clinical decisions are made. Both medical and nursing staff identify conflict during patient management discussions. However, it is predominantly nurses who seek to redress this conflict area through developing specific behaviours for this clinical forum. Using this approach to resolve such team issues has grave implications if the government vision of interdisciplinary team working is to be realised.
Ross, Jonathan; Felsen, Uriel R; Cunningham, Chinazo O; Patel, Viraj V; Hanna, David B
HIV-infected undocumented immigrants face unique barriers to care yet little is known about their clinical outcomes. We performed a retrospective cohort study of HIV-infected adults in clinical care from 2006-2014 at a large academic medical center in a setting where medical insurance is available to HIV-infected undocumented immigrants. Undocumented status was assessed based on Social Security number and insurance status and verified through medical chart review. Using Poisson regression models, we compared undocumented and documented patients with respect to retention in care (≥ 2 HIV-related lab tests ≥ 90 days apart), antiretroviral therapy (ART) prescription (≥ 3 active antiretroviral agents prescribed in a year) and viral suppression (HIV RNA <200 copies/ml for the last measured viral load) for each year in care. Of 7,551 patients included in the analysis, we classified 173 (2.3%) as undocumented. For each year of the analysis, higher proportions of undocumented patients were retained in care, prescribed ART and virally suppressed. In adjusted models, undocumented status was associated with increased probability of retention in care (risk ratio [RR] 1.05, 95% confidence interval [CI] 1.01-1.09), ART prescription (RR 1.05, 95% CI 1.01-1.08) and viral suppression (RR 1.13, 95% CI 1.08-1.19) compared to documented status. Undocumented patients achieved clinical outcomes at modestly higher rates than documented patients, despite entering care with more advanced disease. In a setting where insurance is available to undocumented patients, similar outcomes along the HIV care continuum may be achieved regardless of immigration status.
DiScala, Sandra Lee; Onofrio, Sarah; Miller, Maura; Nazario, Mitchell; Silverman, Michael
The primary objective of this quality improvement (QI) project was to determine if the Interdisciplinary Palliative Care Outpatient Clinic (IPCOC) at the West Palm Beach Veterans Affairs Medical Center offered improved symptom assessment and palliative care treatment outcomes. Secondary objectives were to identify, classify, and resolve medication problems and calculate the number of pharmacist recommendations accepted by prescribing providers. An IPCOC was created by selecting disciplines for a core group including a nurse practitioner, clinical pharmacist, social worker, chaplain, and physician. Consult referrals were recruited by providing educational sessions. The patient assessments were completed using the Edmonton Symptom Assessment System: (revised version; ESAS-R). The clinical pharmacist classified and resolved drug-related problems. The pharmacy resident telephoned veterans for completion of the "Patient Assessment: Overall Satisfaction with Outpatient Palliative Care Clinic." Seventeen consults were received, 6 patients were excluded, and 11 were seen in clinic. One (9%) of 11 patients met the outcomes measure of system assessment documentation in the past year. At completion, 11 (100%) of 11 patients met the outcomes data measure. The Patient Satisfaction Assessment revealed veterans strongly agree to recommend the IPCOC. The clinical pharmacist identified 20 drug-related problems, made 16 recommendations, had a 93.7% implementation rate, and facilitated implementation of medication changes. This QI project demonstrates that an IPCOC improved symptom assessment and palliative care outcomes in addition to resolution of medication prescribing issues in veterans with advanced cancer by integration of a clinical pharmacist into the core team.
McCaffrey, Nikki; Fazekas, Belinda; Cutri, Natalie; Currow, David C
Audits have been proposed for estimating possible recruitment rates to randomized controlled trials (RCTs), but few studies have compared audit data with subsequent recruitment rates. To compare the accuracy of estimates of potential recruitment from a retrospective consecutive cohort audit of actual participating sites and recruitment to four Phase III multisite clinical RCTs. The proportion of potentially eligible study participants estimated from an inpatient chart review of people with life-limiting illnesses referred to six Australian specialist palliative care services was compared with recruitment data extracted from study prescreening information from three sites that participated fully in four Palliative Care Clinical Studies Collaborative RCTs. The predominant reasons for ineligibility in the audit and RCTs were analyzed. The audit overestimated the proportion of people referred to the palliative care services who could participate in the RCTs (pain 17.7% vs. 1.2%, delirium 5.8% vs. 0.6%, anorexia 5.1% vs. 0.8%, and bowel obstruction 2.8% vs. 0.5%). Approximately 2% of the referral base was potentially eligible for these effectiveness studies. Ineligibility for general criteria (language, cognition, and geographic proximity) varied between studies, whereas the reasons for exclusion were similar between the audit and pain and anorexia studies but not for delirium or bowel obstruction. The retrospective consecutive case note audit in participating sites did not predict realistic recruitment rates, mostly underestimating the impact of study-specific inclusion criteria. These findings have implications for the applicability of the results of RCTs. Prospective pilot studies are more likely to predict actual recruitment. Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
Arnold, Trisha; Brinkley-Rubinstein, Lauren; Chan, Philip A.; Perez-Brumer, Amaya; Bologna, Estefany S.; Beauchamps, Laura; Johnson, Kendra; Mena, Leandro; Nunn, Amy
Pre-exposure prophylaxis (PrEP) is a biomedical intervention that can reduce rates of HIV transmission when taken once daily by HIV-negative individuals. Little is understood about PrEP uptake and retention in care among the populations most heavily impacted by the HIV epidemic, particularly among young men who have sex with men (YMSM) in the Deep South. Therefore, this study explored the structural, social, behavioral, and clinical factors that affect PrEP use and retention in care among YMSM in Jackson, Mississippi. Thirty MSM who were prescribed PrEP at an outpatient primary care clinic were interviewed and included 23 men who had been retained in PrEP care and seven who had not been retained. The mean age of participants was 26.6 years. Most (23) participants were African American. Major factors affecting PrEP use and retention in PrEP care included 1) structural factors such as cost and access to financial assistance for medications and clinical services; 2) social factors such as stigma and relationship status; 3) behavioral factors including sexual risk behaviors; and 4) clinical factors such as perceived and actual side effects. Many participants also discussed the positive spillover effects of PrEP use and reported that PrEP had a positive impact on their health. Four of the seven individuals who had not been retained re-enrolled in PrEP care after completing their interviews, suggesting that case management and ongoing outreach can enhance retention in PrEP care. Interventions to enhance retention in PrEP care among MSM in the Deep South will be most effective if they address the complex structural, social, clinical, and behavioral factors that influence PrEP uptake and retention in PrEP care. PMID:28222118
Bender, Miriam; Williams, Marjory; Su, Wei; Hites, Lisle
Clinical nurse leader(TM) (CNL)-integrated care delivery is a new model for organizing master's-level nursing clinical leadership at the microsystem level. While there is growing evidence of improved patient care quality and safety outcomes associated with CNL practice, organizational and implementation characteristics that influence CNL success are not well characterized. The purpose of this study was to identify organization and implementation factors associated with perceived success of CNL integration into microsystem care delivery models. A survey was developed and administered to a nationwide sample of certified CNLs and managers, leaders, educators, clinicians, and change agents involved in planning or integrating CNLs into a health system's nursing care delivery model. Items addressed organizational and implementation characteristics and perceived level of CNL initiative success. Generalized linear modeling was used to analyze data. The final sample included 585 respondents. The final model accounted for 35% of variance in perceived CNL initiative success, and included five variables: phase of CNL initiative, CNL practice consistency, CNL instructor or preceptor involvement, CNL reporting structure, and CNL setting ownership status. CNL initiative success is associated with modifiable organizational and implementation factors. Study findings can be used to inform the development of successful implementation strategies for CNL practice integration into care delivery models to improve care quality outcomes. © 2016 Sigma Theta Tau International.
Drucker, Ernest; Anderson, Kenneth; Haemmig, Robert; Heimer, Robert; Small, Dan; Walley, Alex; Wood, Evan; van Beek, Ingrid
This paper examines the role of clinical practitioners and clinical researchers internationally in establishing the utility of harm-reduction approaches to substance use. It thus illustrates the potential for clinicians to play a pivotal role in health promoting structural interventions based on harm-reduction goals and public health models. Popular media images of drug use as uniformly damaging, and abstinence as the only acceptable goal of treatment, threaten to distort clinical care away from a basis in evidence, which shows that some ways of using drugs are far more harmful than others and that punitive approaches and insistence on total abstinence as the only goal of treatment often increases the harms of drug use rather than reducing drug use. Therefore the leadership and scientific authority of clinicians who understand the health impact of harm-reduction strategies is needed. Through a review of harm-reduction interventions in Canada, the United Kingdom, the United States, Australia, Switzerland, and the Netherlands, we identify three ways that clinicians have helped to achieve a paradigm shift from punitive approaches to harm-reduction principles in clinical care and in drug policy: (1) through clinical research to provide data establishing the effectiveness and feasibility of harm-reduction approaches, (2) by developing innovative clinical programmes that employ harm reduction, and thereby (3) changing the standard of care to include routine use of these evidence-based (but often misunderstood) approaches in their practices. We argue that through promotion of harm-reduction goals and methods, clinicians have unique opportunities to improve the health outcomes of vulnerable populations.
Marcus, Zachary; Park, Nanah Suk
Most children in the United States with intermittent, mild, and moderate persistent asthma are cared for by primary care practitioners (PCPs). Despite inhaled corticosteroids (ICS) being highly effective at controlling asthma symptoms, many PCPs are uncomfortable prescribing these medications. Cumbersome guidelines, increasing numbers of medication choices, and concerns regarding side effects are some of the barriers to prescribing ICS for children with asthma. This article serves as a quick-start guide for PCPs that (1) condenses the routine diagnosis and management of asthma into concise clinical tools for children who would benefit from ICS therapy and (2) provides clinical pearls to aid in the treatment of mild- to moderate-persistent asthma. [Pediatr Ann. 2017;46(2):e34-e39.]. Copyright 2017, SLACK Incorporated.
Hsu, Eric Y; Schwend, Richard M; Julia, Leamon
Many primary care physicians believe that there are too few pediatric orthopaedic specialists available to meet their patients' needs. However, a recent survey by the Practice Management Committee of the Pediatric Orthopaedic Society of North America found that new referrals were often for cases that could have been managed by primary care practitioners. We wished to determine how many new referral cases seen by pediatric orthopaedic surgeons are in fact conditions that can be readily managed by a primary care physician should he/she chose to do so. We prospectively studied all new referrals to our hospital-based orthopaedic clinic during August 2010. Each new referral was evaluated for whether it met the American Board of Pediatrics criteria for being a condition that could be managed by a primary care pediatrician. Each referral was also evaluated for whether it met the American Academy of Pediatrics Surgery Advisory Panel guidelines recommending referral to an orthopaedic specialist, regardless of whether it is for general orthopaedics or pediatric orthopaedics. On the basis of these criteria, we classified conditions as either a condition manageable by primary care physicians or a condition that should be referred to an orthopaedic surgeon or a pediatric orthopaedic surgeon. We used these guidelines not to identify diagnosis that primary care physicians should treat but, rather, to compare the guideline-delineated referrals with the actual referrals our specialty pediatric orthopaedic clinic received over a period of 1 month. A total of 529 new patient referrals were seen during August 2010. A total of 246 (47%) were considered primary care conditions and 283 (53%) orthopaedic specialty conditions. The most common primary care condition was a nondisplaced phalanx fracture (25/246, 10.1%) and the most common specialty condition was a displaced single-bone upper extremity fracture needing reduction (36/283, 13%). Only 77 (14.6%) of the total cases met the strict
Stokkermans, T J; Dunbar, M T
Most reports of solar retinopathy describe epidemics of patients who go to the eye doctor after viewing a solar eclipse. Rarely is it encountered by the primary eye care provider during a routine eye examination. For 26 months, patients who went to the primary care eye clinic and found to have macular lesions consistent with solar retinopathy were identified from the total clinic population. These patients were documented in a coded log and fundus photographs were obtained (when possible). Twenty-six eyes of twenty patients (0.14% incidence) were determined to have macular lesions consistent with solar retinopathy. Visual acuity was 20/25 or better in 100% of the patients and 85% were 20/20. Patients were predominantly men (75%) of middle age (average age, 43 years; SD, 11 years) with a history relevant for solar retinopathy (80%)--consisting of sungazing, 60%; looking at welding light without eye protection, 15%; substance abuse, 15%; and psychiatric condition, 5%. Forty percent had solar lesions in both eyes. Amsler grid testing revealed a defect in only 20%, and macular threshold visual-field testing was normal in all the eyes tested. This is the first report to characterize solar retinopathy in a primary eye care population. Management includes correct differentiation from other macular disorders, acquisition of a careful detailed history, and provision of patient education regarding the dangers of sungazing.
Roberts, Helen C; Dodds, Richard; Sayer, Avan A
As sarcopenia is common and associated with risk of adverse health consequences, strategies for clinical care of such patients are needed. Individuals with slow gait speed (<0.8 m/s) should be evaluated for low grip strength and low muscle mass. Progressive resistance exercise in patients with sarcopenia is beneficial, but evidence for protein or vitamin D supplementation is inconclusive. Comprehensive geriatric assessment with involvement of a multidisciplinary team enables clinicians to optimize treatment of complex older individuals with sarcopenia.
Zweig, Richard A; Siegel, Lawrence; Hahn, Steven; Kuslansky, Gail; Byrne, Kathy; Fyffe, Denise; Passman, Vicki; Stewart, Douglas; Hinrichsen, Gregory A
Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica, to clinical psychology doctoral students within a large urban professional psychology program. In an innovative effort to provide the most disadvantaged elderly with comprehensive mental health treatment and maximize trainee exposure to an interdisciplinary treatment model, the program also pairs selected doctoral psychology trainees with medical residents to optimize integrated mental health service delivery for primary care elderly. The program has the following core objectives: (1) Infuse the mental health and aging knowledge base into the regular graduate curriculum; (2) Provide interdisciplinary training in geropsychological diagnostic and consultative services within an urban primary care setting; (3) Provide interdisciplinary training in the practice of psychological and neuropsychological evaluation of elderly; (4) Provide training in geropsychological psychotherapeutic intervention, including individual, couples/family, and brief/psycho-educational therapies with outpatient older adults. These objectives are achieved by pooling the resources of a graduate school of psychology, a local public hospital, and an academic medical center to achieve educational and clinical service goals.
Drummond, C; Simpson, A
WHAT IS KNOWN ON THE SUBJECT?: A written plan is designed to improve communication and co-ordinate care between mental health inpatient wards and community settings. Reports of care plan quality issues and staff and service user dissatisfaction with healthcare bureaucracy have focused on working age mental health or general hospital settings. Little is known about mental health staff perspectives on the value of written care plans in supporting dementia care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Competing demands on staff time and resources to meet administrative standards for care plans caused a tension with their own professional priorities for supporting care. Mental health staff face difficulties using electronic records alongside other systems of information sharing. Further exploration is needed of the gap between frontline staff values and those of the local organization and managers when supporting good dementia care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Frontline staff should be involved in designing new information systems including care plans. Care plan documentation needs to be refocused to ensure it is effective in enabling staff to communicate amongst themselves and with others to support people with dementia. Practice-based mentors could be deployed to strengthen good practice in effective information sharing. Background Reports of increased healthcare bureaucracy and concerns over care plan quality have emerged from research and surveys into staff and service user experiences. Little is known of mental health staff perspectives on the value of written care plans in supporting dementia care. Aim To investigate the experiences and views of staff in relation to care planning in dementia services in one National Health Service (NHS) provider Trust in England. Method Grounded Theory methodology was used. A purposive sample of 11 multidisciplinary staff were interviewed across three sites in one NHS Trust. Interviews were transcribed, coded
Palombini, Analice de Lima; Onocko-Campos, Rosana Teresa; Silveira, Marília; Gonçalves, Laura Lamas Martins; Zanchet, Lívia; Xavier, Maria Angélica Zamora; de Castro e Marques, Cecília
This paper is derived from the experience of conducting research with mental health users (not about them, nor for them), analyzing aspects of a study in which different ways of structuring the relationship between clinical practice and research were put into play, thereby questioning the boundaries and ethical issues involved. The clinical practice and research fields that are dealt with are studied with the input of authors who, on the basis of institutional analysis, propose the idea of interventional research, and in the context of public health, revert to the concept of broadened clinical care. The relationship between these two terms - interventional research and broadened clinical care - is based on the notion of subjectivity that operates within the scope of public health and which culminates in the concept of autonomy. Lastly, co-management is proposed as a strategy based on which the different actors involved in conducting research and exercising clinical care can collectively build working principles that are both therapeutic and ethical.
Kashdan, Todd B; Frueh, B Christopher; Knapp, Rebecca G; Hebert, Renée; Magruder, Kathryn M
To examine the prevalence and correlates of social anxiety disorder (SAD) in veterans, 733 veterans from four VA primary care clinics were evaluated using self-report questionnaires, telephone interviews, and a 12-month retrospective review of primary care charts. We also tested the concordance between primary care providers' detection of anxiety problems and diagnoses of SAD from psychiatric interviews. For the multi-site sample, 3.6% met criteria for SAD. A greater rate of SAD was found in veterans with than without post-traumatic stress disorder (PTSD) (22.0% vs. 1.1%), and primary care providers detected anxiety problems in only 58% of veterans with SAD. The elevated rate of comorbid psychiatric diagnoses and suicidal risk associated with SAD was not attributable to PTSD symptom severity. Moreover, even after controlling for the presence of major depressive disorder, SAD retained unique, adverse effects on PTSD diagnoses and severity, the presence of other psychiatric conditions, and suicidal risk. These results attest to strong relations between SAD and PTSD, the inadequate recognition of SAD in primary care settings, and the significant distress and impairment associated with SAD in veterans.
Gutierrez, Jennifer C; Terwiesch, Christian; Pelak, Mary; Pettit, Amy R; Marcus, Steven C
Medical home models seek to increase efficiency and maximize the use of resources by ensuring that all care team members work at the top of their licenses. We sought to break down primary care office visits into measurable activities to better under stand how primary care providers (PCPs) currently spend visit time and to provide insight into potential opportunities for revision or redistribution of healthcare tasks. We videotaped 27 PCPs during office visits with 121 patients at four Veterans Health Administration medical centers. Based on patterns emerging from the data, we identified a taxonomy of 12 provider activity categories that enabled us to quantify the frequency and duration of activities occurring during routine primary care visits. We conducted descriptive and multivariate analyses to examine associations between visit characteristics and provider and clinic characteristics. We found that PCPs spent the greatest percentage of their visit time discussing existing conditions (20%), discussing new conditions (18%), record keeping (13%), and examining patients (13%). Providers spent the smallest percentage of time on preventive care and coordination of care. Mean visit length was 22.9 minutes (range 7.9-58.0 minutes). Site-level ratings of medical home implementation were not associated with differences in how visit time was spent. These data provide a window into how PCPs are spending face-to-face time with patients. The methodology and taxonomy presented here may prove useful for future quality improvement and research endeavors, particularly those focused on opportunities to increase nonappointment care and to ensure that team members work at the top of their skill level.
Blake, Diane R; Spielberg, Freya; Levy, Vivian; Lensing, Shelly; Wolff, Peter A; Venkatasubramanian, Lalitha; Acevedo, Nincoshka; Padian, Nancy; Chattopadhyay, Ishita; Gaydos, Charlotte A
Results of a recent demonstration project evaluating feasibility, acceptability, and cost of a Web-based sexually transmitted infection (STI) testing and e-prescription treatment program (eSTI) suggest that this approach could be a feasible alternative to clinic-based testing and treatment, but the results need to be confirmed by a randomized comparative effectiveness trial. We modeled a decision tree comparing (1) cost of eSTI screening using a home collection kit and an e-prescription for uncomplicated treatment versus (2) hypothetical costs derived from the literature for referral to standard clinic-based STI screening and treatment. Primary outcome was number of STIs detected. Analyses were conducted from the clinical trial perspective and the health care system perspective. The eSTI strategy detected 75 infections, and the clinic referral strategy detected 45 infections. Total cost of eSTI was $94,938 ($1266/STI detected) from the clinical trial perspective and $96,088 ($1281/STI detected) from the health care system perspective. Total cost of clinic referral was $87,367 ($1941/STI detected) from the clinical trial perspective and $71,668 ($1593/STI detected) from the health care system perspective. Results indicate that eSTI will likely be more cost-effective (lower cost/STI detected) than clinic-based STI screening, both in the context of clinical trials and in routine clinical care. Although our results are promising, they are based on a demonstration project and estimates from other small studies. A comparative effectiveness research trial is needed to determine actual cost and impact of the eSTI system on identification and treatment of new infections and prevention of their sequelae.
Grand, Jacob HG; Caspar, Sienna; MacDonald, Stuart WS
Dementia is a clinical syndrome of widespread progressive deterioration of cognitive abilities and normal daily functioning. These cognitive and behavioral impairments pose considerable challenges to individuals with dementia, along with their family members and caregivers. Four primary dementia classifications have been defined according to clinical and research criteria: 1) Alzheimer’s disease; 2) vascular dementias; 3) frontotemporal dementias; and 4) dementia with Lewy bodies/Parkinson’s disease dementia. The cumulative efforts of multidisciplinary healthcare teams have advanced our understanding of dementia beyond basic descriptions, towards a more complete elucidation of risk factors, clinical symptoms, and neuropathological correlates. The characterization of disease subtypes has facilitated targeted management strategies, advanced treatments, and symptomatic care for individuals affected by dementia. This review briefly summarizes the current state of knowledge and directions of dementia research and clinical practice. We provide a description of the risk factors, clinical presentation, and differential diagnosis of dementia. A summary of multidisciplinary team approaches to dementia care is outlined, including management strategies for the treatment of cognitive impairments, functional deficits, and behavioral and psychological symptoms of dementia. The needs of individuals with dementia are extensive, often requiring care beyond traditional bounds of medical practice, including pharmacologic and non-pharmacologic management interventions. Finally, advanced research on the early prodromal phase of dementia is reviewed, with a focus on change-point models, trajectories of cognitive change, and threshold models of pathological burden. Future research goals are outlined, with a call to action for social policy initiatives that promote preventive lifestyle behaviors, and healthcare programs that will support the growing number of individuals affected by
Tzoulis, Ploutarchos; Shah, Farrukh; Jones, Romilla; Prescott, Emma; Barnard, Maria
Diabetes is a significant complication of β-thalassemia major (β-TM) and most patients receive fragmented diabetes care. In 2005, we developed a unique Joint Diabetes Thalassaemia Clinic, based at the Department of Diabetes, Whittington Health, London, UK, where patients were reviewed jointly by a multidisciplinary team, including Consultant Diabetologist and Hematologist. Study of the Joint Diabetes Thalassaemia Clinic (2005-2009) showed improvement in glycemic control with fructosamine reduction from 344 umol/L to 319 umol/L over a 1-year period as well as improvement in lipid profiles. The proportion of patients attending the Joint Clinic who achieved metabolic targets compared to the National Diabetes Audit for England was higher for glycemic control (73.0 Joint Diabetes Thalassaemia Clinic vs. 63.0% nationally), blood pressure control (58.0 Joint Diabetes Thalassaemia Clinic vs. 30.0% nationally) and cholesterol control (81.0 Joint Diabetes Thalassaemia Clinic vs. 78.0% nationally). Five patients (22.7%) had microvascular complications. A significant proportion of our patients had endocrinopathies (86.0% hypogonadism, 18.0% hypothyroidism, 23.0% hypoparathyroidism). The unique partnership of our Joint Diabetes Thalassaemia Clinic, allowed these very complex patients to be managed effectively.
Rogers, Anne; Oliver, Dianne; Bower, Peter; Lovell, Karina; Richards, Dave
Self-help programmes are increasingly advocated as a means of managing mental health problems. This qualitative study explored patients' understandings of the use of a UK primary care-based self-help clinic (facilitated by a nurse). As part of a wider evaluation of the clinic, in-depth interviews were conducted with a purposive sub-sample of clinic users. Data indicate that people understand their problem as one of having lost an ability to cope, and that the ethos underlying the clinic is well matched to restore a sense of coping, by motivating patients to re-establish and retain control over their everyday lives. However, some patients experienced a sense of dissonance between prior expectations and actual use of the self-help clinic. Without prior familiarity with self-help, engaging the patient as the mechanism of change may be difficult. Some patients expected formal counselling and were influenced in this by their previous experience of services and discussions with the GP at the point of referral. It takes time and active engagement with self-help materials before patients become aware that they are a crucial mechanism of change. Patients may benefit from information and a referral process, which emphasises the centrality of self-efficacy and the patient as 'change agent' prior to referral.
Levine, Adam C; Barry, Meagan A; Agrawal, Pooja; Duber, Herbert C; Chang, Mary P; Mackey, Joy M; Hansoti, Bhakti
There are many barriers impeding the conduct of high-quality emergency care research, particularly in low- and middle-income countries. Several of these barriers were originally outlined in 2013 as part of the Academic Emergency Medicine Global Health and Emergency Care Consensus Conference. This paper seeks to establish a broader consensus on the barriers to emergency care research globally and proposes a comprehensive array of new recommendations to overcome these barriers. An electronic survey was conducted of a purposive sample of global emergency medicine research experts from around the world to describe the major challenges and solutions to conducting emergency care research in low-resource settings and rank them by importance. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting utilized a modified Delphi technique for consensus-based decision making to categorize and expand upon these barriers and develop a comprehensive array of proposed solutions. The working group identified four broad categories of barriers to conducting emergency care research globally, including 1) the limited availability of research personnel, particularly those with prior research training; 2) logistic barriers and lack of standardization of data collection; 3) ethical barriers to conducting research in resource-limited settings, particularly when no local institutional review board is available; and 4) the relative dearth of funding for global emergency care research. Proposed solutions included building a diverse and interdisciplinary research team structured to promote mentorship of junior researchers, utilizing local research assistants or technologic tools such as telemedicine for language translation, making use of new tools such as mobile health (mHealth) to standardize and streamline data collection, identifying alternatives to local institutional review board approval and the use of
Zgierska, Aleksandra; Rabago, David; Miller, Michael M
Background Although patient satisfaction ratings often drive positive changes, they may have unintended consequences. Objective The study reported here aimed to evaluate the clinician-perceived effects of patient satisfaction ratings on job satisfaction and clinical care. Methods A 26-item survey, developed by a state medical society in 2012 to assess the effects of patient satisfaction surveys, was administered online to physician members of a state-level medical society. Respondents remained anonymous. Results One hundred fifty five physicians provided responses (3.9% of the estimated 4,000 physician members of the state-level medical society, or approximately 16% of the state’s emergency department [ED] physicians). The respondents were predominantly male (85%) and practicing in solo or private practice (45%), hospital (43%), or academia (15%). The majority were ED (57%), followed by primary care (16%) physicians. Fifty-nine percent reported that their compensation was linked to patient satisfaction ratings. Seventy-eight percent reported that patient satisfaction surveys moderately or severely affected their job satisfaction; 28% had considered quitting their job or leaving the medical profession. Twenty percent reported their employment being threatened because of patient satisfaction data. Almost half believed that pressure to obtain better scores promoted inappropriate care, including unnecessary antibiotic and opioid prescriptions, tests, procedures, and hospital admissions. Among 52 qualitative responses, only three were positive. Conclusion These pilot-level data suggest that patient satisfaction survey utilization may promote, under certain circumstances, job dissatisfaction, attrition, and inappropriate clinical care among some physicians. This is concerning, especially in the context of the progressive incorporation of patient satisfaction ratings as a quality-of-care metric, and highlights the need for a rigorous evaluation of the optimal methods
Iserson, Kenneth V
Hypnosis has been used in medicine for nearly 250 years. Yet, emergency clinicians rarely use it in emergency departments or prehospital settings. This review describes hypnosis, its historical use in medicine, several neurophysiologic studies of the procedure, its uses and potential uses in emergency care, and a simple technique for inducing hypnosis. It also discusses reasons why the technique has not been widely adopted, and suggests methods of increasing its use in emergency care, including some potential research areas. A limited number of clinical studies and case reports suggest that hypnosis may be effective in a wide variety of conditions applicable to emergency medical care. These include providing analgesia for existing pain (e.g., fractures, burns, and lacerations), providing analgesia and sedation for painful procedures (e.g., needle sticks, laceration repair, and fracture and joint reductions), reducing acute anxiety, increasing children's cooperation for procedures, facilitating the diagnosis and treatment of acute psychiatric conditions, and providing analgesia and anxiolysis for obstetric/gynecologic problems. Although it is safe, fast, and cost-effective, emergency clinicians rarely use hypnosis. This is due, in part, to the myths surrounding hypnosis and its association with alternative-complementary medicine. Genuine barriers to its increased clinical use include a lack of assured effectiveness and a lack of training and training requirements. Based on the results of further research, hypnosis could become a powerful and safe nonpharmacologic addition to the emergency clinician's armamentarium, with the potential to enhance patient care in emergency medicine, prehospital care, and remote medical settings. Copyright © 2014 Elsevier Inc. All rights reserved.
Ruiz Sánchez, Míriam; Borrell-Carrió, Francisco; Ortodó Parra, Cristina; Fernàndez I Danés, Neus; Fité Gallego, Anna
To identify organizational processes, violations of rules, or professional performances that pose clinical levels of insecurity. Descriptive cross-sectional survey with customized externally-behavioral verification and comparison of sources, conducted from June 2008 to February 2010. Thirteen of the 53 primary care teams (PCT) of the Catalonian Health Institute (ICS Costa de Ponent, Barcelona). Employees of 13 PCT classified into: director, nurse director, customer care administrators, and general practitioners. Non-random selection, teaching (TC)/non-teaching, urban (UC)/rural and small/large (LC) health care centers (HCC). A total of 33 indicators were evaluated; 15 of procedures, 9 of attitude, 3 of training, and 6 of communication. Level of uncertainty: <50% positive answers for each indicator. no collaboration. A total of 55 professionals participated (84.6% UC, 46.2% LC and 76.9% TC). Rank distribution: 13 customer care administrators, 13 nurse directors, 13 HCC directors, and 16 general practitioners. Levels of insecurity emerged from the following areas: reception of new medical professionals, injections administration, nursing weekend home calls, urgent consultations to specialists, aggressive patients, critical incidents over the agenda of the doctors, communication barriers with patients about treatment plans, and with immigrants. Clinical safety is on the agenda of the health centers. Identified areas of uncertainty are easily approachable, and are considered in the future system of accreditation of the Catalonian Government. General practitioners are more critical than directors, and teaching health care centers, rural and small HCC had a better sense of security. Copyright © 2012 Elsevier España, S.L. All rights reserved.
Buetow, S. A.; Roland, M.
Clinical governance has been introduced as a new approach to quality improvement in the UK national health service. This article maps clinical governance against a discussion of the four main approaches to measuring and improving quality of care: quality assessment, quality assurance, clinical audit, and quality improvement (including continuous quality improvement). Quality assessment underpins each approach. Whereas clinical audit has, in general, been professionally led, managers have driven quality improvement initiatives. Quality assurance approaches have been perceived to be externally driven by managers or to involve professional inspection. It is discussed how clinical governance seeks to bridge these approaches. Clinical governance allows clinicians in the UK to lead a comprehensive strategy to improve quality within provider organisations, although with an expectation of greatly increased external accountability. Clinical governance aims to bring together managerial, organisational, and clinical approaches to improving quality of care. If successful, it will define a new type of professionalism for the next century. Failure by the professions to seize the opportunity is likely to result in increasingly detailed external control of clinical activity in the UK, as has occurred in some other countries. PMID:10847876
Glasser, Irene; Wang, Fei; Reardon, Jane; Vergara, Cunegundo D; Salvietti, Ralph; Acevedo, Myrtha; Santana, Blanca; Fortunato, Gil
We conducted a focus group study in an urban hospital-based primary care teaching clinic serving an indigent and Hispanic (predominantly Puerto Rican) population in New England in order to learn how patients with Chronic Obstructive Lung Disease (COPD) perceive their disease, how they experience their medical care, and the barriers they face managing their disease and following medical recommendations. The research team included medical doctors, nurses, a medical anthropologist, a clinical pharmacist, a hospital interpreter, and a systems analyst. Four focus groups were conducted in Spanish and English in April and May 2014. The demographic characteristics of the 25 focus group participants closely reflected the demographics of the total COPD clinic patients. The participants were predominantly female (72%) and Hispanic (72%) and had a median age of 63. The major themes expressed in the focus groups included: problems living with COPD; coping with complexities of comorbid illnesses; challenges of quitting smoking and maintaining cessation; dealing with second-hand smoke; beliefs and myths about quitting smoking; difficulty paying for and obtaining medications; positive experiences obtaining and managing medications; difficulties in using sleep machines at home; expressions of disappointment with the departure of their doctors; and overall satisfaction with the clinic health care providers. The study led to the creation of an action plan that addresses the concerns expressed by the focus study participants. The action plan is spearheaded by a designated bilingual and bicultural nurse and is now in operation.
Moats, Susan K; Richard, B Jeffery
This article discusses the lessons learned by an interdisciplinary team in a large metropolitan specialty hospital during the implementation of the Code Aorta protocol for aortic emergencies and the subsequent application of technological enhancements to improve data transfer. Aortic dissections require rapid diagnosis and surgical treatment; thus, in order to optimize patient outcomes, clinicians must be accessible, data must be readily available, and proper prompts and notifications must be made to alert and ready teams. An interdisciplinary team reviewed our hospital's processes and architecture of systems to define how we provide care during aortic emergencies. Based on this insight into patient flow, we ultimately developed a Code Aorta protocol to streamline provision of care during aortic emergencies. This process focused on protocol development, human-technology interfaces, and outcome-oriented metrics. The team also aimed to heighten awareness of the emergent process and to understand relevant outcomes data. After introduction of the Code Aorta protocol, a 78% reduction was achieved in time-to-treatment from the previous year's average time. In addition, the average length of stay was reduced by 2.4 days (18%). The team's efforts focused on clinical communication, aiming to link technology to maximize clinical efficiency. The initial results of our Code Aorta protocol show promise that continual refinement of patient care processes during aortic emergencies will improve outcomes for patients suffering aortic dissection.
Silverman, Morton M.; And Others
Elaborates on standards of care for assessment, management, and treatment of hospitalized suicidal patients. Attempts to synthesize concepts of minimal standard of care with clinical risk management and clinical judgment. Points out areas of overlap and shows where optimum care diverges from legal standards of care. Tables differentiate…
van Eijk, Marieke
What is a clinician to do when people needing medical care do not have access to consistent or sufficient health insurance coverage and cannot pay for care privately? Analyzing ethnographically how clinicians at a university-based transgender clinic in the United States responded to this challenge, I examine the U.S. health insurance system, insurance paperwork, and administrative procedures that shape transgender care delivery. To buffer the impact of the system's failure to provide sufficient health insurance coverage for transgender care, clinicians blended administrative routines with psychological therapy, counseled people's minds and finances, and leveraged the prestige of their clinic in attempts to create space for gender nonconforming embodiments in gender conservative insurance policies. My analysis demonstrates that in a market-based health insurance system with multiple payers and gender binary insurance rules, health care may be unaffordable, or remain financially challenging, even for transgender people with health insurance. Moreover, insurance carriers' "reliance" on clinicians' insurance-related labor is problematic as it exacerbates existing insurance barriers to the accessibility and affordability of transgender care and obscures the workings of a financial payment model that prioritizes economic expediency over gender nonconforming health.
Despite increases in health care premiums, the effect of relaxing cost-containment mechanisms on health care utilization is not yet well understood at the microlevel. This study used a regulatory change in the California workers' compensation system to examine the effect of relaxing broad-based utilization management constraints and increasing clinical autonomy on methods of treatment and service intensity, and compared the responses of managed care network and fee-for-service providers. Between 1993 and 2000, the likelihood of a fee-for-service claim receiving a chiropractic treatment increased from 22% to 32%, the likelihood of receiving diagnostic radiology decreased from 24% to 15%, and the likelihood of receiving physical medicine with diagnostic services remained relatively stable. Treating fee-for-service claims with network care would have decreased the likelihood of receiving manipulations by 13 percentage points and physical medicine with diagnostic services by two percentage points. The likelihood of receiving office-visit-only treatment would have increased by 130% (14 percentage points), and the likelihood of receiving a diagnostic radiology treatment would have increased by 28% (4 percentage points). Treatment by network providers would have reduced the number of office visits by 18%, diagnostic radiology and ultrasound exams by 26%, passive physical medicine procedures by 40%, active physical medicine procedures by 43%, physical medicine assessments by 45%, and chiropractic treatments by 46%.
The objective of this study is to discuss and analyze the use of automated SNOMED CT clinical coding in clinical decision support systems (CDSSs) for preventive care. The central question that this study seeks to answer is whether the utilization of SNOMED CT in CDSSs can improve preventive care. PubMed, Google Scholar, and Cochrane Library were searched for articles published in English between 2001 and 2012 on SNOMED CT, CDSS, and preventive care. Outcome measures were the sensitivity or specificity of SNOMED CT coded data and the positive predictive value or negative predictive value of SNOMED CT coded data. Additionally, we documented the publication year, research question, study design, results, and conclusions of these studies. The reviewed studies suggested that SNOMED CT successfully represents clinical terms and negated clinical terms. The use of SNOMED CT in CDSS can be considered to provide an answer to the problem of medical errors as well as for preventive care in general. Enhancement of the modifiers and synonyms found in SNOMED CT will be necessary to improve the expected outcome of the integration of SNOMED CT with CDSS. Moreover, the application of the tree-augmented naïve (TAN) Bayesian network method can be considered the best technique to search SNOMED CT data and, consequently, to help improve preventive health services.
Objective The objective of this study is to discuss and analyze the use of automated SNOMED CT clinical coding in clinical decision support systems (CDSSs) for preventive care. The central question that this study seeks to answer is whether the utilization of SNOMED CT in CDSSs can improve preventive care. Method PubMed, Google Scholar, and Cochrane Library were searched for articles published in English between 2001 and 2012 on SNOMED CT, CDSS, and preventive care. Outcome Measures Outcome measures were the sensitivity or specificity of SNOMED CT coded data and the positive predictive value or negative predictive value of SNOMED CT coded data. Additionally, we documented the publication year, research question, study design, results, and conclusions of these studies. Results The reviewed studies suggested that SNOMED CT successfully represents clinical terms and negated clinical terms. Conclusion The use of SNOMED CT in CDSS can be considered to provide an answer to the problem of medical errors as well as for preventive care in general. Enhancement of the modifiers and synonyms found in SNOMED CT will be necessary to improve the expected outcome of the integration of SNOMED CT with CDSS. Moreover, the application of the tree-augmented naïve (TAN) Bayesian network method can be considered the best technique to search SNOMED CT data and, consequently, to help improve preventive health services. PMID:28566995
Ketcham, Jonathan D; Lutfey, Karen E; Gerstenberger, Eric; Link, Carol L; McKinlay, John B
The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians' diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT's effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.
DeFina, Philip A.; Lichtenstein, Jonathan D.; Fellus, Jonathan
Of the approximately 6.8 million Americans who have been diagnosed with dementia, over 5 million have been diagnosed with Alzheimer's Disease (AD). Due to the rise in the aging population, these figures are expected to double by 2050. The following paper provides an up-to-date review of clinical issues and relevant research. Research related to the methods of the earliest possible detection of AD is ongoing. Health care professionals should play a critical role in differentially diagnosing AD patients, as well as supporting their families. Novel interventions, including medications, natural supplements, and behavioral techniques, are constantly appearing in the literature. It is necessary for the health practitioner to remain current, regarding AD, as such information will facilitate better care for patients and their families. PMID:24083026
Kalil, Andre C; Sun, Junfeng
To review Bayesian methodology and its utility to clinical decision making and research in the critical care field. Clinical, epidemiological, and biostatistical studies on Bayesian methods in PubMed and Embase from their inception to December 2013. Bayesian methods have been extensively used by a wide range of scientific fields, including astronomy, engineering, chemistry, genetics, physics, geology, paleontology, climatology, cryptography, linguistics, ecology, and computational sciences. The application of medical knowledge in clinical research is analogous to the application of medical knowledge in clinical practice. Bedside physicians have to make most diagnostic and treatment decisions on critically ill patients every day without clear-cut evidence-based medicine (more subjective than objective evidence). Similarly, clinical researchers have to make most decisions about trial design with limited available data. Bayesian methodology allows both subjective and objective aspects of knowledge to be formally measured and transparently incorporated into the design, execution, and interpretation of clinical trials. In addition, various degrees of knowledge and several hypotheses can be tested at the same time in a single clinical trial without the risk of multiplicity. Notably, the Bayesian technology is naturally suited for the interpretation of clinical trial findings for the individualized care of critically ill patients and for the optimization of public health policies. We propose that the application of the versatile Bayesian methodology in conjunction with the conventional statistical methods is not only ripe for actual use in critical care clinical research but it is also a necessary step to maximize the performance of clinical trials and its translation to the practice of critical care medicine.
Hisham, Mohamed; Sivakumar, Mudalipalayam N; Veerasekar, Ganesh
A critically ill patient is treated and reviewed by physicians from different specialties; hence, polypharmacy is a very common. This study was conducted to assess the impact and effectiveness of having a clinical pharmacist in an Indian Intensive Care Unit (ICU). It also evaluates the clinical pharmacist interventions with a focus on optimizing the quality of pharmacotherapy and patient safety. The prospective, observational study was carried out in medical and surgical/trauma ICU over a period of 1 year. All detected drug-related problems and interventions were categorized based on the Pharmaceutical Care Network Europe system. During the study period, average monthly census of 1032 patients got treated in the ICUs. A total of 986 pharmaceutical interventions due to drug-related problems were documented, whereof medication errors accounted for 42.6% (n = 420), drug of choice problem 15.4% (n = 152), drug-drug interactions were 15.1% (n = 149), Y-site drug incompatibility was 13.7% (n = 135), drug dosing problems were 4.8% (n = 47), drug duplications reported were 4.6% (n = 45), and adverse drug reactions documented were 3.8% (n = 38). Drug dosing adjustment done by the clinical pharmacist included 140 (11.9%) renal dose, 62 (5.2%) hepatic dose, 17 (1.4%) pediatric dose, and 104 (8.8%) insulin dosing modifications. A total of 577 drug and poison information queries were answered by the clinical pharmacist. Clinical pharmacist as a part of multidisciplinary team in our study was associated with a substantially lower rate of adverse drug event caused by medication errors, drug interactions, and drug incompatibilities.
McGuire, M K; Nunn, M E
Recently, a genetic marker (IL-1 genotype) that identifies individuals at higher risk for developing severe periodontal disease was discovered. A subgroup of the population reported on earlier was evaluated to determine if knowledge of the patient's IL-1 genotype would improve accuracy in assignment of prognoses and prediction of tooth loss. This subgroup consisted of 42 patients (1,044 teeth) in maintenance care for 14 years; 16 tested IL-1 genotype-positive (IL-1GP). Nine were smokers, and 30 had a history of smoking, with an average of 29.44 pack years. A multiple Cox regression model and Kaplan-Meier survival plots were fit to the subset of patients to evaluate tooth loss. Both IL-1GP and heavy smoking were significantly related to tooth loss. A positive IL-1 genotype increased the risk of tooth loss by 2.7 times, and heavy smoking by 2.9 times. The combined effect of IL-1GP and heavy smoking increased the risk of tooth loss by 7.7 times. The value of clinical parameters traditionally used to assign prognosis was found to be dependent on IL-genotype and smoking status. In the model that included IL-1 genotype and heavy smoking, none of the clinical parameters added significantly to the model for tooth loss while mobility, probing depth, crown-to-root ratio, and percent bone loss added significantly to the model, which included IL-1 genotype in non-smokers. IL-1GP patients and patients who smoked heavily demonstrated a much worse tooth survival rate when compared to IL-1 genotype-negative patients and non-smokers, respectively. Knowledge of the patient's IL-1 genotype and smoking status will improve the clinician's ability to accurately assign prognosis and predict tooth survival. Clinical implications are as follows. Investigators were unable to judge which patients would be IL-GP or negative based on their clinical presentation or family history of tooth loss due to periodontal disease. Since periodontal diseases are multifactorial, knowledge of the patient
of having an evaluation or treatment intervention for breast disease. • Create and maintain an environment (medical, physical , psychological ...informatics companion to the prospective serum I breast tissue bank. 5. Clinical Care: • Decrease the negative psychological impact on the patient ...longitudinally assess the patient’s psychological response to evaluation and intervention , and base modifications on those results. 5 WSJXWH-05-2-0053
Solomon, Eric S.; And Others
This study examined costs of providing care by undergraduate dental students in dental school clinics. Cost estimates for each procedure were compared to fees charged, determining net cost of providing care. The model is recommended for improving clinic efficiency in this and other dental education clinical settings. (MSE)
Trent, Ronald J; Cheong, Pak Leng; Chua, Eng Wee; Kennedy, Martin A
Understanding human genetic variation and how it impacts on gene function is a major focus in genomic-based research. Translation of this knowledge into clinical care is exemplified by pharmacogenetics/pharmacogenomics. The identification of particular gene variants that might influence drug uptake, metabolism, distribution or excretion promises a more effective personalised medicine approach in choosing the right drug or its dose for any particular individual. Adverse drug responses can then be avoided or mitigated. An understanding of germline or acquired (somatic) DNA mutations can also be used to identify drugs that are more likely to be therapeutically beneficial. This represents an area of growing interest in the treatment of cancer.
Lewin, Warren H; Schaefer, Kristen G
Heart failure (HF) affects nearly 5.7 million Americans and is described as a chronic incurable illness carrying a poor prognosis. Patients living with HF experience significant symptoms including dyspnea, pain, anxiety, fatigue, and depression. As the illness advances into later stages, symptoms become more intense and refractory to standard treatments, leading to recurrent acute-care utilization and contributing to poor quality of life. Advanced HF symptoms have been described to be as burdensome, if not more than, those in cancer populations. Yet access to and provision of palliative care (PC) for this population has been described as suboptimal. The Institute of Medicine recently called for better access to PC for seriously ill patients. Despite guidelines recommending the inclusion of PC into the multidisciplinary HF care team, there is little data offering guidance on how to best operationalize PC skills in caring for this population. This paper describes the emerging literature describing models of PC integration for HF patients and aims to identify key attributes of these care models that may help guide future multi-site clinical trials to define best practices for the successful delivery of PC for patients living with advanced HF.
Edwards, Thomas D.; Young, Richard A.; Lowe, Adonna F.
Primary care physicians are rarely mentioned in medical disaster plans. We describe how a group of mostly family physicians and administrators of the JPS Health Network (JPS) took primary responsibility for 3,700 evacuees of Hurricane Katrina who came to Tarrant County, Texas. JPS provided medical care to 1,664 (45%) evacuees during a 2-week period. The most common needs were medications for chronic illnesses and treatment of skin infections (primarily on the feet). The JPS Emergency Department saw only 148 evacuees, most of whom arrived by their own transportation and were not seriously ill. JPS created a triage center located several miles from the hospital that referred almost all evacuees with health care needs to a primary care clinic. It was an effective approach for caring for the medical needs of disaster victims and prevented an emergency department and hospital from being overwhelmed. The JPS experience may guide future planning efforts for natural or manmade disasters, especially pandemic threats. PMID:17389543
Hripcsak, G; Knirsch, C A; Jain, N L; Stazesky, R C; Pablos-Mendez, A; Fulmer, T
The purpose of this study was to use a health information network and innovative technology to coordinate tuberculosis care. An innercity medical center, a local health department, and a home care nurse service in northern Manhattan were used. The organizations were linked with computer networks. An automated decision support system with a natural language processor was used to detect tuberculosis cases and report them to the health department, and to select patients for respiratory isolation. Educational materials were placed on the World Wide Web and a Web-based kiosk. Home care nurses were outfitted with wireless pen-based computers, and data were relayed to the medical center. Automated tuberculosis case reporting resulted in time savings but not improved accuracy. Automated rules resulted in significant improvements in respiratory isolation. Kiosk educational materials were well-used. Wireless computing led to better access to information for both nurses and physicians, but not to reduction of workload. The key success element was recognition of critical priorities. It is concluded that innovative technology can facilitate the coordination of clinical care, public health, and home care. Copyright 1999 Academic Press.
Stilos, Kalli; Daines, Pat
Demand for palliative care services in Canada will increase owing to an aging population and the evolving role of palliative care in non-malignant illness. Increasing healthcare demands continue to shape the clinical nurse specialist (CNS) role, especially in the area of palliative care. Clinical nurse specialists bring specialized knowledge, skills and leadership to the clinical setting to enhance patient and family care. This paper highlights the clinical leadership role of the CNS as triage leader for a hospital-based palliative care consulting team. Changes to the team's referral and triage processes are emphasized as key improvements to team efficiency and timely access to care for patients and families.
Tong, Seng Fah; Khoo, Ee Ming; Nordin, Saleh; Teng, Cheong-Lieng; Lee, Verna Kar Mun; Zailinawati, Abu Hassan; Chen, Wei Seng; Mimi, Omar
This study aimed to compare the process of care and the choice of antihypertensive medications used in both public and private primary care clinics in Malaysia. A cross-sectional survey was completed in 2008 on randomly selected 100 public health clinics and 114 private primary care clinics in Malaysia. A total of 4076 patient records, 3753 (92.1%) from public clinics and 323 (7.9%) from private clinics were analyzed. Less than 80% of the records documented the recommended clinical and laboratory assessments. The rates of documentation for smoking status, family history of premature death, retinal assessment, and urine albumin tests were lower in public clinics. Overall, 21% of the prescription practices were less than optimal. The process of care and the use of antihypertensive medications were not satisfactory in both settings.
Lee, Joseph; Milligan, James; Hillier, Loretta M; McMillan, Colleen
Persons with mobility impairments experience significant barriers to primary healthcare. This study examines key lessons learned, as derived from interviews with referral sources and Centre for Family Medicine Mobility Clinic team members, in the development and implementation of a primary care-based mobility clinic aimed at reducing these barriers, and it reflects on the implications of this model of care on the system of care. Results highlight the importance of accessibility, specialized equipment, promotional activities and management support as well as challenges reflected by system barriers to care. The results of this study have implications for the application of this model of care in other settings.
Groenvold, Mogens; Petersen, Morten Aagaard; Damkier, Anette; Neergaard, Mette Asbjoern; Nielsen, Jan Bjoern; Pedersen, Lise; Sjøgren, Per; Strömgren, Annette Sand; Vejlgaard, Tove Bahn; Gluud, Christian; Lindschou, Jane; Fayers, Peter; Higginson, Irene J; Johnsen, Anna Thit
Beneficial effects of early palliative care have been found in advanced cancer, but the evidence is not unequivocal. To investigate the effect of early specialist palliative care among advanced cancer patients identified in oncology departments. The Danish Palliative Care Trial (DanPaCT) (ClinicalTrials.gov NCT01348048) is a multicentre randomised clinical trial comparing early referral to a specialist palliative care team plus standard care versus standard care alone. The planned sample size was 300. At five oncology departments, consecutive patients with advanced cancer were screened for palliative needs. Patients with scores exceeding a predefined threshold for problems with physical, emotional or role function, or nausea/vomiting, pain, dyspnoea or lack of appetite according to the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) were eligible. The primary outcome was the change in each patient's primary need (the most severe of the seven QLQ-C30 scales) at 3- and 8-week follow-up (0-100 scale). Five sensitivity analyses were conducted. Secondary outcomes were change in the seven QLQ-C30 scales and survival. Totally 145 patients were randomised to early specialist palliative care versus 152 to standard care. Early specialist palliative care showed no effect on the primary outcome of change in primary need (-4.9 points (95% confidence interval -11.3 to +1.5 points); p = 0.14). The sensitivity analyses showed similar results. Analyses of the secondary outcomes, including survival, also showed no differences, maybe with the exception of nausea/vomiting where early specialist palliative care might have had a beneficial effect. We did not observe beneficial or harmful effects of early specialist palliative care, but important beneficial effects cannot be excluded.
Pintor, S; Mennuni, G; Fontana, M; Nocchi, S; Giarrusso, P; Serio, A; Fraioli, A
The clinical ethics is the identification, analysis and solution of moral problems that can arise during the care of a patient. Given that when dealing with ethical issues in health care some risks will be encountered (talking about ethics in general, or as a problem overlapped with others in this area, or by delegation to legislative determinations) in the text certain important aspects of the topic are examined. First of all ethics as human quality of the relationship between people for the common good, especially in health services where there are serious problems like the life and the health. It is also necessary a "humanizing relationship" between those who work in these services in order to achieve quality and efficiency in this business. It is important a proper training of health professionals, especially doctors, so that they can identify the real needs and means of intervention. It is also important that scientific research must respect fundamental ethical assumptions. In conclusion, ethics in health care is not a simple matter of "cookbook" rules, but involves the responsibility and consciousness of individual operators.
Leigh, Andrew James; O'Hanlon, Katie; Sheldrick, Russell; Surr, Claire; Hare, Dougal Julian
Person-centred care can improve the well-being of patients and is therefore a key driver in healthcare developments in the UK. The current study aims to investigate the complex relationship between cognitive impairment, dependency and well-being in people with a wide range of acquired brain and spinal injuries. Sixty-five participants, with varied acquired brain and spinal injuries, were selected by convenience sampling from six inpatient clinical neuroscience settings. Participants were observed using Dementia Care Mapping - Neurorehabilitation (DCM-NR) and categorised based on severity of cognitive impairment. A significant difference in the behaviours participants engaged in, their well-being and dependency was found between the severe cognitive impairment group and the mild, moderate or no cognitive impairment groups. Dependency and cognitive impairment accounted for 23.9% of the variance in well-ill-being scores and 17.2% of the variance in potential for positive engagement. The current study highlights the impact of severe cognitive impairment and dependency on the behaviours patients engaged in and their well-being. It also affirms the utility of DCM-NR in providing insights into patient experience. Consideration is given to developing DCM-NR as a process that may improve person-centred care in neuroscience settings.
Rincon, Fred; Mayer, Stephan A
Intracerebral hemorrhage is by far the most destructive form of stroke. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging. Ventilatory support, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, treatment of hyerglycemia, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Dexamethasone and other glucocorticoids should be avoided. Ventricular drainage should be performed urgently in all stuporous or comatose patients with intraventricular blood and acute hydrocephalus. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage. PMID:19108704
Litvin, Cara B; Ornstein, Steven M; Wessell, Andrea M; Nemeth, Lynne S
To systematically solicit recommendations from Meaningful Use (MU) exemplars to inform Stage 3 MU clinical quality measure (CQM) requirements. The study combined an electronic health record (EHR)-based CQM performance assessment with focus groups among primary care practices with high performance (top tertile), or "exemplars." This qualitative exploratory study was conducted in PPRNet, a national primary care practice-based research network. Focus groups among lead physicians from practices in the top tertile of performance on a CQM summary measure were held in early 2014 to learn their perspectives on questions posed by the Office of the National Coordinator related to Stage 3 MU CQMs. Twenty-three physicians attended the focus groups. There was consensus that CQMs should be evidence-based and focus on high-priority conditions relevant to primary care providers. Participants thought the emphasis of CQMs should largely be on outcomes and that reporting of CQMs should limit the burden on providers. Incorporating patient-generated data and accepting locally developed CQMs were viewed favorably. Participants unanimously concurred that platforms for population management were vital tools for improving health outcomes. Using a series of focus groups, we solicited Stage 3 MU CQM recommendations from a group of physicians who have already achieved "meaningful use" of their EHR, as demonstrated by their high performance on current MU CQMs. Adhering to the standards deemed to be important to high-performing real-world physicians could ensure that the MU Incentive Programs achieve their ultimate goal to improve outcomes.
Haggerty, Lois A; Grace, Pamela
Clinical wisdom, an essential foundation of nursing care that provides for the "good" of individual patients while taking into account the common good, is a concept that is difficult to define and comprehend. However, understanding what constitutes clinical wisdom is essential for the education of the types of nurses who are most likely to provide leadership that is consistent with the goals of nursing as outlined in the 2005 Code of Ethics for Nurses of the International Council of Nurses and the 2001 Code of Ethics for Nurses With Interpretive Statements of the American Nurses Association. The three key elements of wisdom, derived from the psychology and philosophy literature, are (1) balancing and providing for the good of another and the common good, (2) the use of intellect and affect in problem solving, and (3) the demonstration of experience-based tacit knowing in problematic situations. We conceptualized clinical wisdom as a more specific variant of general wisdom by examining how the core elements described can be linked to wisdom for nursing practice. In doing so, the nature of clinical wisdom is clarified and strategies are suggested to assist nurse educators in developing wise nurses.
Hurlow, Jennifer; Couch, Kara; Laforet, Karen; Bolton, Laura; Metcalf, Daniel; Bowler, Phil
Significance: Biofilms have been implicated in a variety of wound complications. Recent Advances: Research has confirmed that biofilms form in wounds of patients experiencing delayed healing and may be a precursor to infection. Critical Issues: Research into the strength of this association is still in its infancy. Is biofilm formation a cause of these complications, a step toward them, or a signal that unresolved factors injuring tissue or delaying healing are setting the stage for biofilm formation, infection, and healing delay? To qualify biofilms for use in informing clinical practice decisions, biofilm characteristics supporting those decisions need standardized definitions and valid evidence that they predict or diagnose healing or infection outcomes. Literature searches of relevant terms reviewed biofilm definitions and validation of their role in predicting and diagnosing delayed wound healing or infection. Future Directions: Further research is needed to provide a rapid accurate technique to identify and characterize biofilms in ways that optimize their validity in diagnosing or screening patient risk of infection or delayed healing and to inform clinical decisions. This research will help validate biofilm's capacity to support wound care clinical practice decisions and establish their importance in guiding clinical practice. PMID:26005595
Ponte, C; Sznajd, J; O'Neill, L; Luqmani, R A
The systemic vasculitides are a group of rare, chronic, relapsing, but often progressive inflammatory conditions. They are associated with a significant burden of morbidity both due to scarring from the disease itself and as a consequence of treatment with glucocorticoids and other potent immunosuppressive agents. Careful assessment of disease activity is critical to guide appropriate use of these potentially toxic therapies. It is also important to differentiate features of active disease from those attributable to damage, which will not respond to immunosuppression. As these are chronic complex conditions, the impact on a patient's functional ability and quality of life are also important considerations. Given the lack of a reliable biomarker for assessment of disease activity or damage in systemic vasculitis, clinical tools developed and validated for use initially in clinically trials are key outcome measures in the evaluation of these patients. While the conduct of randomised clinical trials in vasculitis has been significantly enhanced by the development and use of validated outcome measures, regular use of validated disease activity and damage measurements as part of routine care offers a structured approach, which can serve as the basis of justifying treatment decisions. The authors review the concepts of clinical assessment tools used in the evaluation of patients with systemic vasculitis in the setting of clinical practice, clinical trials and long term databases with particular emphasis on disease activity, damage, prognosis and function.
Goodman, Claire; L Davies, Sue; Norton, Christine; Fader, Mandy; Morris, Jackie; Wells, Mandy; Gage, Heather
A quasi-experimental study tested a clinical benchmarking tool (Essence of Care) to improve bowel-related care for older people living in six care homes. In the intervention care homes, district nurses and care home staff used the clinical benchmarking tool to discuss and plan how to improve bowel care for residents. In the control care homes, staff were provided with detailed information about the residents and continence services contact details. The intervention was acceptable to care home and district nursing staff, and possible to incorporate into existing working patterns. The study did not demonstrate a significant reduction in bowel-related problems, although there was evidence in one care home of reduction in episodes of avoidable faecal incontinence. At an individual level of care, there were observable benefits, and examples of person-centred care were prompted through participating in the intervention and improved staff awareness. Clinical benchmarking tools can be used to structure discussion between district nurses and care home staff to review and plan care for residents. However, it takes time to achieve change and embedding this kind of approach requires either robust pre-existing working relationships or the involvement of a facilitator.
Brustrom, Jennifer; Thibadeau, Judy; John, Lisa; Liesmann, Jaime; Rose, Shyanika
Although the potential benefits of care coordination are widely recognized, little is known about care coordination in the multidisciplinary spina bifida clinic setting. This study examined several aspects of care coordination in this environment. We conducted semi-structured interviews with clinic staff (N = 43) and focus groups with caregivers (N = 38) at seven spina bifida clinics in the United States. Clinic staff described several primary goals of care coordination, including coordinating multiple services during one visit to ease the burden on families. Although the structure of care coordination varied across the clinics, several clinics had a dedicated care coordinator. Barriers and facilitators to care coordination included staffing issues, clinic day logistics, community resources, and family-related concerns. Despite challenges associated with care coordination processes, clinic staff and caregivers alike believed that care coordination is beneficial. Study findings suggest ways that care might be coordinated optimally in spina bifida clinics. A synthesis of these findings for clinics interested in implementing care coordination or improving the care coordination services they currently offer is provided. Copyright © 2012 National Association of Pediatric Nurse Practitioners. All rights reserved.
Hayes, Daniel F
Physicians have provided personalized care with as much precision as possible for several centuries. However, increasingly sophisticated understanding of the human genome and of cancer biology has permitted identification of genetic and phenotypic distinctions that might permit development of new tumor biomarker tests for risk categorization, screening, differential diagnosis, prognosis, prediction, and monitoring. Both commercial and academic laboratories are offering tests for single analytes, panels of tests of single analytes, multiparameter assays coalesced into a signature, and total genomic, transcriptomic, or proteomic analyses. However, the absence of a consistent regulatory environment has led to marketing of assays without proven analytic validity or clinical utility. U.S. Food and Drug Administration (FDA) approval or clearance does not necessarily imply that use of the test will improve patient outcomes, and FDA discretion to permit laboratory-developed tests results in unknown benefit, or harm, of others. In this regard, a "bad tumor marker is as bad as a bad drug." Caveat emptor is not a satisfactory approach to delivering high-quality care. Rather, adoption of tumor biomarker tests should be based on high levels of evidence generated in scientifically rigorous studies that demonstrate both analytical validity and clinical utility. Doing so will ensure that clinicians and patients are confident that a tumor biomarker test is likely to improve their outcomes.
Barasa, Edwine W.; English, Mike
Summary Increasingly attention is shifting towards delivering essential packages of care, often based on clinical practice guidelines, as a means to improve maternal, child and newborn survival in low-income settings. Cost effectiveness analysis (CEA), allied to the evaluation of less complex intervention, has become an increasingly important tool for priority setting. Arguably such analyses should be extended to inform decisions around the deployment of more complex interventions. In the discussion, we illustrate some of the challenges facing the extension of CEA to this area. We suggest that there are both practical and methodological challenges to overcome when conducting economic evaluation for packages of care interventions that incorporate clinical guidelines. Some might be overcome by developing specific guidance on approaches, for example clarity in identifying relevant costs. Some require consensus on methods. The greatest challenge, however, lies in how to incorporate, as measures of effectiveness, process measures of service quality. Questions on which measures to use, how multiple measures might be combined, how improvements in one area might be compared with those in another and what value is associated with improvement in health worker practices are yet to be answered. PMID:21371210
Lazarus, Jeffrey V; Laut, Kamilla Grønborg; Safreed-Harmon, Kelly; Peters, Lars; Johnson, Margaret; Fätkenheuer, Gerd; Khromova, Irina; Vandekerckhove, Linos; Maciejewska, Katarzyna; Radoi, Roxana; Ridolfo, Anna Lisa; Mocroft, Amanda
Although advances in HIV medicine have yielded increasingly better treatment outcomes in recent years, HIV-positive people with access to antiretroviral therapy (ART) still face complex health challenges. The EuroSIDA Study Group surveyed its clinics to explore regional differences in clinic services. The EuroSIDA study is a prospective observational cohort study that began enrolling patients in 1994. In early 2014, we conducted a 59-item survey of the 98 then-active EuroSIDA clinics. The survey covered HIV clinical care and other aspects of patient care. The EuroSIDA East Europe study region (Belarus, Estonia, Lithuania, the Russian Federation and Ukraine) was compared to a "non-East Europe" study region comprised of all other EuroSIDA countries. A larger proportion of clinics in the East Europe group reported deferring ART in asymptomatic patients until the CD4 cell count dropped below 350 cells/mm(3) (75 % versus 25 %, p = 0.0032). Considerably smaller proportions of East Europe clinics reported that resistance testing was provided before ART initiation (17 % versus 86 %, p < 0.0001) and that it was provided upon treatment failure (58 % versus 90 %, p = 0.0040). Only 33 % of East Europe clinics reported providing hepatitis B vaccination, compared to 88 % of other clinics (p < 0.0001). Only 50 % of East Europe clinics reported having access to direct-acting antivirals for hepatitis C treatment, compared to 89 % of other clinics (p = 0.0036). There was significantly less tuberculosis/HIV treatment integration in the East Europe group (27 % versus 84 % p < 0.0001) as well as significantly less screening for cardiovascular disease (58 % versus 90 %, p = 0.014); tobacco use (50 % versus 93 %, p < 0.0001); alcohol consumption (50 % versus 93 %, p < 0.0001); and drug use (58 % versus 87 %, p = 0.029). Study findings demonstrate how specific features of HIV clinics differ across Europe. Significantly more East
Bali, Rajeev K; Feng, David Dagan; Burstein, Frada; Dwivedi, Ashish N
Clinical and health-care knowledge management (KM) as a discipline has attracted increasing worldwide attention in recent years. The approach encompasses a plethora of interrelated themes including aspects of clinical informatics, clinical governance, artificial intelligence, privacy and security, data mining, genomic mining, information management, and organizational behavior. This paper introduces key manuscripts which detail health-care and clinical KM cases and applications.
Chu, Stephanie; Boxer, Richard; Madison, Pauline; Kleinman, Leonard; Skolarus, Ted; Altman, Lisa; Bennett, Carol; Shelton, Jeremy
To report the use of telemedicine to deliver general urologic care to remote locations within the Veterans Affairs Greater Los Angeles Healthcare System. We describe the diagnoses managed, patient satisfaction, safety, and benefit to patients in terms of saved travel time and expense. We conducted a retrospective chart review examining care delivered through urology telemedicine clinics over a 6-month period. We examined the urologic conditions, patient satisfaction, and emergency department visits within 30 days of the visit. We estimated patient benefit by calculating travel distance and time and the saved travel-associated costs using Google Maps and US Census income data. Ninety-seven unique telemedicine visits were conducted and a total of 171 urologic diseases were assessed. The most common conditions were lower urinary tract symptoms (35%), elevated prostate-specific antigen level (15%), and prostate cancer (14%). One patient was seen in the emergency department within 30 days with an unpreventable urologic complaint. Patient satisfaction was "very good" to "excellent" in 95% of cases, and 97% would refer another veteran to the urology telemedicine clinic. Patients saved an average of 277 travel miles, 290 minutes of travel time, $67 in travel expenses, and $126 in lost opportunity cost. Telemedicine was successfully and safely used to evaluate and treat a wide range of urologic conditions within the Veterans Affairs Greater Los Angeles Healthcare System, and saves patients nearly 5 hours and up to $193 per visit. Further investigation of the potential of telemedicine for the delivery of urologic care in a cost-effective manner is warranted. Copyright © 2015 Elsevier Inc. All rights reserved.
Hansoti, Bhakti; Aluisio, Adam R; Barry, Meagan A; Davey, Kevin; Lentz, Brian A; Modi, Payal; Newberry, Jennifer A; Patel, Melissa H; Smith, Tricia A; Vinograd, Alexandra M; Levine, Adam C
Despite recent strides in the development of global emergency medicine (EM), the field continues to lag in applying a scientific approach to identifying critical knowledge gaps and advancing evidence-based solutions to clinical and public health problems seen in emergency departments (EDs) worldwide. Here, progress on the global EM research agenda created at the 2013 Academic Emergency Medicine Global Health and Emergency Care Consensus Conference is evaluated and critical areas for future development in emergency care research internationally are identified. A retrospective review of all studies compiled in the Global Emergency Medicine Literature Review (GEMLR) database from 2013 through 2015 was conducted. Articles were categorized and analyzed using descriptive quantitative measures and structured data matrices. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting then further conceptualized and defined global EM research priorities utilizing consensus-based decision making. Research trends in global EM research published between 2013 and 2015 show a predominance of observational studies relative to interventional or descriptive studies, with the majority of research conducted in the inpatient setting in comparison to the ED or prehospital setting. Studies on communicable diseases and injury were the most prevalent, with a relative dearth of research on chronic noncommunicable diseases. The Global Emergency Medicine Think Tank Clinical Research Working Group identified conceptual frameworks to define high-impact research priorities, including the traditional approach of using global burden of disease to define priorities and the impact of EM on individual clinical care and public health opportunities. EM research is also described through a population lens approach, including gender, pediatrics, and migrant and refugee health. Despite recent strides in global EM research and
Gill, Preetinder Singh
Background Engaged employees are an asset to any organization. They are instrumental in ensuring good commercial outcomes through continuous innovation and incremental improvement. A health care facility is similar to a regular work setting in many ways. A health care provider and a patient have roles akin to a team leader and a team member/stakeholder, respectively. Hence it can be argued that the concept of employee engagement can be applied to patients in health care settings in order to improve health outcomes. Methods Patient engagement data were collected using a survey instrument from a primary care clinic in the northern Indian state of Punjab. Canonical correlation equations were formulated to identify combinations which were strongly related to each other. In addition, the cause-effect relationship between patient engagement and patient-perceived health outcomes was described using structural equation modeling. Results Canonical correlation analysis showed that the first set of canonical variables had a fairly strong relationship, ie, a magnitude > 0.80 at the 95% confidence interval, for five dimensions of patient engagement. Structural equation modeling analysis yielded a β ≥ 0.10 and a Student’s t statistic ≥ 2.96 for these five dimensions. The threshold Student’s t statistic was 1.99. Hence it was found the β values were significant at the 95% confidence interval for all census regions. Conclusion A scaled reliable survey instrument was developed to measured patient engagement. Better patient engagement is associated with better patient-perceived health outcomes. This study provides preliminary evidence that patient engagement has a causal relationship with patient-perceived health outcomes. PMID:23515133
Barnes, T A
The development of the AHA Guidelines for CPR and ECC and the AARC RACH Clinical Practice Guideline should both be instrumental in improving the performance of RCPs on in-hospital resuscitation teams. The AARC and AHA are assuming important leadership roles in this movement by publishing CPGs for CPR and ECC. RCPs with ACLS training are in a prime position to assume more responsibility on resuscitation teams within acute care facilities. They should be prominent members of the resuscitation team--committed to the entire team's performance--and be actively involved in ACLS training. The first step in that process is to study the current levels of RCP competence in ACLS. Further, RCPs and health-care providers should define the goals of resuscitation in terms of long-term survival, quality of life, and years of useful life after CPR. The cost of inadequate attention to which patients should have DNR orders is a drain on the entire health-care system. Research on the impact of disease categories on CPR outcome should be used to educate physicians, nurses, and RCPs so they can help patients better understand their chances of regaining their pre-CPR quality of life. Successful CPR outcome should be carefully defined using the patient's disease category. Each patient should be individually evaluated for DNR orders. As suggested by Schwenzer, "Patients' perception of their quality of life before and after CPR should guide their and our decisions." However, we must all accept the responsibility for defining the limitations of medical technology and try to determine when CPR is futile.
Gill, Preetinder Singh
Engaged employees are an asset to any organization. They are instrumental in ensuring good commercial outcomes through continuous innovation and incremental improvement. A health care facility is similar to a regular work setting in many ways. A health care provider and a patient have roles akin to a team leader and a team member/stakeholder, respectively. Hence it can be argued that the concept of employee engagement can be applied to patients in health care settings in order to improve health outcomes. Patient engagement data were collected using a survey instrument from a primary care clinic in the northern Indian state of Punjab. Canonical correlation equations were formulated to identify combinations which were strongly related to each other. In addition, the cause-effect relationship between patient engagement and patient-perceived health outcomes was described using structural equation modeling. Canonical correlation analysis showed that the first set of canonical variables had a fairly strong relationship, ie, a magnitude > 0.80 at the 95% confidence interval, for five dimensions of patient engagement. Structural equation modeling analysis yielded a β ≥ 0.10 and a Student's t statistic ≥ 2.96 for these five dimensions. The threshold Student's t statistic was 1.99. Hence it was found the β values were significant at the 95% confidence interval for all census regions. A scaled reliable survey instrument was developed to measured patient engagement. Better patient engagement is associated with better patient-perceived health outcomes. This study provides preliminary evidence that patient engagement has a causal relationship with patient-perceived health outcomes.
Derrett, Sarah; Gunter, Kathryn E; Nocon, Robert S; Quinn, Michael T; Coleman, Katie; Daniel, Donna M; Wagner, Edward H; Chin, Marshall H
Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients' needs. Currently, little is known about care integration for rural patients. To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. Qualitative case study. Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. Care integration was supported by 2 fundamental changes to organize and deliver care to patients-(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities.
Iedema, Rick; Flabouris, Arthas; Grant, Susan; Jorm, Christine
This paper considers the rise across acute care settings in the industrialized world of techniques that encourage clinicians to record their experiences about adverse events they are personally involved in; that is, to share narratives about errors, mishaps or 'critical incidents'. The paper proposes that critical incident reporting and the 'root cause' investigations it affords, are both central to the effort to involve clinicians in managing and organizing their work, and a departure from established methods and approaches to achieve clinicians' involvement in these non-clinical domains of health care. We argue that critical incident narratives render visible details of the clinical work that have thus far only been discussed in closed, paperless meetings, and that, as narratives, they incite individuals to share personal experiences with parties previously excluded from knowledge about failure. Drawing on a study of 124 medical retrieval incident reports, the paper provides illustrations and interpretations of both the narrative and the meta-discursive dimensions of critical incident reporting. We suggest that, as a new and complex genre, critical incident reporting achieves three important objectives. First, it provides clinicians with a channel for dealing with incidents in a way that brings problems to light in a non-blaming way and that might therefore be morally satisfying and perhaps even therapeutic. Second, these narrations make available new spaces for the apprehension, identification and performance of self. Here, the incident report becomes a space where clinicians publicly perform concern about what happened. Third, incident reporting becomes the basis for radically altering the clinician-organization relationship. As a complex expression of clinical failure and its re-articulation into organizational meta-discourse, incident reporting puts doctors' selves and feelings at risk not just within the relative safety of personal or intra
Jang, Raymond W; Burman, Debika; Swami, Nadia; Kotler, Jennifer; Banerjee, Subrata; Ridley, Julia; Mak, Ernie; Bryson, John; Rodin, Gary; Le, Lisa W; Zimmermann, Camilla
Home care (HC) is important for patients with cancer as performance status declines. Our study of 1224 patients at a Canadian cancer center examined the impact of an oncology palliative care clinic (OPCC) on HC referral. The HC referral frequency was calculated before and after the first OPCC consultation, in total and according to performance status (Palliative Performance Scale, PPS). Characteristics associated with HC referral were investigated. After the first OPCC consultation, there was an increase in HC referral from 39% (477 of 1224; 49% of those with PPS ≤60) to 69% (841 of 1224; 88% of those with PPS ≤60). Factors independently associated with HC referral were poor PPS (P < .001) and older age (P = .003). Thus OPCC involvement resulted in markedly increased HC referrals, particularly for older patients with poor performance status.
Coonrod, Dean V; Jack, Brian W; Stubblefield, Phillip G; Hollier, Lisa M; Boggess, Kim A; Cefalo, Robert; Cox, Shanna N; Dunlop, Anne L; Hunter, Kam D; Prasad, Mona R; Lu, Michael C; Conry, Jeanne A; Gibbs, Ronald S; Hogan, Vijaya K
A number of infectious diseases should be considered for inclusion as part of clinical preconception care. Those infections strongly recommended for health promotion messages and risk assessment or for the initiation of interventions include Chlamydia infection, syphilis, and HIV. For selected populations, the inclusion of interventions for tuberculosis, gonorrheal infection, and herpes simplex virus are recommended. No clear evidence exists for the specific inclusion in preconception care of hepatitis C, toxoplasmosis, cytomegalovirus, listeriosis, malaria, periodontal disease, and bacterial vaginosis (in those with a previous preterm birth). Some infections that have important consequences during pregnancy, such as bacterial vaginosis (in those with no history of preterm birth), asymptomatic bacteriuria, parvovirus, and group B streptococcus infection, most likely would not be improved through intervention in the preconception time frame.
Arena, Fabio; Scolletta, Sabino; Marchetti, Luca; Galano, Angelo; Maglioni, Enivarco; Giani, Tommaso; Corsi, Elisabetta; Lombardi, Silvia; Biagioli, Bonizella; Rossolini, Gian Maria
A preintervention-postintervention study was carried out over a 4-year period to assess the impact of an antimicrobial stewardship intervention, based on clinical microbiologist ward rounds (clinical microbiology-intensive care partnership [CMICP]), at a cardiothoracic intensive care unit. Comparison of clinical data for 37 patients with diagnosis of bacteremia (18 from preintervention period, 19 from postintervention period) revealed that CMICP implementation resulted in (1) significant increase of appropriate empirical treatments (+34%, P = .029), compliance with guidelines (+28%, P = .019), and number of de-escalations (+42%, P = .032); and (2) decrease (average = 2.5 days) in time to optimization of antimicrobial therapy and levofloxacin (Δ 2009-2012 = -74 defined daily dose [DDD]/1,000 bed days) and teicoplanin (Δ 2009-2012 = -28 DDD/1,000 bed days) use. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Perez-Hoyos, Santiago; Agra-Varela, Yolanda
Abstract Background Primary care physicians (PCPs) have a major responsibility in the management of palliative patients. Online palliative care (PC) education has not been shown to have a clinical impact on patients that is equal or different to traditional training. Objective This study tested the clinical effectiveness of online PC education of physicians through impact on symptom control, quality of life (QOL), caregiver satisfaction, and knowledge-attitude of physicians at 18 months of the intervention. Methods We conducted a randomized clinical trial. Subjects were 169 physicians randomly assigned to receive the online model or traditional training. Consecutive patients with advanced cancer requiring PC were included. Physicians and patients completed the Palliative Care Outcome Scale (POS), and patients the Brief Pain Inventory (BPI) and the Rotterdam Symptom Checklist (RSCL) twice, 7 to 10 days apart. Caregivers completed the SERVQUAL. Physicians' level of knowledge-attitude was measured at 18 months. Results Sixty-seven physicians enrolled 117 patients. The intervention group had reduced scores for pain, symptoms, and family anxiety. The global RSCL scale showed a difference between groups. There was no significant difference in the questionnaires used. Caregiver satisfaction was comparable between groups. Physicians in the intervention group significantly increased their knowledge without any differences in attitude. Online training was completed by 86.6% in the intervention group, whereas 13.4% in the control group accessed traditional training. Conclusions Participation in an online PC education program by PCPs improved patient scores for some symptoms and family anxiety on the POS and also showed improved global QOL. Significant differences were found in physicians' knowledge at short and long term. PMID:23987657
Gibbs, Jo; Sutcliffe, Lorna J; Gkatzidou, Voula; Hone, Kate; Ashcroft, Richard E; Harding-Esch, Emma M; Lowndes, Catherine M; Sadiq, S Tariq; Sonnenberg, Pam; Estcourt, Claudia S
Despite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England. Using the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway). Use of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation. The Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway's standardised method of collecting data on demographics and sexual behaviour, with
Johnston, Donna L; Halton, Jacqueline; Bassal, Mylène; Klaassen, Robert J; Mandel, Karen; Ramphal, Raveena; Simpson, Ewurabena; Peckan, Li
Providing the best care in both the inpatient and outpatient settings to pediatric oncology patients is all programs goal. Using continuous improvement methodologies, we changed from a solely team-based physician care model to a hybrid model. All patients were assigned a dedicated oncologist. There would then be 2 types of weeks of outpatient clinical service. A "Doc of the Day" week where each oncologist would have a specific day in clinic when their assigned patients would be scheduled, and then a "Doc of the Week" week where one physician would cover clinic for the week. Patient satisfaction surveys done before and 14 months after changing the model of care showed that patients were very satisfied with the care they received in both models. A questionnaire to staff 14 months after changing showed that the biggest effect was increased continuity of care, followed by more efficient clinic workflow and increased consistency of care. Staff felt it provided better planning and delivery of care. A hybrid model of care with a primary physician for each patient and assigned clinic days, alternating with weeks of single physician coverage is a feasible model of care for a medium-sized pediatric oncology program.
Rochette, Annie; Racine, Eric; Lefebvre, Helene; Bastien, Josee; Tellier, Myriam
To document the gap between actual and desired ideal services for relatives post-stroke from three perspectives: relatives, stroke clients and health professionals. A two-phase qualitative design and consisting of in-depth interviews (Phase 1) and 3 focus groups (Phase 2). The interview sample consisted of 25 relatives (mean age 53.4 (standard deviation 12.7); women = 21/25) and 16 individuals with a first stroke (mean age = 55.7 (standard deviation 11.2); women = 7/16). The focus group sample size varied from 5 to 7 participants. An interview guide validated by experts was used. Audio content was transcribed verbatim and rigorously analyzed by two team members. Services received by relatives are diversified, and relatives' perceptions range from receiving no services to being satisfied with services received. Even when participants were satisfied, ideal services were still desired: they would have liked to receive services earlier and without having to seek. Four main factors emerged as influencing the amount and quality of services received, including the individual's ability to seek. A gap remains between actual and ideal services for relatives post-stroke. It is crucial to legitimized relatives' role as clients and to systematically assess the patient's social environment in order to provide services in accordance with needs.
to be completed effectively, productively and within budget. Health care quality and safety; skill decay; physicians; declarative knowledge; clinical...context for studying skill degradation among pediatric health care providers • Objective 2: Develop and validate quality metrics, test alternative...experience less demand for certain clinical skills. Upon resuming domestic practice, they may exhibit skill decay, reducing health care quality and
... AFFAIRS Agency Information Collection: (PACT Clinical Innovation Study: Engaging Caregivers in the Care of... being requested for information needed to improve dementia care for patients and care givers. DATES... No. 2900--New (VA Form 10-0537). SUPPLEMENTARY INFORMATION: Title: PACT Clinical Innovation...
Jelic, Sanja; Cunningham, Jennifer A; Factor, Phillip
Maintenance of airway secretion clearance, or airway hygiene, is important for the preservation of airway patency and the prevention of respiratory tract infection. Impaired airway clearance often prompts admission to the intensive care unit (ICU) and can be a cause and/or contributor to acute respiratory failure. Physical methods to augment airway clearance are often used in the ICU but few are substantiated by clinical data. This review focuses on the impact of oral hygiene, tracheal suctioning, bronchoscopy, mucus-controlling agents, and kinetic therapy on the incidence of hospital-acquired respiratory infections, length of stay in the hospital and the ICU, and mortality in critically ill patients. Available data are distilled into recommendations for the maintenance of airway hygiene in ICU patients. PMID:18423061
Michel-Lepage, Audrey; Boyer, Sylvie; Raoult, Didier
SUMMARY Point-of-care (POC) laboratories that deliver rapid diagnoses of infectious diseases were invented to balance the centralization of core laboratories. POC laboratories operate 24 h a day and 7 days a week to provide diagnoses within 2 h, largely based on immunochromatography and real-time PCR tests. In our experience, these tests are conveniently combined into syndrome-based kits that facilitate sampling, including self-sampling and test operations, as POC laboratories can be operated by trained operators who are not necessarily biologists. POC laboratories are a way of easily providing clinical microbiology testing for populations distant from laboratories in developing and developed countries and on ships. Modern Internet connections enable support from core laboratories. The cost-effectiveness of POC laboratories has been established for the rapid diagnosis of tuberculosis and sexually transmitted infections in both developed and developing countries. PMID:27029593
Capella, Jeannette; Smith, Stephen; Philp, Allan; Putnam, Tyler; Gilbert, Carol; Fry, William; Harvey, Ellen; Wright, Andi; Henderson, Krista; Baker, David; Ranson, Sonya; Remine, Stephen
We investigated these questions: Does formal team training improve team behaviors in the trauma resuscitation bay? If yes, then does improved teamwork lead to more efficiency in the trauma bay and/or improved clinical outcomes? This intervention study used a pretraining/posttraining design. The intervention was TeamSTEPPS augmented by simulation. The evaluation instrument, which was the Trauma Team Performance Observation Tool (TPOT), was used by trained evaluators to assess teams' performance during trauma resuscitations. From November 2008 to February 2009, a convenience sample (n = 33) of trauma resuscitations was evaluated. From February to April 2009, team training was conducted. From May to July 2009, another sample (n = 40) of resuscitations were evaluated. Clinical data were gathered from our trauma registry. The clinical parameters included time from arrival to computed tomography (CT) scanner, arrival to intubation, arrival to operating room, arrival to Focused Assessment Sonography in Trauma (FAST) examination, time in emergency department (ED), hospital length of stay (LOS), intensive care unit LOS, complications, and mortality. Comparing pretraining and posttraining resuscitations, we calculated means, standard deviations, and p values for teamwork ratings and clinical parameters, and we determined significance using the independent samples t-test. Level I Trauma Center. The trauma team included surgery residents, faculty, and nurses. Our trauma team showed significant improvement in all teamwork domain ratings and overall ratings from pretraining to posttraining-leadership (2.87-3.46, p = 0.003), situation monitoring (3.30-3.91, p = 0.009), mutual support (3.40-3.96, p = 0.004), communication (2.90-3.46, p = 0.001), and overall (3.12-3.70, p < 0.001). The times from arrival to the CT scanner (26.4-22.1 minutes, p = 0.005), endotracheal intubation (10.1-6.6 minutes, p = 0.49) and the operating room (130.1-94.5 minutes, p = 0.021) were decreased
Dhabali, A A H; Awang, R; Zyoud, S H
Drug-drug interactions (DDIs) cause considerable morbidity and mortality worldwide and may lead to hospital admission. Sophisticated computerized drug information and monitoring systems, more recently established in many of the emerging economies, including Malaysia, are capturing useful information on prescribing. Our aim is to report on an investigation of potentially serious DDIs, using a university primary care-based system capturing prescription records from its primary care services. We retrospectively collected data from two academic years over 20 months from computerized databases at the Universiti Sains Malaysia (USM) from users of the USM primary care services. Three hundred and eighty-six DDI events were observed in a cohort of 208 exposed patients from a total of 23,733 patients, representing a 2-year period prevalence of 876·4 per 100,000 patients. Of the 208 exposed patients, 138 (66·3%) were exposed to one DDI event, 29 (13·9%) to two DDI events, 15 (7·2%) to three DDI events, 6 (2·9%) to four DDI events and 20 (9·6%) to more than five DDI events. Overall, an increasing mean number of episodes of DDIs was noted among exposed patients within the age category ≥70 years (P=0·01), an increasing trend in the number of medications prescribed (P<0·001) and an increasing trend in the number of long-term therapeutic groups (P<0·001). We describe the prevalence of clinically important DDIs in an emerging economy setting and identify the more common potentially serious DDIs. In line with the observations in developed economies, a higher number of episodes of DDIs were seen in patients aged ≥70 years and with more medications prescribed. The easiest method to reduce the frequency of DDIs is to reduce the number of medications prescribed. Therapeutic alternatives should be selected cautiously. © 2011 Blackwell Publishing Ltd.
Jonas, Stephan; Hannig, Andreas; Spreckelsen, Cord; Deserno, Thomas M.
Wearable technology defines a new class of smart devices that are accessories or clothing equipped with computational power and sensors, like Google Glass. In this work, we propose a novel concept for supporting everyday clinical pathways with wearable technology. In contrast to most prior work, we are not focusing on the omnipresent screen to display patient information or images, but are trying to maintain existing workflows. To achieve this, our system supports clinical staff as a documenting observer, only intervening adequately if problems are detected. Using the example of medication preparation and administration, a task known to be prone to errors, we demonstrate the full potential of the new devices. Patient and medication identifier are captured with the built-in camera, and the information is send to a transaction server. The server communicates with the hospital information system to obtain patient records and medication information. The system then analyses the new medication for possible side-effects and interactions with already administered drugs. The result is sent to the device while encapsulating all sensitive information respecting data security and privacy. The user only sees a traffic light style encoded feedback to avoid distraction. The server can reduce documentation efforts and reports in real-time on possible problems during medication preparation or administration. In conclusion, we designed a secure system around three basic principles with many applications in everyday clinical work: (i) interaction and distraction is kept as low as possible; (ii) no patient data is displayed; and (iii) device is pure observer, not part of the workflow. By reducing errors and documentation burden, our approach has the capability to boost clinical care.
Hoque, Dewan Md Emdadul; Kumari, Varuni; Hoque, Masuma; Ruseckaite, Rasa; Romero, Lorena; Evans, Sue M
Clinical quality registries (CQRs) are playing an increasingly important role in improving health outcomes and reducing health care costs. CQRs are established with the purpose of monitoring quality of care, providing feedback, benchmarking performance, describing pattern of treatment, reducing variation and as a tool for conducting research. To synthesise the impact of clinical quality registries (CQRs) as an 'intervention' on (I) mortality/survival; (II) measures of outcome that reflect a process or outcome of health care; (III) health care utilisation; and (IV) healthcare-related costs. The following electronic databases were searched: MEDLINE, EMBASE, CENTRAL, CINAHL and Google Scholar. In addition, a review of the grey literature and a reference check of citations and reference lists within articles was undertaken to identify relevant studies in English covering the period January 1980 to December 2016. The PRISMA-P methodology, checklist and standard search strategy using pre-defined inclusion and exclusion criteria and structured data extraction tools were used. Data on study design and methods, participant characteristics attributes of included registries and impact of the registry on outcome measures and/or processes of care were extracted. We identified 30102 abstracts from which 75 full text articles were assessed and finally 17 articles were selected for synthesis. Out of 17 studies, six focused on diabetes care, two on cardiac diseases, two on lung diseases and others on organ transplantations, rheumatoid arthritis, ulcer healing, surgical complications and kidney disease. The majority of studies were "before after" design (#11) followed by cohort design (#2), randomised controlled trial (#2), experimental non randomised study and one cross sectional comparison. The measures of impact of registries were multifarious and included change in processes of care, quality of care, treatment outcomes, adherence to guidelines and survival. Sixteen of 17 studies
Everett, Janine S.; Budescu, Mia; Sommers, Marilyn S.
The background of this article is that assessment and quantification of skin color is important to health care; color is one indicator of overall health and is linked to oxygenation, tissue perfusion, nutritional status, and injury. The purpose is to describe how skin color varies across racial/ethnic groups so that the information can be applied to clinical practice. The method used is cross-sectional, descriptive design (n = 257). We recorded self-defined race/ethnicity and used a spectrophotometer to measure skin color at two anatomic sites. Skin color variables included L* (light/dark), a* (red/green), and b* (yellow/blue). As regards results, we found significant differences in L*, a*, and b* values by site and race/ethnicity in White, Asian, and Biracial participants. L*: F(3, 233) = 139.04, p < .01 and F(3, 233) = 118.47, p < .01. Black participants had significantly lower mean L* values and wider ranges of L*, a*, and b* as compared with other groups. In regard to application, these findings suggest that clinicians and researchers should plan and provide care based on skin color, rather than race/ethnicity. PMID:22645403
Goebel, Joy R; Ahluwalia, Sangeeta C; Chong, Kelly; Shreve, Scott T; Goldzweig, Caroline L; Austin, Colletta; Asch, Steven M; Lorenz, Karl A
Increasing emphasis in performance-based payment, public reporting, and quality improvement (QI) has led to widespread interest in measuring and improving the quality of care. By 2014, hospice programs will be required to report quality data to the federal government or incur financial penalties. With this increased interest in quality reporting comes an opportunity to develop informatics tools to capture data that reflect the complex practices involved in palliative care (PC). Therefore, there is a need to disseminate information on developing tools that facilitate capturing data and fostering improved performance. The Veterans Health Care Administration, a national leader in health information technology (HIT) and PC, established the Quality Improvement Resource Center (QuIRC) to develop innovative HIT tools to standardize and improve PC practices throughout the 153 Department of Veterans Affairs (VA) medical centers nationwide. The aim of the paper is to describe the development of the Palliative Care-National Clinical Template (PC-NCT) for documenting initial PC consults. Domains of quality of life provided the foundation for this template. Principles of user-centered informatics design guided development activities. A national consensus panel of PC experts prioritized quality indicators as targets for QI. An interdisciplinary team of PC providers identified desired aspects of template functionality. QuIRC balanced PC providers' desired aspects of functionality against the feasibility within the VA HIT system. Formal pilot and usability testing contributed to numerous iterations of the PC-NCT currently piloted in five geographically distributed sites. This paper presents a robust approach to developing an informatics tool for PC practice. Data collected via the PC-NCT will bring variations in current practice into view and assist in directing resources at "important targets" for QI. Although the development of HIT tools to quantify PC practice is complex, there
The preferable route of iron delivery for most iron-deficient patients is oral. Parenteral iron therapy is used in patients who cannot tolerate oral iron or in cases in which oral iron is not sufficiently effective. The most frequent indications for parenteral iron therapy are unbearable gastrointestinal side effects induced by oral iron itself, worsening of inflammatory bowel disease symptoms, insufficient intestinal absorption, renal failure-caused anemia that is treated with erythropoietin, and unresolved ongoing bleeding, which would cause the acceptable oral doses of iron therapy to be exceeded. The serious adverse effects of iron dextran that was used in the past could explain the reluctance of medical personnel to prescribe this effective treatment. Patients with iron deficiency anemia were treated with intravenous iron in a primary care clinic. The iron gluconate was given in a dosage of 62.5 mg diluted in 150 mL of normal saline and was infused intravenously over 30 min, while iron sucrose was given in a dosage of 100 mg diluted in the same volume of normal saline and given at the same rate. In total, 724 infusions were administered to 57 patients. Iron sucrose was used in 628 infusions, and iron gluconate was used in the remaining 96. The frequency of the infusion treatments depended on the underlying disease and ranged from three times a week to once a month. Adverse effects were seldom observed and were minor in patients receiving iron gluconate, and were not registered at all in patients treated with iron sucrose. Two cases of flushing with paresthesias occurred. Slowing the infusion rate successfully eliminated these side effects. One case of hypotension was treated successfully with 500 cc of normal saline infusion. One case of dropout occurred, due to the patient's refusal to cooperate. No anaphylactic reactions were observed. Iron gluconate and iron sucrose are effective and safe for use in primary care clinics. The risk of adverse effects is low.
Sicat, Brigitte Luong; Huynh, Christine; Willett, Rita; Polich, Susan; Mayer, Sallie
Interprofessional education (IPE) can be hindered by the lack of infrastructure required to support it. We developed a clinical IPE experience for medical and pharmacy students built upon an existing infrastructure. We created tools to orient students to IPE and had students participate in pharmacist-led and physician-led IPE clinics. Results from the surveys indicated that after participating in the IPE experience, there were no significant changes in attitudes toward interprofessional teamwork or attitudes toward different members of the healthcare team. Students found less value in tools outlining roles and responsibilities of team members, on-line modules about the other profession, and IPE group discussion. They placed more value on the actual clinical experience. Themes derived from analysis of open-ended survey questions reflected the value that students placed on interprofessional interaction in the setting of direct patient care.
Song, Hummy; Ryan, Molly; Tendulkar, Shalini; Fisher, Josephine; Martin, Julia; Peters, Antoinette S; Frolkis, Joseph P; Rosenthal, Meredith B; Chien, Alyna T; Singer, Sara J
Team-based care is essential for delivering high-quality, comprehensive, and coordinated care. Despite considerable research about the effects of team-based care on patient outcomes, few studies have examined how team dynamics relate to provider outcomes. The aim of this study was to examine relationships among team dynamics, primary care provider (PCP) clinical work satisfaction, and patient care coordination between PCPs in 18 Harvard-affiliated primary care practices participating in Harvard's Academic Innovations Collaborative. First, we administered a cross-sectional survey to all 548 PCPs (267 attending clinicians, 281 resident physicians) working at participating practices; 65% responded. We assessed the relationship of team dynamics with PCPs' clinical work satisfaction and perception of patient care coordination between PCPs, respectively, and the potential mediating effect of patient care coordination on the relationship between team dynamics and work satisfaction. In addition, we embedded a qualitative evaluation within the quantitative evaluation to achieve a convergent mixed methods design to help us better understand our findings and illuminate relationships among key variables. Better team dynamics were positively associated with clinical work satisfaction and quality of patient care coordination between PCPs. Coordination partially mediated the relationship between team dynamics and satisfaction for attending clinicians, suggesting that higher satisfaction depends, in part, on better teamwork, yielding more coordinated patient care. We found no mediating effects for resident physicians. Qualitative results suggest that sources of satisfaction from positive team dynamics for PCPs may be most relevant to attending clinicians. Improving primary care team dynamics could improve clinical work satisfaction among PCPs and patient care coordination between PCPs. In addition to improving outcomes that directly concern health care providers, efforts to
Campbell, Stephen M; Sweeney, Grace M
This power considers the process of implementing clinical governance in primary care and its impact on quality improvement. It discuss how clinical governance is being implemented both at the level of Primary Care Organisations and general practices, and the challenges to implementing clinical governance. It also suggests a model for promoting the factors that will help clinical governance improve quality of care. The experience of implementing clinical governance is broadly positive to date. However, the government needs to match its commitment to a ten-year programme of change with realistic timetables to secure the cultural and organisational changes needed to improve quality of care. PMID:12389764
Chen, Alissa; Revere, Lee; Ramphul, Ryan
This article evaluates the spatial relationship between primary care provider clinics and walk-in clinics. Using ZIP code level data from Harris County, Texas, the results suggest that primary care physicians and walk-in clinics are similarly located at lower rates in geographic areas with populations of lower socioeconomic status. Although current clinic location choices effectively broaden the gap in primary care access for the lower income population, the growing number of newly insured individuals may make it increasingly attractive for walk-in clinics to locate in geographic areas with populations of lower socioeconomic status and less competition from primary care physicians.
Greer, Gillian A; Tamhane, Ashutosh; Malhotra, Rakhi; Burkholder, Greer A; Mugavero, Michael J; Raper, James L; Zinski, Anne
Following the release of the 2010 National HIV/AIDS Strategy for the United States, the Institute of Medicine (IOM) issued core clinical indicators for measuring health outcomes in HIV-positive persons. As early retention in HIV primary care is associated with improved long-term health outcomes, we employed IOM indicators as a guide to examine a cohort of persons initiating HIV outpatient medical care at a university-affiliated HIV clinic in the Southern United States (January 2007-July 2012). Using indicators for visit attendance, CD4 and viral load laboratory testing frequency, and antiretroviral therapy initiation, we evaluated factors associated with achieving IOM core indicators among care- and treatment-naïve patients during the first year of HIV care. Of 448 patients (mean age = 35 years, 35.7% white, 79.0% male, 58.4% education beyond high school, 35.9% monthly income > $1,000 US, 47.3% uninsured), 84.6% achieved at least four of five IOM indicators. In multivariable analyses, persons with monthly income > $1,000 (ORadj. = 3.71; 95% CI: 1.68-8.19; p = 0.001) and depressive symptoms (ORadj. = 2.13; 95% CI: 1.02-4.45; p = 0.04) were significantly more likely to achieve at least four of the five core indicators, while patients with anxiety symptoms were significantly less likely to achieve these indicators (ORadj. = 0.50; 95% CI: 0.26-0.97; p = 0.04). Age, sex, race, education, insurance status, transportation barriers, alcohol use, and HIV status disclosure to family were not associated with achieving core indicators. Evaluating and addressing financial barriers and anxiety symptoms during the first year of HIV outpatient care may improve individual health outcomes and subsequent achievement of the National HIV/AIDS Strategy.
Sivananthan, Saskia N; Puyat, Joseph H; McGrail, Kimberlyn M
To determine to what extent actual practice as reported in the literature is consistent with clinical guidelines for dementia care. A systematic review of empirical studies of clinical services provided by physicians to older adults with a diagnosis of dementia. All settings involving primary care physicians in which a diagnosis of dementia is provided. Physicians providing care to individuals aged 60 and older with a primary or secondary diagnosis of dementia. Seven dementia care processes recommended by guidelines: formal memory testing, imaging, laboratory testing, interventions, counseling, community service, and specialist referrals. Web of Knowledge, PubMed, Science Direct, MedLine, PsychINFO, EMBASE, and Google Scholar databases were searched for articles in English published before March 1, 2012. Twelve studies met the final inclusion criteria, all of which were self-reported cross-sectional surveys. There was broad variation in the proportion of physicians who reported conducting each dementia care process, with the widest variation in formal memory testing (4-96%). Recently published studies reflected a shift in scope of care, reporting that high proportions of physicians provided interventions, counseling, and referrals to specialist. Despite the availability and dissemination of established best practice guidelines, there is still wide variation in physician practice patterns in dementia care. The quality of currently available studies limits the ability to draw strong conclusions. Better information on practice patterns and their relationship to outcomes for individuals with dementia and their caregivers using more-robust study designs is needed to address the needs of the increasing number of individuals who will require dementia care. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
Tzeghai, Ghebre E; Ajayi, Funmilayo O; Miller, Kenneth W; Imbescheid, Frank; Sobel, Jack D; Farage, Miranda A
Feminine hygiene products and menstruation education have transformed the lives of women throughout the world. The P&G Feminine Care Clinical Innovation Research Program has played a key role by expanding scientific knowledge as well as developing technical insights and tools for the development of feminine hygiene products. The aim has been to meet the needs of women throughout their life stages, advancing their urogenital health beyond just menstruation, as well as helping to understand the role of sex hormones in various important health issues that women face. This review article highlights key contributions and research findings in female hygiene products, urogenital health research, and method development. The clinical research team focused on utilizing the results of clinical safety studies to advance the acceptance of feminine hygiene products world-wide. Key findings include that perception of skin sensitivity is not limited to the facial area, but is also relevant to the body and the genital area. Also, they shed light on the role of estrogen in autoimmune diseases as well as premenstrual syndrome. Efforts in the method development area focused on innovative tools that are reliable, predictive of clinical trial results and capable of measuring wear comfort, genital skin health, and the impact of product use on the consumer's quality of life. A novel method, behind-the-knee (BTK) test, developed to model irritation under normal wear conditions, was the first to account for both chemical and mechanical sources of irritation. The method has been accepted by the FDA as a substitute in clinical trials in some cases, and by American Society for Testing and Materials as a global standard test method. Additional proprietary methods were developed to enhance visual grading of irritation using cross-polarized light, to measure the amount of lotion transferred from sanitary pads, and to evaluate the skin mildness. Finally, the Farage Quality of Life tool was created
Coffey, C C; Campbell, D L; Myers, W R; Zhuang, Z; Das, S
Quantitative fit tests (QNFT) have been assumed to be predictive of the protection respirators would provide to a wearer in the workplace. Workplace studies have consistently found no correlation between quantitative fit factors and workplace protection factors. This article is the first in a series of three describing a study designed to compare the fit factors from six QNFT methods against the actual dose of 1,1,2 trichloro-1,2,2 trifluoroethane (Freon-113) received under the same laboratory conditions. Five preliminary studies conducted to develop the protocol to assess the respirator wearer's dose through end-exhaled air analysis are described in this article: (1) chamber characterization, (2) end-exhaled air sampling, (3) skin absorption testing, (4) pharmacokinetic modeling, and (5) subject characterization. It was established that the concentration of corn oil aerosol and Freon-113 could be generated simultaneously in the chamber. It was ascertained that the optimum time to sample the exhaled breath was 30 minutes after the subject exited the chamber. It was also found that in a chamber concentration of 500 ppm, without any respiratory exposure, Freon-113 was still present in the end-exhaled air. This was attributed to skin absorption. The end-exhaled air of subjects exposed to 0.5, 3, 5, 25, 50, and 100 ppm (30 minute time-weighted average) of Freon-113 was evaluated at 30 minutes postexposure. This characterization was then used to predict the actual dose of Freon-113 received during the method comparison and validation testing to be described in subsequent articles.
Turner, Philip J; Van den Bruel, Ann; Jones, Caroline H D; Plüddemann, Annette; Heneghan, Carl; Thompson, Matthew J; Price, Christopher P; Howick, Jeremy
Background. A number of point-of-care diagnostic tests are commercially available in the UK, however, not much is known regarding GPs’ desire for these tests or the clinical areas of interest. Objective. We sought to establish for which conditions point-of-care tests (POCTs) would be most helpful to UK GPs for diagnosis, reduction of referrals, and monitoring of chronic conditions. Methods. A total of 1635 regionally representative GPs were invited to complete an online cross-sectional survey between 31 September and 16 October 2012. Results. A total of 1109 (68%) GPs responded to the survey. The most frequently cited conditions were urinary tract infections for diagnosis (47% of respondents), pulmonary embolism/deep vein thrombosis for referral reduction (47%) and international normalized ratio/anticoagulation for monitoring (49%). Conclusions. This survey has identified the conditions for which UK GPs would find POCTs most helpful. Comments by respondents suggest that quite radical system-level adjustments will be required to allow primary care clinicians to capitalize on the potential benefits of POCTs. PMID:27048525
Rohrer, James E; Angstman, Kurt B; Garrison, Gregory M; Maxson, Julie A; Furst, Joseph W
The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied. Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers. Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics. Continuity of care should be monitored as retail medicine continues to expand.
Yehia, Baligh R; Agwu, Allison L; Schranz, Asher; Korthuis, P Todd; Gaur, Aditya H; Rutstein, Richard; Sharp, Victoria; Spector, Stephen A; Berry, Stephen A; Gebo, Kelly A
The patient-centered medical home (PCMH) has been introduced as a model for providing high-quality, comprehensive, patient-centered care that is both accessible and coordinated, and may provide a framework for optimizing the care of youth living with HIV (YLH). We surveyed six pediatric/adolescent HIV clinics caring for 578 patients (median age 19 years, 51% male, and 82% black) in July 2011 to assess conformity to the PCMH. Clinics completed a 50-item survey covering the six domains of the PCMH: (1) comprehensive care, (2) patient-centered care, (3) coordinated care, (4) accessible services, (5) quality and safety, and (6) health information technology. To determine conformity to the PCMH, a novel point-based scoring system was devised. Points were tabulated across clinics by domain to obtain an aggregate assessment of PCMH conformity. All six clinics responded. Overall, clinics attained a mean 75.8% [95% CI, 63.3-88.3%] on PCMH measures-scoring highest on patient-centered care (94.7%), coordinated care (83.3%), and quality and safety measures (76.7%), and lowest on health information technology (70.0%), accessible services (69.1%), and comprehensive care (61.1%). Clinics moderately conformed to the PCMH model. Areas for improvement include access to care, comprehensive care, and health information technology. Future studies are warranted to determine whether greater clinic PCMH conformity improves clinical outcomes and cost savings for YLH.
Doherty, Robert B; Crowley, Ryan A
The U.S. health care system is undergoing a shift from individual clinical practice toward team-based care. This move toward team-based care requires fresh thinking about clinical leadership and responsibilities to ensure that the unique skills of each clinician are used to provide the best care for the patient as the patient's needs dictate, while the team as a whole must work together to ensure that all aspects of a patient's care are coordinated for the benefit of the patient. In this position paper, the American College of Physicians offers principles, definitions, and examples to dissolve barriers that prevent movement toward dynamic clinical care teams. These principles offer a framework for an evolving, updated approach to health care delivery, providing policy guidance that can be useful to clinical teams in organizing the care processes and clinician responsibilities consistent with professionalism.
Montessori, V; Scharf, S; Holland, S; Werker, D H; Roberts, F J; Bryce, E
An outbreak of epidemic keratoconjunctivitis (EKC) occurred at a tertiary referral eye care clinic between late September and mid-November 1995. Before the outbreak, instruments were cleaned with 70% isopropyl alcohol and handwashing between patients was not routine. Infection control measures were implemented when the outbreak was recognized in mid-October. Control measures included triaging suspected cases to a separate waiting area, cohorting cases to a specific examining room, endorsing the use of gloves and handwashing during examinations of patients, and cleaning instruments with a buffered bleach solution. Thirty-six cases were diagnosed before the infection control measures were taken, and 3 cases were seen after the control measures were taken. Also, numerous secondary cases occurred in the community. No additional cases were diagnosed from DEcember to February 25, 1996. Acquisition of the infection was linked to visits to 4 of 20 physicians in the eye clinic with 61% of cases associated with visits to 1 of those 4 physicians. The use of diagnostic lenses applied directly to the eye was associated with infection (odds ratio = 2.83, 95% confidence interval = 0.79 to 10.4), although this did not reach statistical significance. The use of tonometers, ophthalmic solutions, or laser therapy was not associated with infection, and all environmental cultures were negative. This outbreak emphasizes the need for implementation of routine infection control guidelines to prevent nosocomial transmission of epidemic keratoconjunctivitis and stresses the need for appropriate disinfection of instruments.
Levy, Linda S.; Sexton, Patrick; Willeford, K. Sean; Barnum, Mary G.; Guyer, M. Susan; Gardner, Greg; Fincher, A. Louise
The purpose of this literature review is to compare both clinical instructor and student perceptions of helpful and hindering clinical instructor characteristics, behaviors and skills in athletic training and allied health care settings. Clinical education in athletic training is similar to that of other allied health care professions. Clinical…
Thrun, Mark; Cook, Paul F.; Bradley-Springer, Lucy A.; Gardner, Lytt; Marks, Gary; Wright, Julie; Wilson, Tracey E.; Quinlivan, E. Byrd; O'Daniels, Christine; Raffanti, Stephen; Thompson, Melanie; Golin, Carol
The Centers for Disease Control and Prevention have recommended that HIV care clinics incorporate prevention into clinical practice. This report summarizes HIV care providers' attitudes and counseling practices before and after they received training to deliver a counseling intervention to patients. Providers at seven HIV clinics received training…
Levy, Linda S.; Sexton, Patrick; Willeford, K. Sean; Barnum, Mary G.; Guyer, M. Susan; Gardner, Greg; Fincher, A. Louise
The purpose of this literature review is to compare both clinical instructor and student perceptions of helpful and hindering clinical instructor characteristics, behaviors and skills in athletic training and allied health care settings. Clinical education in athletic training is similar to that of other allied health care professions. Clinical…
Summary Objectives To summarize excellent current research in the field of Bioinformatics and Translational Informatics with application in the health domain and clinical care. Method We provide a synopsis of the articles selected for the IMIA Yearbook 2015, from which we attempt to derive a synthetic overview of current and future activities in the field. As last year, a first step of selection was performed by querying MEDLINE with a list of MeSH descriptors completed by a list of terms adapted to the section. Each section editor has evaluated separately the set of 1,594 articles and the evaluation results were merged for retaining 15 articles for peer-review. Results The selection and evaluation process of this Yearbook’s section on Bioinformatics and Translational Informatics yielded four excellent articles regarding data management and genome medicine that are mainly tool-based papers. In the first article, the authors present PPISURV a tool for uncovering the role of specific genes in cancer survival outcome. The second article describes the classifier PredictSNP which combines six performing tools for predicting disease-related mutations. In the third article, by presenting a high-coverage map of the human proteome using high resolution mass spectrometry, the authors highlight the need for using mass spectrometry to complement genome annotation. The fourth article is also related to patient survival and decision support. The authors present datamining methods of large-scale datasets of past transplants. The objective is to identify chances of survival. Conclusions The current research activities still attest the continuous convergence of Bioinformatics and Medical Informatics, with a focus this year on dedicated tools and methods to advance clinical care. Indeed, there is a need for powerful tools for managing and interpreting complex, large-scale genomic and biological datasets, but also a need for user-friendly tools developed for the clinicians in their
Wessinger, Matthew H; Hennink, Monique M; Kaiser, Bonnie N; Mangal, Jed P; Gokhale, Runa H; Ruchin, Lauren; Moanna, Abeer; Rimland, David; Farber, Eugene W; Marconi, Vincent C
Institutional barriers in HIV primary care settings can contribute substantially to disparities in retention in HIV treatment and HIV-related outcomes. This qualitative study compared the perceptions of clinic experiences of persons living with HIV (PLWH) in a Veterans Affairs HIV primary care clinic setting who were retained in care with the experiences of those who were not retained in care. Qualitative data from 25 in-depth interviews were analyzed to identify facilitators and barriers to retention in HIV care. Results showed that participants not retained in care experienced barriers to retention involving dissatisfaction with clinic wait times, low confidence in clinicians, and customer service concerns. For participants retained in care, patience with procedural issues, confidence in clinicians, and interpersonal connections were factors that enhanced retention despite the fact that these participants recognized the same barriers as those who were not retained in care. These findings can inform interventions aimed at improving retention in HIV care.
Warren, Charlotte E; Ndwiga, Charity; Sripad, Pooja; Medich, Melissa; Njeru, Anne; Maranga, Alice; Odhiambo, George; Abuya, Timothy
Despite years of growing concern about poor provider attitudes and women experiencing mistreatment during facility based childbirth, there are limited interventions that specifically focus on addressing these issues. The Heshima project is an evidence-based participatory implementation research study conducted in 13 facilities in Kenya. It engaged a range of community, facility, and policy stakeholders to address the causes of mistreatment during childbirth and promote respectful maternity care. We used the consolidated framework for implementation research (CFIR) as an analytical lens to describe a complex, multifaceted set of interventions through a reflexive and iterative process for triangulating qualitative data. Data from a broad range of project documents, reports, and interviews were collected at different time points during the implementation of Heshima. Assessment of in-depth interview data used NVivo (Version 10) and Atlas.ti software to inductively derive codes for themes at baseline, supplemental, and endline. Our purpose was to generate categories of themes for analysis found across the intervention design and implementation stages. The implementation process, intervention characteristics, individual champions, and inner and outer settings influenced both Heshima's successes and challenges at policy, facility, and community levels. Implementation success stemmed from readiness for change at multiple levels, constant communication between stakeholders, and perceived importance to communities. The relative advantage and adequacy of implementation of the Respectful Maternity Care (RMC) resource package was meaningful within Kenyan politics and health policy, given the timing and national promise to improve the quality of maternity care. We found the CFIR lens a promising and flexible one for understanding the complex interventions. Despite the relatively nascent stage of RMC implementation research, we feel this study is an important start to
Schiefer, J.L.; Alischahi, A.; Perbix, W.; Grigutsch, D.; Graeff, I.; Zinser, M.; Demir, E.; Fuchs, P.C.; Schulz, A.
Summary Severe burn injuries often require specialized treatment at a burn center. It is known that prompt admission to an intensive care unit is essential for achieving good outcome. Nevertheless, very little is known about the duration of time before a patient is admitted to a specialized center after a burn injury in Germany, and whether the situation has improved over time. We retrospectively analyzed time from burn injury to admission to the burn intensive care unit in the Cologne-Merheim Medical Center - one of Germany’s specialized burn centers - over the last 25 years. Moreover, we analyzed the data based on differences according to time of injury and day of the week, as well as severity of the burn injury. There was no weekend effect with regard to transfer time; instead transfer time was particularly short on a Monday or on Sundays. Furthermore, patients with severe burn injuries of 40-89% total body surface area (TBSA) showed the least differences in transfer time. Interestingly, the youngest and the oldest patients arrived at the burn intensive care unit (BICU) the fastest. This study should help elucidate published knowledge regarding transfer time from the scene of the accident to admission to a BICU in Germany. PMID:27857646
Schiefer, J L; Alischahi, A; Perbix, W; Grigutsch, D; Graeff, I; Zinser, M; Demir, E; Fuchs, P C; Schulz, A
Severe burn injuries often require specialized treatment at a burn center. It is known that prompt admission to an intensive care unit is essential for achieving good outcome. Nevertheless, very little is known about the duration of time before a patient is admitted to a specialized center after a burn injury in Germany, and whether the situation has improved over time. We retrospectively analyzed time from burn injury to admission to the burn intensive care unit in the Cologne-Merheim Medical Center - one of Germany's specialized burn centers - over the last 25 years. Moreover, we analyzed the data based on differences according to time of injury and day of the week, as well as severity of the burn injury. There was no weekend effect with regard to transfer time; instead transfer time was particularly short on a Monday or on Sundays. Furthermore, patients with severe burn injuries of 40-89% total body surface area (TBSA) showed the least differences in transfer time. Interestingly, the youngest and the oldest patients arrived at the burn intensive care unit (BICU) the fastest. This study should help elucidate published knowledge regarding transfer time from the scene of the accident to admission to a BICU in Germany.
Parsell, Bradley W.; Leichliter, Jami S.; Habel, Melissa A.; Tao, Guoyu; Pearson, William S.; Gift, Thomas L.
Objectives. We assessed the characteristics of sexually transmitted disease (STD) clinic patients, their reasons for seeking health services in STD clinics, and their access to health care in other venues. Methods. In 2013, we surveyed persons who used publicly funded STD clinics in 21 US cities with the highest STD morbidity. Results. Of the 4364 STD clinic patients we surveyed, 58.5% were younger than 30 years, 72.5% were non-White, and 49.9% were uninsured. They visited the clinic for STD symptoms (18.9%), STD screening (33.8%), and HIV testing (13.6%). Patients chose STD clinics because of walk-in, same-day appointments (49.5%), low cost (23.9%), and expert care (8.3%). Among STD clinic patients, 60.4% had access to another type of venue for sick care, and 58.5% had access to another type of venue for preventive care. Most insured patients (51.6%) were willing to use insurance to pay for care at the STD clinic. Conclusions. Despite access to other health care settings, patients chose STD clinics for sexual health care because of convenient, low-cost, and expert care. Policy Implication. STD clinics play an important role in STD prevention by offering walk-in care to uninsured patients. PMID:26447908
Gross, Karin; Armstrong Schellenberg, Joanna; Kessy, Flora; Pfeiffer, Constanze; Obrist, Brigit
The potential of antenatal care for reducing maternal morbidity and improving newborn survival and health is widely acknowledged. Yet there are worrying gaps in knowledge of the quality of antenatal care provided in Tanzania. In particular, determinants of health workers' performance have not yet been fully understood. This paper uses ethnographic methods to document health workers' antenatal care practices with reference to the national Focused Antenatal Care guidelines and identifies factors influencing health workers' performance. Potential implications for improving antenatal care provision in Tanzania are discussed. Combining different qualitative techniques, we studied health workers' antenatal care practices in four public antenatal care clinics in the Kilombero Valley, south-eastern Tanzania. A total of 36 antenatal care consultations were observed and compared with the Focused Antenatal Care guidelines. Participant observation, informal discussions and in-depth interviews with the staff helped to identify and explain health workers' practices and contextual factors influencing antenatal care provision. The delivery of antenatal care services to pregnant women at the selected antenatal care clinics varied widely. Some services that are recommended by the Focused Antenatal Care guidelines were given to all women while other services were not delivered at all. Factors influencing health workers' practices were poor implementation of the Focused Antenatal Care guidelines, lack of trained staff and absenteeism, supply shortages and use of working tools that are not consistent with the Focused Antenatal Care guidelines. Health workers react to difficult working conditions by developing informal practices as coping strategies or "street-level bureaucracy". Efforts to improve antenatal care should address shortages of trained staff through expanding training opportunities, including health worker cadres with little pre-service training. Attention should be paid to
Briggs, Michelle; Closs, S José; Marczewski, Kath; Barratt, Joanne
Chronic pain is common and management hampered by lack of resources in primary and secondary care. Nurse- or pharmacist-led clinics have been shown to lead to improvements in care for patients with chronic pain. This study showed that a combined nurse/pharmacist-led clinic for managing chronic pain in primary care can lead to improvements in management of pain, reduction in use of secondary care resources and high rates of satisfaction.
Avila-Alvarez, Alejandro; Carbajal, Ricardo; Courtois, Emilie; Pertega-Diaz, Sonia; Anand, Kanwaljeet J S; Muñiz-Garcia, Javier
Clinical scales are currently the best method to assess pain in the neonate, given the impossibility of self-report in this age group. A study is designed with the aim of determining the current practices as regards the clinical assessment of pain in Spanish Neonatal Units and the factors associated with the use of clinical scales. A prospective longitudinal observational study was conducted. A total of 30 Units participated and 468 neonates were included. Only 13 Units (43.3%) had pain assessment protocols. Pain was evaluated with a scale in 78 neonates (16.7%, 95% CI; 13.1-20.1) and the mean number of pain assessments per patient and per day was 2.3 (Standard Deviation; 4.8), with a median of 0.75. Of the total number of 7,189 patient-days studied, there was at least one pain assessment in 654 (9.1%). No pain assessment was performed with a clinical scale on any patient in 20 (66.7%) Units. Among those that did, a wide variation was observed in the percentage of patients in whom pain was assessed, as well as in the scales used. The CRIES (C-Crying; R-Requires increased oxygen administration; I-Increased vital signs; E-Expression; S-Sleeplessness) scale was that used in most Units. In the multivariate analysis, only invasive mechanical ventilation was associated with receiving a pain assessment with a scale (OR 1.46, P=.042). The majority of neonates admitted into Intensive Care in Spain do not receive a pain assessment. Many units still do not routinely use clinical scales, and there is a wide variation between those that do use them. These results could serve as a basis for preparing national guidelines as regards pain in the neonate. Copyright © 2015 Asociación Española de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.
Bakken, Suzanne; Ruland, Cornelia M
Clinical informatics intervention research suffers from a lack of attention to external validity in study design, implementation, evaluation, and reporting. This hampers the ability of others to assess the fit of a clinical informatics intervention with demonstrated efficacy in one setting for implementation in their setting. The objective of this model formulation paper is to demonstrate the applicability of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework with proposed extensions to clinical informatics intervention research and describe the framework's role in facilitating the translation of evidence into practice and generation of evidence from practice. Both aspects are essential to reap the clinical and public health benefits of clinical informatics research. We expanded RE-AIM through the addition of assessment questions relevant to clinical informatics intervention research including those related to predisposing, enabling, and reinforcing factors and validated it with two case studies. The first case study supported the applicability of RE-AIM to inform real world implementation of a clinical informatics intervention with demonstrated efficacy in randomized controlled trials (RCTs)--the Choice (Creating better Health Outcomes by Improving Communication about Patients' Experiences) intervention. The second, an RCT of a personal digital assistant-based decision support system for guideline-based care, illustrated how RE-AIM can be used to inform the design of an efficacy RCT that captures essential contextual details typically lacking in RCT design and reporting. The case studies validate, through example, the applicability of RE-AIM to inform the design, implementation, evaluation, and reporting of clinical informatics intervention studies.
Sharp, Sandra; McAllister, Margaret; Broadbent, Marc
Person-centred care is a policy priority for health services seeking to assure the public they provide safe, high-quality care, in keeping with rising consumer expectations. However, study of person-centred care rarely includes acute-care patients' perspectives. In 2013, semi-structured interviews were held with 10 former patients of an Australian regional health service and examined via thematic analysis to understand patients' experiences of nursing care, interpret findings in the context of person-centred care principles and identify ways to enhance and support compassionate, person-centred care in everyday nursing practice. Clinically competent care, delivered compassionately through a positive nurse-patient relationship, resulted in personal, emotional or spiritual responses that were the catalyst for patient empowerment and participation in care, and a positive outlook toward recovery. Nurses wishing to implement person-centred care need to recognise the importance of prioritising human connection and compassion in conjunction with clinical competence.
Smith, Cardinale B; Phillips, Tanyanika; Smith, Thomas J
Palliative care alongside usual oncology care is now recommended by ASCO as the standard of care for any patient with advanced cancer on the basis of multiple randomized trials that show better results with concurrent care than with usual oncology care. Some benefits include better quality of life, better symptom management, reduced anxiety and depression, less caregiver distress, more accordance of care with the wishes of the patient, and less aggressive end-of-life care. Several studies show a survival advantage of several months, and many show considerable cost savings: better care at an affordable cost. However, there are not enough palliative care specialists available, so oncologists must practice exemplary primary palliative care. Protocols used in the clinical trials, similar to those designed for new chemotherapy agents, help oncologists use the TEAM approach of extra time, typically an hour a month spent with the palliative care team; education, especially about prognostic awareness and realistic options, which include formal setting of goals of care and discussion of advance directives; formal assessments for symptoms and for spiritual and psychosocial health; and management by an interdisciplinary team. These are all potentially accomplished by an oncology practice to replicate the services provided by concurrent palliative care.
Overholser, Linda S; Moss, Kerry M; Kilbourn, Kristin; Risendal, Betsy; Jones, Alison F; Greffe, Brian S; Garrington, Timothy; Leonardi-Warren, Kristin; Yamashita, Traci E; Kutner, Jean S
Describe the development and evolution of a primary-care-based, multidisciplinary clinic to support the ongoing care of adult survivors of childhood cancer. A consultative clinic for adult survivors of childhood cancer has been developed that is located in an adult, academic internal medicine setting and is based on a long-term follow-up clinic model available at Children's Hospital Colorado. The clinic opened in July 2008. One hundred thirty-five patients have been seen as of April 2014. Referrals and clinic capacity have gradually increased over time, and a template has been developed in the electronic medical record to help facilitate completion of individualized care plan letters. A primary care-based, multidisciplinary consultative clinic for adults with a history of childhood cancer survivor is feasible and actively engages adult primary care resources to provide risk-based care for long-term pediatric cancer survivors. This model of care planning can help support adult survivors of pediatric cancer and their primary care providers in non-academic, community settings as well. Copyright © 2015 Elsevier Inc. All rights reserved.
Wang, Margaret C; Ryan, Gery; McGlynn, Elizabeth A; Mehrotra, Ateev
Retail clinics are an increasingly popular new model of ambulatory care. To understand why patients seek care at these clinics and what their experiences were like, we interviewed 61 patients at six retail clinics. Patients were satisfied with the overall experience and were attracted to retail clinics because of their convenient location and fixed, transparent pricing. Patients with a primary care provider (PCP) sought care at these clinics primarily because their PCPs were not available in a timely manner. If retail clinics were not available, a quarter of patients report they would have gone to the emergency department. Retail clinics appear to be responding to the need for convenient, affordable, and consumer-centered care. PMID:20142442
Sprague Martinez, Linda; Freeman, Elmer R; Winkfield, Karen M
Despite efforts to ameliorate disparities in cancer care and clinical trials, barriers persist. As part of a multiphase community-engaged assessment, an exploratory community-engaged research partnership, forged between an academic hospital and a community-based organization, set out to explore perceptions of cancer care and cancer clinical trials by black Bostonians. Key informant interviews with health care providers and patient advocates in community health centers (CHCs), organizers from grassroots coalitions focused on cancer, informed the development of a focus group protocol. Six focus groups were conducted with black residents in Boston, including groups of cancer survivors and family members. Transcripts were coded thematically and a code-based report was generated and analyzed by community and academic stakeholders. While some participants identified clinical trials as beneficial, overall perceptions conjured feelings of fear and exploitation. Participants describe barriers to clinical trial participation in the context of cancer care experiences, which included negative interactions with providers and mistrust. Primary care physicians (PCPs) reported being levied as a trusted resource for patients undergoing care, but lamented the absence of a mechanism by which to gain information about cancer care and clinical trials. Confusion about cancer care and clinical trials persists, even among individuals who have undergone treatment for cancer. Greater coordination between PCPs and CHC care teams and oncology care teams may improve patient experiences with cancer care, while also serving as a mechanism to disseminate information about treatment options and clinical trials. Inequities in cancer care and clinical trial participation persist. The findings of this study indicate that greater coordination with primary care physicians (PCPs) and community health center (CHC) providers may be an important step for both improving the quality of cancer care in
Murira, N; Munjanja, S P; Zhanda, I; Lindmark, G; Nystrom, L
The aim of this study was to evaluate how health education is currently practiced in the antenatal clinics in Harare and to make recommendations for its improvement. This was a descriptive study in which data was collected through subject interviews and by observations of antenatal clinics in progress. Antenatal sessions at primary care clinics in Harare. 100 pregnant women and 65 midwives. The timing, frequency and methods used in health education and the attitude of the pregnant mothers and staff to health education. The results revealed that health education was given once in pregnancy, on the first visit only. The lecture was the most used teaching method. The lecture was full of distractions which affected the concentration of the audience. Midwives decided on the subject matter for health education without consultation with the expectant women. As a result many women could not follow the practical advice given to them. Midwives overestimated their use of other methods of health education. Both the staff and the pregnant women agreed that there should be greater use of written material for women to read at home with their spouses. The lecture is not the most appropriate method of health education during pregnancy and greater use should be made of other methods of communication such as the mass media and pamphlets.
... HUMAN SERVICES Indian Health Service Office of Clinical and Preventive Services; Elder Care Initiative Long-Term Care Grant Program Announcement Type: New. Funding Announcement Number: HHS-2010-IHS-EHC-0001... Service (IHS) announces the availability of up to $600,000 for competitive grants through the Elder...
Cancer Pharmacogenomics: Integrating Discoveries in Basic, Clinical and Population Sciences to Advance Predictive Cancer Care, a 2010 workshop sponsored by the Epidemiology and Genomics Research Program.
Roney, Linda; Sumpio, Catherine; Beauvais, Audrey M; O'Shea, Eileen R
A major safety initiative in acute care settings across the United States has been to transform hospitals into High Reliability Organizations. The initiative requires developing cognitive awareness, best practices, and infrastructure so that all healthcare providers including clinical faculty are accountable to deliver quality and safe care. To describe the experience of baccalaureate clinical nursing faculty concerning safety and near miss events, in acute care hospital settings. A mixed method approach was used to conduct the pilot study. Nurse faculty (n=18) completed study surveys from the Agency for Healthcare Research and Quality (AHRQ) to track patient safety concerns: Incidents; Near misses; or Unsafe conditions, during one academic semester, within 9 different acute care hospitals. Additionally, seven nurse faculty participated in end of the semester focus groups to discuss the semester long experience. Clinical faculty identified a total of 24 patient occurrences: 15 Incidents, 1 Near miss event, and 8 Unsafe conditions. Focus group participants (n=7) described benefits and challenges experienced by nursing clinical faculty and students in relation to the culture of safety in acute care hospital settings. Six themes resulted from the content analysis. Utilizing nursing clinical faculty and students may add significant value to promoting patient safety and the delivery of quality care, within acute care hospital settings. Copyright © 2016 Elsevier Ltd. All rights reserved.
Heilmann, Rachel M F; Campbell, Stephanie M; Kroner, Beverly A; Proksel, Jenel R; Billups, Sarah J; Witt, Daniel M; Helling, Dennis K
The impact of the declining number of primary care physicians is exacerbated by a growing elderly population in need of chronic disease management. Primary care clinical pharmacy specialists, with their unique knowledge and skill set, are well suited to address this gap. At Kaiser Permanente of Colorado (KPCO), primary care clinical pharmacy specialists have a long history of integration with medical practices and are located in close proximity to physicians, nurses, and other members of the health care team. Since 1992, Primary Care Clinical Pharmacy Services (PCCPS) has expanded from 4 to 30 full-time equivalents (FTEs) to provide services in all KPCO medical office buildings. With this growth in size, PCCPS has evolved to play a vital role in working with primary care medical teams to ensure that drug therapy is effective, safe, and affordable. In addition, PCCPS specialists provide ambulatory teaching sites for pharmacy students and pharmacy residents. There is approximately 1 specialist FTE for every 13,000 adult KPCO members and every 9 clinical FTEs of internal medicine and family medicine physicians. All clinical pharmacy specialists in the pharmacy department are required to have a PharmD degree, to complete postgraduate year 2 residencies, and, as a condition of employment, to become board certified in an applicable specialty. The evolution, current structure, and role of PCCPS at KPCO, including factors facilitating successful integration within the medical team, are highlighted. Patient and nonpatient care responsibilities are described.
Wainwright, Mark S; Grimason, Michele; Goldstein, Joshua; Smith, Craig M; Amlie-Lefond, Catherine; Revivo, Gadi; Noah, Zehava L; Harris, Zena L; Epstein, Leon G
We describe our 10-year experience developing the Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program at Northwestern University Feinberg School of Medicine. The neurocritical care team includes intensivists, neurologists, and an advanced practice nurse who have expertise in critical care neurology and who continue care in long-term follow-up of intensive care unit patients in a dedicated neurocritical care outpatient clinic. Brain-directed critical care requires collaboration between intensivists and neurologists with specific expertise in neurocritical care, using protocol-directed consistent care, and physiological measures to protect brain function. The heterogeneity of neurologic disorders in the pediatric intensive care unit requires a background in the relevant basic science and pathophysiology that is beyond the scope of standard neurology or critical care fellowships. To address this need, we also created a fellowship in neurocritical care for intensivists, neurologists, and advanced practice nurses. Last, we discuss the implications for pediatric neurocritical care from the experience of management of pediatric stroke and the development of stroke centers.
[Creating a good relationship between hospital and clinic for the support of end-of-life home care patients-usefulness of questionnaires to indicate the capacity of home care-supporting clinics for palliative care].
Takahashi, Osamu; Kato, Toshihiko; Shimizu, Kazuko; Chiba, Yasuko; Ishiguro, Motoko; Iwadare, Midori
We have been practicing palliative care for terminal cancer patients at outpatient sections, patient wards, by home care, and by visiting nursing stations for the last 4 years. After the establishment of our palliative care unit in June 2011, it became difficult for us to provide sufficient home care support by ourselves, because of the increasing number of the patients and their widespread locations. It is therefore necessary to cooperate with regional medical clinics in order to support the patients who need home care even after their condition deteriorates. To determine the extent to which the home care-supporting clinics perform palliative care, we used an original questionnaire. Twenty-five clinics agreed to the publication of their names as our cooperating clinics. The number of patients who received palliative care at home from home care clinics after visiting our hospital increased from 8% to 14%, and the rate of patients who died at home also increased from 10% to 13%. Information about cooperating with home care clinics is very important and the improvement of palliative care skills necessary for home care doctors to continue their support for End-Of-Life cancer patients. Furthermore, the hospital should offer a strict and timely backup when the condition of patients treated at home suddenly deteriorates.
Mncube-Barnes, Fatima M.; Lee, Ben; Esuruoso, Olumuyiwa; Gona, Phil N.; Daphnis, Stephane
Objectives Using library subscriptions and accessible on handheld devices, this study sought to promote authoritative health information apps, and evidence-based point-of-care resources. Methods Three cohorts of internal medicine residents were issued iPads at the beginning of their second year, and were trained to skillfully access resources from the digital library. Pre- and post-intervention surveys were respectively administered at the beginning of the second year and end of the third year of training. The residents' computer experience and computer knowledge was assessed. Additionally, before and after formal introduction to iPads, perceptions on the use of computers to access clinical information were assessed. Survey responses were compared using two sample methods and summarized through descriptive statistics. Results Sixty-eight residents completed the pre-survey questionnaires and 45 completed the post-surveys. There were significant improvements in the residents' level of computer experience, and familiarity with medical apps. Furthermore, there was increased knowledge obtained in accessing clinical information through electronic medical records. Residents positively perceived the potential effects of computers and electronic medical records in medicine. Conclusion Study findings suggested that health science libraries can be instrumental in providing search skills to health professionals, especially residents in training. Participants showed appreciation of iPads and library support that facilitated successful completion of their related tasks. Replicating this study with a larger sample derived from multiple sites is recommended for future studies. Participation of mid-level healthcare professionals, such as Physician Assistants and Nurse Practitioners is suggested. PMID:28210418
Hysong, Sylvia J; Best, Richard G; Pugh, Jacqueline A
Background The Department of Veterans Affairs (VA) mandated the system-wide implementation of clinical practice guidelines (CPGs) in the mid-1990s, arming all facilities with basic resources to facilitate implementation; despite this resource allocation, significant variability still exists across VA facilities in implementation success. Objective This study compares CPG implementation strategy patterns used by high and low performing primary care clinics in the VA. Research Design Descriptive, cross-sectional study of a purposeful sample of six Veterans Affairs Medical Centers (VAMCs) with high and low performance on six CPGs. Subjects One hundred and two employees (management, quality improvement, clinic personnel) involved with guideline implementation at each VAMC primary care clinic. Measures Participants reported specific strategies used by their facility to implement guidelines in 1-hour semi-structured interviews. Facilities were classified as high or low performers based on their guideline adherence scores calculated through independently conducted chart reviews. Findings High performing facilities (HPFs) (a) invested significantly in the implementation of the electronic medical record and locally adapting it to provider needs, (b) invested dedicated resources to guideline-related initiatives, and (c) exhibited a clear direction in their strategy choices. Low performing facilities exhibited (a) earlier stages of development for their electronic medical record, (b) reliance on preexisting resources for guideline implementation, with little local adaptation, and (c) no clear direction in their strategy choices. Conclusion A multifaceted, yet targeted, strategic approach to guideline implementation emphasizing dedicated resources and local adaptation may result in more successful implementation and higher guideline adherence than relying on standardized resources and taxing preexisting channels. PMID:17355583
Elliott, Malcolm; Page, Karen; Worrall-Carter, Linda
Many patients discharged from intensive care units (ICU) have complex care needs, placing them at risk of an adverse event in a ward environment. Currently, there is limited understanding of factors associated with these events in the post-intensive care population. A recent study explored intensive care liaison nurses' opinions on factors associated with these events; 25 factors were identified, highlighting the multifaceted nature of post-intensive care adverse events. This study aimed to clinically validate 25 factors intensive care liaison nurses believe are associated with post-intensive care adverse events, to determine the factors' relevance and importance to clinical practice. Prospective, clinical validation study. Data were prospectively collected on a convenience sample of 52 patients at 4 tertiary referral hospitals in an Australian capital city. All patients had experienced an adverse event after intensive care discharge. Each of the 25 factors contributed to adverse events in at least 6 patients. The factors associated with the most adverse events were those that related to the patient such as illness severity and co-morbidities. Clinical care and research should focus on modifiable factors in care processes to reduce the risk of future adverse events in post-intensive care patients. Many patients are at risk of post-ICU adverse events due to the contribution of non-modifiable factors. However, by focusing on modifiable factors in care processes, the risk of post-ICU adverse events may be reduced. © 2014 British Association of Critical Care Nurses.
Kwan, Lawrence; Ho, Cheryl J; Preston, Charles; Le, Viet
Traditional primary care models for medically vulnerable populations such as the homeless and injection-drug users do not deliver optimal and efficient medical care. We propose an integrated model for the delivery of primary care to a vulnerable population emphasizing open access, outreach, groups, and a team approach to care. Methods: We monitored the health care use patterns of a group of 408 injection-drug users during a five-year period at Puentes Clinic, an integrated primary care site within a larger county health care system, Santa Clara Valley Health and Hospital System of California. We specifically compared use patterns before and after the inception of this new primary care site. Results: Emergency Department and urgent care visit rates decreased from 3.8 visits in the 18 months prior to the clinic's opening to 0.8 visits in the first 18 months of the clinic's operation. Simultaneously, primary care visits increased from 2.8 visits per 18 months prior to the clinic's operation to a current use rate of 5.9 visits per 18 months. Conclusion: This changing health care use pattern after the implementation of an integrated primary care model suggests that a “medical home” for a vulnerable population can influence the way that populations interact with a larger health care system. PMID:21369506
Humayun, Ayesha; Fatima, Noor; Naqqash, Shahid; Hussain, Salwa; Rasheed, Almas; Imtiaz, Huma; Imam, Sardar Zakariya
Background The principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which doctors in Lahore adhere to these principles during outpatient consultations. Material & Method The study was conducted at medical out-patient departments (OPDs) of two tertiary care hospitals (one public and one private hospital) of Lahore, selected using multi-stage sampling. 93 patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was observed through client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made by our data collectors. Results Some degree of informed consent was obtained from only 9.7% patients in the public hospital and 47.8% in the private hospital. 81.4% of patients in the public hospital and 88.4% in the private hospital were accorded at least some degree of privacy. Complete informational confidentiality was maintained only in 10.8% and 35.5% of cases in public & private hospitals respectively. Informed consent and confidentiality were better practiced in the private compared to the public hospital (two-sample t-test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of our trained data collectors. Conclusion Observance of medical ethics is inadequate in hospitals of Lahore. Doctors should be imparted formal training in medical ethics and national legislation on medical ethics is needed. Patients should be made aware of their rights to medical ethics. PMID:18816413
The effect of communicating the genetic risk of cardiometabolic disorders on motivation and actual engagement in preventative lifestyle modification and clinical outcome: a systematic review and meta-analysis of randomised controlled trials.
Li, Sherly X; Ye, Zheng; Whelan, Kevin; Truby, Helen
Genetic risk prediction of chronic conditions including obesity, diabetes and CVD currently has limited predictive power but its potential to engage healthy behaviour change has been of immense research interest. We aimed to understand whether the latter is indeed true by conducting a systematic review and meta-analysis investigating whether genetic risk communication affects motivation and actual behaviour change towards preventative lifestyle modification. We included all randomised controlled trials (RCT) since 2003 investigating the impact of genetic risk communication on health behaviour to prevent cardiometabolic disease, without restrictions on age, duration of intervention or language. We conducted random-effects meta-analyses for perceived motivation for behaviour change and clinical changes (weight loss) and a narrative analysis for other outcomes. Within the thirteen studies reviewed, five were vignette studies (hypothetical RCT) and seven were clinical RCT. There was no consistent effect of genetic risk on actual motivation for weight loss, perceived motivation for dietary change (control v. genetic risk group standardised mean difference (smd) -0·15; 95 % CI -1·03, 0·73, P=0·74) or actual change in dietary behaviour. Similar results were observed for actual weight loss (control v. high genetic risk SMD 0·29 kg; 95 % CI -0·74, 1·31, P=0·58). This review found no clear or consistent evidence that genetic risk communication alone either raises motivation or translates into actual change in dietary intake or physical activity to reduce the risk of cardiometabolic disorders in adults. Of thirteen studies, eight were at high or unclear risk of bias. Additional larger-scale, high-quality clinical RCT are warranted.
O'Grady, Erin L; VanGraafeiland, Brigit
Care coordination has been identified as a gap in the nursing care of children and families who experience an encounter within the health care system. The educational preparation of the clinical nurse leader (CNL) enables the CNL to address many gaps found in health care. Current evidence suggests various gaps in care, as reported by patients, families, nurses, and other health care providers. Identified gaps in care include problems with communication, coordination, education, research, advocacy, psychological and social support, and the needs of siblings. The CNL may improve quality of care for children through efficient care coordination by acting as a liaison and advocate between the patient, family, and health care team to bridge gaps in the current practices of care.
Lyons, John S.; Epstein, Richard A.; Jordan, Neil
The current article proposes that further specification of the system of care concept is required. Based on the assertions that the system of care concept (a) refers to an ideal as opposed to an observable phenomenon, and (b) is engaged in offering transformational experiences, the authors propose that the system of care definition must be…
Lyons, John S.; Epstein, Richard A.; Jordan, Neil
The current article proposes that further specification of the system of care concept is required. Based on the assertions that the system of care concept (a) refers to an ideal as opposed to an observable phenomenon, and (b) is engaged in offering transformational experiences, the authors propose that the system of care definition must be…
Runciman, W; Merry, A
A "crisis" in health care is "the point in the course of a disease at which a decisive change occurs, leading either to recovery or to death". The daunting challenges faced by clinicians when confronted with a crisis are illustrated by a tragic case in which a teenage boy died after a minor surgical procedure. Crises are challenging for reasons which include: presentation with non-specific signs or symptoms, interaction of complex factors, progressive evolution, new situations, "revenge effects", inadequate assistance, and time constraints. In crises, clinicians often experience anxiety- and overload-induced performance degradation, tend to use "frequency gambling", run out of "rules" and have to work from first principles, and are prone to "confirmation bias". The effective management of crises requires formal training, usually simulator-based, and ideally in the inter-professional groups who will need to function as a team. "COVER ABCD–A SWIFT CHECK" is a precompiled algorithm which can be applied quickly and effectively to facilitate a systematic and effective response to the wide range of potentially lethal problems which may occur suddenly in anaesthesia. A set of 25 articles describing additional precompiled responses collated into a manual for the management of any crisis under anaesthesia has been published electronically as companion papers to this article. This approach to crisis management should be applied to other areas of clinical medicine as well as anaesthesia. PMID:15933309
Quint, Elisabeth H
Adolescents with special needs have unique reproductive health care needs related to their physical and cognitive issues. This review discusses some of the most common concerns that are encountered in clinical practice, as the clinician will partner with the adolescent and her family to guide her through the pubertal transition and to help navigate the risks and rights of reproduction. Families often seek anticipatory guidance before menarche on menstrual hygiene, abuse risk and sexuality and can be reassured that most teens with special needs do very well with menstruation. The clinician needs to evaluate the teenager's reproductive knowledge as well her risk for abuse and coercion and her ability to consent to sexual activity, if she requests contraception. Menstrual management is mostly based on the impact of the menstrual cycles on the teenager's life and activities. The adolescents may have a decreased ability to tolerate menses or pain, or experience changes in seizure pattern or altered mood. Hormonal treatment is often used to assist with menstrual hygiene, cyclical mood changes or dysmenorrhea. The goal of treatment can be complete amenorrhea, alleviate pain or regulate and decrease menstrual flow. The unique risks and benefits of hormonal treatment for this special population are highlighted.
Moreschi, Carlo; Broi, Ugo Da
Clinical Practice Guidelines are clinical tools addressed to medical and health professionals and are normally employed to improve quality and safety of diagnostic and therapeutical procedures but may sometimes limit the autonomy of medical and other health care professionals. The adherence to Clinical Practice Guidelines should not be an exclusive step to evaluate the liability and respect of standards of care in case of medico-legal investigations being each clinical case very specific. Medical liability and respect of standards of care should be evaluated with the support of Clinical Practice Guidelines and the extensive examination of all specific features, professional background and experience requested to treat each single patient.
Levenson, Steven A
There are intense efforts to improve the quality of long-term care. However, it is unclear whether these efforts are based on understanding root causes of the deficits in quality. This article focuses on processes of clinical problem solving and decision making as a means to enable safe, effective, efficient, and person-centered care that reflects key principles discussed in the initial article in this series. The care delivery process is the means for applying these principles to deliver care. The techniques used in clinical decision-making and problem-solving activities are not unique to health care. Whether or not it is recognized, clinical problem-solving and decision-making activities are occurring continually in all long-term care facilities. But only some staff and practitioners do them well. There is much talk about applying "evidence-based care" in all settings, including the nursing home. However, the term is widely misunderstood and only sometimes applied properly. True evidence-based care requires combining scientific evidence with sufficiently detailed evidence about the individual patient. This article applies the discussion to identify criteria for "expertise" in long-term care. We may identify characteristics of "experts" in long-term care, regardless of discipline, as well as factors that distinguish levels of expertise. Experts have the skill and judgment to apply knowledge effectively to individual patient situations. Based on these criteria, only some of the claims to expertise in caring for, advising about, or overseeing long-term care residents and patients are warranted.
Helfrich, Christian D; Dolan, Emily D; Fihn, Stephan D; Rodriguez, Hector P; Meredith, Lisa S; Rosland, Ann-Marie; Lempa, Michele; Wakefield, Bonnie J; Joos, Sandra; Lawler, Lauren H; Harvey, Henry B; Stark, Richard; Schectman, Gordon; Nelson, Karin M
Team-based care is central to the patient-centered medical home (PCMH), but most PCMH evaluations measure team structure exclusively. We assessed team-based care in terms of team structure, process and effectiveness, and the association with improvements in teams׳ abilities to deliver patient-centered care. We fielded a cross-sectional survey among 913 VA primary care clinics implementing a PCMH model in 2012. The dependent variable was clinic-level respondent-reported improvements in delivery of patient-centered care. Independent variables included three sets of measures: (1) team structure, (2) team process, and (3) team effectiveness. We adjusted for clinic workload and patient comorbidity. 4819 surveys were returned (25% estimated response rate). The highest ratings were for team structure (median of 89% of respondents being assigned to a teamlet, i.e., a PCP working with the same clinical associate, nurse care manager and clerk) and lowest for team process (median of 10% of respondents reporting the lowest level of stress/chaos). In multivariable regression, perceived improvements in patient-centered care were most strongly associated with participatory decision making (β=32, P<0.0001) and history of change in the clinic (β=18, P=0008) (both team processes). A stressful/chaotic clinic environment was associated with higher barriers to patient centered care (β=0.16-0.34, P=<0.0001), and lower improvements in patient-centered care (β=-0.19, P=0.001). Team process and effectiveness measures, often omitted from PCMH evaluations, had stronger associations with perceived improvements in patient-centered care than team structure measures. Team process and effectiveness measures may facilitate synthesis of evaluation findings and help identify positive outlier clinics. Published by Elsevier Inc.
Cutcliffe, John R; Travale, Rodger
The concept of "Green Care" can increasingly be found in mental health and addictions literature and some Psychiatric/Mental Health Nurses are practicing in facilities that base their approach on some or all of the underpinning theoretical elements of Green Care. However, Green Care is not yet widely considered to be part of mainstream psychiatry. Unearthing and articulating its theoretical underpinnings and clinical applications may further advance its legitimacy. Accordingly, this article identifies four principal theoretical elements of Green Care: Connectedness; Contact with Nature; Benefits of Exercise; and Occupation/Work as Therapeutic, each of which is explored and articulated by drawing on relevant literature.
Bhattacharyya, Neil; Kepnes, Lynn J
Objectives. Determine the influence of the acute otitis externa clinical practice guideline on clinical care. Study Design. Cross-sectional study with historical controls. Setting. Outpatient departments in the United States. Methods. Cases of acute otitis externa occurring in 2004-2005 (before guideline publication) and 2007-2008 (after guideline publication) were extracted from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey. Prescribing rates for ototopical medications, analgesic recommendations, and oral antibiotics were determined and compared before and after guideline publication and relative to guideline recommendations. Results. An estimated 5.50 (standard error of the estimated mean, 0.38) million visits (mean age, 27.7 [1.7] years; 49.8% male) with a primary and singular coded diagnosis of acute otitis externa were studied (2.64 [0.26] million visits for 2004-2005 and 2.86 [0.28] million visits for 2007-2008). Prescribing rates for ototopical preparations were 67.2% (5.3%) and 67.6% (5.0%) before and after guideline publication, respectively (P = .955). Recommendation rates for analgesics were 14.2% (3.3%) and 20.6% (3.9%), respectively (P = .248). Prescription rates for oral antibiotics were 21.7% (4.8%) and 30.5% (3.6%), before and after, respectively (P = .166). Conclusion. Clinician behavior in the medical treatment of acute otitis externa has not significantly changed after guideline publication, despite clear, evidence-based guideline recommendations. These data have important implications for performance measures based on the guideline. Further efforts toward guideline dissemination are likely needed.
Yang, Yih-Ming; Kim, Christopher H; Briones, Michael A; Hilinski, Joseph A; Greenwald, Michael
Effective clinical teaching is essential in physician education, yet faculty members rarely receive formal training in clinical teaching. Formal models for training clinical educators are often tedious and require significant time and effort. Instinctive clinical teaching allows clinicians to seamlessly integrate and promote effective teaching into their clinical practice. The approach is guided by similarities between the components of Kolb's experiential learning cycle-concrete experience, reflective observation, abstract conceptualization, and active experimentation-and the elements of the patient care process-history and physical, initial assessment, differential, hypothesis, final diagnosis, management, and follow-up. Externalization of these clinical thought processes allows for inclusion of learners and promotes effective clinical teaching.
Blake, Diane R; Spielberg, Freya; Levy, Vivian; Lensing, Shelly; Wolff, Peter A.; Venkatasubramanian, Lalitha; Acevedo, Nincoshka; Padian, Nancy; Chattopadhyay, Ishita; Gaydos, Charlotte A.
Background Results of a recent demonstration project evaluating feasibility, acceptability, and cost of a web-based STI testing and e-prescription treatment program (eSTI) suggest that this approach could be a feasible alternative to clinic based testing and treatment, but the results need to be confirmed by a randomized comparative effectiveness trial. Methods We modeled a decision tree comparing: 1) cost of eSTI screening using a home collection kit and an e-prescription for uncomplicated treatment versus 2) hypothetical costs derived from the literature for referral to standard clinic based STI screening and treatment. Primary outcome was number of STIs detected. Analyses were conducted from the clinical trial perspective and the healthcare system perspective. Results The eSTI strategy detected 75 infections, and the Clinic-referral strategy detected 45 infections. Total cost of eSTI was $94,938 ($1,266/STI detected) from the clinical trial perspective and $96,088 ($1,281/STI detected) from the healthcare system perspective. Total cost of clinic referral was $87,367 ($1,941/STI detected) from the clinical trial perspective and $71,668 ($1,593/STI detected) from the healthcare system perspective. Conclusions Results indicate that eSTI will likely be more cost-effective (lower cost/STI detected) than clinic based STI screening, both in the context of clinical trials and in routine clinical care. Although our results are promising, they are based on a demonstration project and estimates from other small studies. A comparative effectiveness research (CER) trial is needed to determine actual cost and impact of the eSTI system on identification and treatment of new infections and prevention of their sequelae. PMID:25504295
OBJECTIVES--To evaluate integrated care for asthma in clinical, social, and economic terms. DESIGN--Pragmatic randomised trial. SETTING--Hospital outpatient clinics and general practices throughout the north east of Scotland. PATIENTS--712 adults attending hospital outpatient clinics with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%. MAIN OUTCOME MEASURES--Use of bronchodilators and inhaled and oral steroids; number of general practice consultations and hospital admissions for asthma; sleep disturbance and other restrictions on normal activity; psychological aspects of health including perceived asthma control; patient satisfaction; and financial costs. RESULTS--After one year there were no significant overall differences between those patients receiving integrated asthma care and those receiving conventional outpatient care for any clinical or psychosocial outcome. For pulmonary function, forced expiratory volume was 76% of predicted for integrated care patients and 75% for conventional outpatients (95% confidence interval for difference -3.6% to 5.0%). Patients who had experienced integrated care were more likely to select it as their preferred course of future management (75% (251/333) v 62% (207/333) (6% to 20%)); they saved 39.52 pounds a year. This was largely because patients in conventional outpatient care consulted their general practitioner as many times as those in integrated care, who were not also visiting hospital. CONCLUSION--Integrated care for moderately severe asthma patients is clinically as effective as conventional outpatient care, cost effective, and an attractive management option for patients, general practitioners, and hospital consultants. PMID:8148678
DiPietro Mager, Natalie A
Preconception care refers to a set of interventions that identify and address biomedical, behavioral, and social risks to a woman's health that may negatively impact a future pregnancy. A great need for preconception care currently exists in the United States, and women's attitudes about discussions with health care providers about healthy and safe pregnancies are positive. Clinical pharmacists are well positioned to work with other health care and public health professionals to ensure that all women of childbearing potential have access to preconception care. As part of the collaborative health care team, clinical pharmacists can directly provide services or support and referrals to other members of the health care team or to community resources through clinical-community linkages. Specifically, clinical pharmacists can provide education, counseling, and/or services to women to address family planning, medication and disease state management, immunizations, screenings, health promotion, and substance use. Clinical pharmacists can also impact preconception care through drug information services, advocacy, and research. Preconception care services can be incorporated into daily pharmacy practice, and there are potential means for reimbursement. Multiple roles exist for clinical pharmacists to fulfill unmet needs in preconception care. © 2016 Pharmacotherapy Publications, Inc.
Penrod, Joan D; Pronovost, Peter J; Livote, Elayne E; Puntillo, Kathleen A; Walker, Amy S; Wallenstein, Sylvan; Mercado, Alice F; Swoboda, Sandra M; Ilaoa, Debra; Thompson, David A; Nelson, Judith E
High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality's National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance. Prospective, multisite, observational study of performance of key intensive care unit palliative care processes. A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital. Consecutive adult patients with length of intensive care unit stay ≥5 days. None. Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: Identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance. Across three intensive care units in this study, performance
Wang, Yong A; Chen, Cheng-Feng; Chen, Chen-Huan; Wang, Ging-Long; Huang, Andrew T
Traditionally, clinical clerkship training in Taiwan does not provide medical students with sufficient patient care responsibilities and often results in inadequate clinical skills. We implemented a pilot clerkship program at a comprehensive cancer center that emphasizes core clinical competency through direct patient care and dedicated faculty and mentors. Students were an integral part of the patient care team held accountable for providing coordinated and holistic care. Students' self-assessment of clinical competencies, faculty evaluation, and objective structured clinical examination were compared against their peers trained by traditional clerkship at a main teaching hospital. Fifty medical students completed the clerkship program in the first 3 years. At the end of the clerkship, participants rated themselves significantly higher than their peers in almost all patient care and clinical skill domains. The most significant areas included physical examination, clinical reasoning, developing management plan, holistic approach, handling ethical issues, and time management skills. The students rated their clerkship teachers significantly higher in time spent with students, skills and enthusiasm in teaching, as well as giving students appropriate patient care responsibilities. There was no significant difference in the end-of-clerkship objective structured clinical examination performance, but participants of the program achieved better grades in their subsequent internship. This pilot collaborative program presented a successful model for clinical education in the teaching of core clinical competencies through direct patient care responsibilities at the clerkship stage. It is hoped that the project will become a catalyst for medical education reform in Taiwan and regions with similar traditions. Copyright © 2015. Published by Elsevier B.V.
Weisz, John R.; Jensen-Doss, Amanda; Hawley, Kristin M.
In the debate over evidence-based treatments (EBTs) for youth, one question is central: Do EBTs produce better outcomes than the usual interventions employed in clinical care? The authors addressed this question through a meta-analysis of 32 randomized trials that directly compared EBTs with usual care. EBTs outperformed usual care. Effects fell…
Ell, Kathleen; Lee, Pey-Jiuan; Xie, Bin
Objective: Increasingly, mental health care is provided within the general health care sector. Accompanying this significant change is the demand for evidence-based as well as cost-effective or cost-neutral care models. Method: The authors present a pooled analysis of three large randomized clinical trials in which social workers provide…
Ell, Kathleen; Lee, Pey-Jiuan; Xie, Bin
Objective: Increasingly, mental health care is provided within the general health care sector. Accompanying this significant change is the demand for evidence-based as well as cost-effective or cost-neutral care models. Method: The authors present a pooled analysis of three large randomized clinical trials in which social workers provide…
Saito, Atsushi; Kikuchi, Momomi; Ueshima, Fumie; Matsumoto, Shinya; Hayakawa, Hiroki; Masuda, Hitomi; Makiishi, Takemi
Background Oral hygiene education is central to every stage of periodontal treatment. Successful management of periodontal disease depends on the patient's capacity for oral self-care. In the present study, the oral self-care and perceptions of patients attending a dental school clinic in Japan were assessed using a short questionnaire referring to existing oral health models. Methods A cross-sectional study design was used. The study population consisted of sixty-five patients (age range 23-77) with chronic periodontitis. The pre-tested 19-item questionnaire comprised 3 domains; 1) oral hygiene, 2) dietary habits and 3) perception of oral condition. The questionnaire was used as a part of the comprehensive assessment. Results Analyses of the assessment data revealed no major problems with the respondents' perceived oral hygiene habits, although their actual plaque control levels were not entirely adequate. Most of the respondents acknowledged the importance of prevention of dental caries and periodontal diseases, but less than one third of them were regular users of the dental care system. Twenty-five percent of the respondents were considered to be reluctant to change their daily routines, and 29% had doubts about the impact of their own actions on oral health. Analyzing the relationships between patient responses and oral hygiene status, factors like 'frequency of tooth brushing', 'approximal cleaning', 'dental check-up' and 'compliance with self-care advice' showed statistically significant associations (P < 0.05) with the plaque scores. Conclusion The clinical utilization of the present questionnaire facilitates the inclusion of multiple aspects of patient information, before initiation of periodontal treatment. The significant associations that were found between some of the self-care behaviors and oral hygiene levels document the important role of patient-centered oral health assessment in periodontal care. PMID:19874626
A team of palliative care clinical nurse specialists at the Phyllis Tuckwell Hospice in Farnham, Surrey, set up a hospice based outpatient clinic to improve services for patients with cancer. This article examines how the team used clinical audit, a staff questionnaire and patient feedback to evaluate the service and make recommendations for the future development of the clinic.
Young, David W
If a hospital is to use profit centers successfully, it should resolve several philosophical, organizational, and accounting matters, including: How much decisionmaking latitude clinical care chiefs should have. Whether to take a cross-subsidization approach. What role clinical care departments should take in a service line strategy.
Bergman, Jonathan; Ballon-Landa, Eric; Lorenz, Karl A; Saucedo, Josemanuel; Saigal, Christopher S; Bennett, Carol J; Litwin, Mark S
We partnered with patients, families, and palliative care clinicians to develop an integrated urology-palliative care clinic for patients with metastatic cancer. We assessed clinician satisfaction with a multidisciplinary palliative care clinic model. We conducted semi-structured interviews with 18 clinicians who practice in our integrated clinic. We analyzed transcripts using a multistage, cutting-and-sorting technique in an inductive approach based on grounded theory analysis. Finally, we administered a validated physician job satisfaction survey. Clinicians found that referring a patient to palliative care in the urology clinic was feasible and appropriate. Patients were receptive to supportive care, and clinicians perceived that quality of care improved following the intervention. An integrated, patient-centered model for individuals with advanced urologic malignancies is feasible and well received by practitioners. © The Author(s) 2014.
Mata-Cases, Manel; Benito-Badorrey, Belén; Roura-Olmeda, Pilar; Franch-Nadal, Josep; Pepió-Vilaubí, Josep Maria; Saez, Marc; Coll-de-Tuero, Gabriel
To assess clinical inertia, defined as failure to intensify antidiabetic treatment of patients who have not achieved the HbA1c therapeutic goal (≤7%). Multicenter cross-sectional study. Clinical inertia was assessed in a random sample of type 2 diabetes mellitus (T2DM) patients seen in primary care centers. A total of 2783 patients (51.3% males; mean age: 68 [±11.5] years; diabetes duration: 7.1 [±5.6] years; mean HbA1c: 6.8 [±1.5]) were analyzed. Of those, 997 (35.8%) had HbA1c >7%. Treatment was intensified in 66.8% and consisted of: dose increase (40.5%); addition of oral antidiabetic (45.8%); or insulin treatment initiation (3.7%). Mean HbA1c values in patients for whom treatment was intensified vs. non-intensified were 8.4% (±1.2) vs. 8.2% (±1.2), p < 0.05. Clinical inertia was detected in 33.2% of patients and diminished along with treatment complexity: lifestyle changes only (38.8%), oral monotherapy (40.3%), combined oral antidiabetics (34.5%), insulin monotherapy (26.1%) and combination of insulin and oral antidiabetics (21.4%). Clinical inertia decreased as HbA1c increased: 37.3% for HbA1c values ranging between 7.1%-8%; 29.4% for the 8.1%-9% HbA1c range and 27.1% for HbA1c ≥9%. Multivariate analysis confirmed that diabetes duration, step of treatment and HbA1c were related to inertia. For each unit of HbA1c increase clinical inertia decreased 47% (OR: 0.53). The retrospective design of the study precluded an accurate investigation about reasons for lack of intensification that could actually be justified by some patient conditions, especially patients' lack of adherence. Clinical inertia affected one third of T2DM patients with poor glycemic control and was greater in patients treated with only lifestyle changes or oral monotherapy. Treatment changes were performed when mean HbA1c values were 1.4 points above therapeutic goals.
Galvin, James E.; Duda, John E.; Kaufer, Daniel I.; Lippa, Carol F.; Taylor, Angela; Zarit, Steven H.
BACKGROUND Lewy body dementia (LBD) is the second most common cause of dementia, however, little is known about how the clinical diagnosis of LBD is obtained in the community or the caregiver experience while seeking the diagnosis. METHODS The Lewy Body Dementia Association (www.LBDA.org) conducted a web-based survey of 962 caregivers over a 6-month period. RESULTS The mean age of respondents was 55.9y; 88% were female and 64% had daily contact with patients. The mean age of LBD patients was 75.4y; 62% were male and 46% lived with a caregiver. The most common presentation of symptoms as reported by LBD caregivers was cognitive (48%), motor (39%) or both (13%). The first diagnoses given to the patients were Parkinson disease or other movement disorder (39%), Alzheimer disease or other cognitive disorder (36%), or mental illness (24%). Fifty percent of patients saw >3 doctors for more than 10 visits over the course of 1 year before an LBD diagnosis was established. Neurologists diagnosed most cases (62%), while primary care-providers diagnosed only 6% of cases. No differences were found between the presentation of disease and the number of physicians, number of office visits, length of time to establish diagnosis, or type of doctor who finally made an LBD diagnosis. Caregivers viewed physicians as knowledgeable about disease manifestations and treatment options, but not about disease course/prognosis and available community resources and referrals. CONCLUSIONS These data highlight a need for increasing physician awareness and knowledge of LBD, which will facilitate accurate diagnosis and treatment. Community resources such as the Lewy Body Dementia Association may serve this end, while also providing practical information and support for caregivers. PMID:20434939
Huslig, Mary Ann; Vardell, Emily
ClinicalKey 2.0, launched September 23, 2014, offers a mobile-friendly design with a search history feature for targeting point-of-care resources for health care professionals. Browsing is improved with searchable, filterable listings of sources highlighting new resources. ClinicalKey 2.0 improvements include more than 1,400 new Topic Pages for quick access to point-of-care content. A sample search details some of the upgrades and content options.
De Smet, Hendrik
Actualization is traditionally seen as the process following syntactic reanalysis whereby an item's new syntactic status manifests itself in new syntactic behavior. The process is gradual in that some new uses of the reanalyzed item appear earlier or more readily than others. This article accounts for the order in which new uses appear during…
Rundall, Thomas G; Wu, Frances M; Lewis, Valerie A; Schoenherr, Karen E; Shortell, Stephen M
The accountable care organization (ACO) is a new type of health care organization incentivized to improve quality of care, improve population health, and reduce the cost of care. An ACO's success in meeting these objectives depends greatly upon its ability to improve patient care management. Numerous studies have found relational coordination to be positively associated with key measures of organizational performance in health care organizations, including quality and efficiency. The purpose of this paper is twofold: (a) identify the extent to which ACO leaders are aware of the dimensions of relational coordination, and (b) identify the ways these leaders believe the dimensions influenced care management practices in their organization. We performed content analysis of interviews with managerial and clinical leaders from a diverse group of 11 ACOs to assess awareness of relational coordination and identify the ways that dimensions of relational coordination were perceived to influence development of care management practices. ACO leaders mentioned four relational coordination dimensions: shared goals, frequency of communication, timeliness of communication, and problem solving communication. Three dimensions - shared knowledge of team members' tasks, mutual respect, and accuracy of communication - were not mentioned. Our analysis identified numerous ways leaders believed the four mentioned dimensions contributed to the development of care management, including contributions to standardization of care, patient engagement, coordination of care, and care planning. We propose two hypotheses for future research on relational coordination and care management. If relational coordination is to have a beneficial influence on ACO performance, organizational leaders must become more aware of relational coordination and its various dimensions and become cognizant of relational coordination's influence on care management in their ACO. We suggest a number of means by which ACO
Pawa, Jasmine; Robson, John; Hull, Sally
Primary care practices are increasingly working in larger groups. In 2009, all 36 primary care practices in the London borough of Tower Hamlets were grouped geographically into eight managed practice networks to improve the quality of care they delivered. Quantitative evaluation has shown improved clinical outcomes. To provide insight into the process of network implementation, including the aims, facilitating factors, and barriers, from both the clinical and managerial perspectives. A qualitative study of network implementation in the London borough of Tower Hamlets, which serves a socially disadvantaged and ethnically diverse population. Nineteen semi-structured interviews were carried out with doctors, nurses, and managers, and were informed by existing literature on integrated care and GP networks. Interviews were recorded and transcribed, and thematic analysis used to analyse emerging themes. Interviewees agreed that networks improved clinical care and reduced variation in practice performance. Network implementation was facilitated by the balance struck between 'a given structure' and network autonomy to adopt local solutions. Improved use of data, including patient recall and peer performance indicators, were viewed as critical key factors. Targeted investment provided the necessary resources to achieve this. Barriers to implementing networks included differences in practice culture, a reluctance to share data, and increased workload. Commissioners and providers were positive about the implementation of GP networks as a way to improve the quality of clinical care in Tower Hamlets. The issues that arose may be of relevance to other areas implementing similar quality improvement programmes at scale. © British Journal of General Practice 2017.
Anton, Blair; Woodson, Sue M.; Twose, Claire; Roderer, Nancy K.
How do clinical questions emerge and move toward resolution in the intensive care setting over the course of 24 hours? In a 20-bed surgical intensive care unit in a large, tertiary-care teaching hospital, informationists shadowed clinicians for 2 48-hour periods to record questions, noting when they were asked and whether they were answered. Thirty-eight percent of 112 recorded questions remained unanswered. Some unanswered questions persisted across shifts, and clinicians' information-seeking behaviors changed over time. Clinical information services can be improved and integrated more fully into clinical workflows based on a fuller understanding of the life cycle of clinical inquiry. PMID:25031562
Kendrick, Sabrina R; Kroc, Karen A; Couture, Eileen; Weinstein, Robert A
Rapid HIV testing with same-visit results should increase the number of individuals who know they are HIV infected. We assessed the acceptability and feasibility of point-of-care rapid testing in three public venues, a sexually transmitted disease clinic, a county jail, and an emergency department. Over 98% of all participants received their results, and 82% of newly identified HIV-positive participants entered care. Point-of-care rapid testing was feasible, acceptable, and may improve entry into care.
Dementiyva, I I; Morozov, Yu A; Tcharnaya, M A; Gontcharova, A V
The article considers the issues of implementation of the point-of-care technology (diagnostic testing at treatment place) in modern clinic of emergency states. The economic practicability and advantages of point-of-care tests as compared with analyses in central laboratory is considered. The data concerning the characteristics of quality control under point-of-care are presented. Separately, the application of basic laboratory analyses using point-of-care technologies in case of emergency states is examined
Shaw, Jenny; Appleby, Louis; Amos, Tim; McDonnell, Ros; Harris, Catherine; McCann, Kerry; Kiernan, Katy; Davies, Sue; Bickley, Harriet; Parsons, Rebecca
Objectives To estimate the rate of mental disorder in those convicted of homicide and to examine the social and clinical characteristics of those with a history of contact with psychiatric services. Design National clinical survey. Setting England and Wales. Subjects Eighteen month sample of people convicted of homicide. Main outcome measures Offence related and clinical information collected from psychiatric court reports on people convicted of homicide. Detailed clinical data collected on those with a history of contact with psychiatric services. Results 718 homicides were reported to the inquiry between April 1996 and November 1997. Of the 500 cases for whom psychiatric reports were retrieved, 220 (44%; 95% confidence interval 40% to 48%) had a lifetime history of mental disorder, while 71 (14%; 11% to 17%) had symptoms of mental illness at the time of the homicide. Of the total sample, 102 (14%; 12% to 17%) were confirmed to have been in contact with mental health services at some time, 58 (8%; 6% to 10%) in the year before the homicide. The commonest diagnosis was personality disorder (20 cases, 22%; 13% to 30%). Alcohol and drug misuse were also common. Only 15 subjects (18%; 10% to 26%) were receiving intensive community care, and 60 (63%; 53% to 73%) were out of contact at the time of the homicide. Conclusions There are substantial rates of mental disorder in people convicted of homicide. Most do not have severe mental illness or a history of contact with mental health services. Inquiry findings suggest that preventing loss of contact with services and improving the clinical management of patients with both mental illness and substance misuse may reduce risk, but clinical trials are needed to examine the effectiveness of such interventions. Key messagesPeople convicted of homicide have substantial rates of mental disorderMost do not have severe mental illness or a history of contact with mental health servicesMental health services need to prevent loss of
While more and more psychologists criticize managed care companies, most must depend upon them in order to maintain their practices. In this study, psychologists were surveyed and asked to identify activities in their own independent practice that fall outside of the purview of managed care. A total of 180 specific activities were identified that…
Lohr, K N
Practice guidelines can make considerable contributions to several areas of health care delivery. Perhaps their greatest promise lies in the area of assessing and improving the quality of health care and health outcomes; secondarily, they may help to rationalize the overall use of health services and thus be a partial means to controlling the use of services and costs of care. Work at the Institute of Medicine of the National Academy of Sciences in the United States has (a) suggested eight characteristics of good guidelines; (b) building on those, pointed the way to methods for developing and assessing guidelines; and (c) shown how sound and realistic guidelines can contribute to better ways to measure and improve the quality of primary medical care. This paper discusses four questions: (1) what are guidelines, and how might they relate to or be of benefit to primary care and family medicine? (2) What criteria or principles should be used to create good practice guidelines? (3) What problems or pitfalls need to be anticipated in developing and disseminating guidelines? (4) In what ways can guidelines help improve the quality of health care, especially through quality assurance and improvement and utilization and cost management? Practice guidelines will not be a quick or painless strategy for improving the quality and value of health care, but unprecedented opportunities lie ahead for physicians in primary care.
Williams-Reade, Jackie; Lamson, Angela L; Knight, Sharon M; White, Mark B; Ballard, Sharon M; Desai, Priti P
Due to multiple issues, integrated interdisciplinary palliative care teams in a neonatal intensive care unit (NICU) may be difficult to access, sometimes fail to be implemented, or provide inconsistent or poorly coordinated care. When implementing an effective institution-specific neonatal palliative care program, it is critical to include stakeholders from the clinical, operational, and financial worlds of healthcare. In this study, researchers sought to gain a multidisciplinary perspective into issues that may impact the implementation of a formal neonatal palliative care program at a tertiary regional academic medical center. In this focused ethnography, the primary researcher conducted semistructured interviews that explored the perspectives of healthcare administrators, finance officers, and clinicians about neonatal palliative care. The perspectives of 39 study participants informed the identification of institutional, financial, and clinical issues that impact the implementation of neonatal palliative care services at the medical center and the planning process for a formal palliative care program on behalf of neonates and their families. Healthcare professionals described experiences that influenced their views on neonatal palliative care. Key themes included: (a) uniqueness of neonatal palliative care, (b) communication and conflict among providers, (c) policy and protocol discrepancies, and (d) lack of administrative support. The present study highlighted several areas that are challenging in the provision of neonatal palliative care. Our findings underscored the importance of recognizing and procuring resources needed simultaneously from the clinical, operational, and financial worlds in order to implement and sustain a successful neonatal palliative care program.
Kuo, Dennis Z.; Berry, Jay G.; Glader, Laurie; Morin, Melinda J.; Johaningsmeir, Sarah; Gordon, John
Objective To describe family-reported health service needs of children with medical complexity, and to assess which needs are more often addressed in a tertiary care center-based structured clinical program for children with medical complexity. Study design Mailed survey to families of children with medical complexity enrolled in a structured-care program providing care coordination and oversight at one of three children’s hospitals. Outcomes included receipt of 14 specific health service needs. Paired t-tests compared unmet health care needs prior to and following program enrollment. Results 441 of 968 (46%) surveys were returned and analyzed. Respondents reported their children had a mean age of 7 (standard deviation 5) years. A majority of respondents reported the child had developmental delay (79%) and feeding difficulties (64%). Of respondents, 56% regarded the primary care provider as the primary point of contact for medical issues. Respondents reported an increase in meeting all fourteen health services needs after enrollment in a tertiary care center-based structured clinical program, including primary care checkups (82% v 96%), therapies (78% v 91%), mental health care (34% v 58%), respite care (56% v 75%), and referrals (51% v 83%) (all p<.001). Conclusions Tertiary care center-based structured clinical care programs for children with medical complexity may address and fulfill a broad range of health service needs that are not met in the primary care setting. PMID:26526361
Kuo, Dennis Z; Berry, Jay G; Glader, Laurie; Morin, Melinda J; Johaningsmeir, Sarah; Gordon, John
To describe family-reported health service needs of children with medical complexity (CMC) and to assess which needs are more often addressed in a tertiary care center-based structured clinical program for CMC. Mailed survey to families of CMC enrolled in a structured-care program providing care coordination and oversight at 1 of 3 children's hospitals. Outcomes included receipt of 14 specific health service needs. Paired t tests compared unmet health care needs prior to and following program enrollment. Four hundred forty-one of 968 (46%) surveys were returned and analyzed. Respondents reported their children had a mean age of 7 (SD 5) years. A majority of respondents reported the child had developmental delay (79%) and feeding difficulties (64%). Of the respondents, 56% regarded the primary care provider as the primary point of contact for medical issues. Respondents reported an increase in meeting all 14 health services needs after enrollment in a tertiary care center-based structured clinical program, including primary care checkups (82% vs 96%), therapies (78% vs 91%), mental health care (34% vs 58%), respite care (56% vs 75%), and referrals (51% vs 83%) (all P < .001). Tertiary care center-based structured clinical care programs for CMC may address and fulfill a broad range of health service needs that are not met in the primary care setting. Copyright © 2016 Elsevier Inc. All rights reserved.
Progress has been made in the past year in the guidance available for health professionals caring for patients with irritable bowel syndrome (IBS). In April 2016, the first National Institute for Health and Care Excellence (NICE) quality standard on IBS in adults was published and new dietary guidelines were developed. Nurses are at the forefront of caring for people with IBS across all healthcare sectors and may have more time to understand the patient's perspective and advise on lifestyle changes than a general practitioner in the average 10-minute consultation. Rapid diagnosis and evidence-based treatments using treatment pathways significantly reduces healthcare costs in primary care and improves quality of life. First-line treatment modalities remain a combination of lifestyle factors, diet and medications, but for persistent refractory symptoms, referral to specialist practitioners should be considered. This article aims to update nurses on new practice guidance and provide information on when it is appropriate to refer patients for specialist care.
Gask, Linda; Rogers, Anne; Campbell, Stephen; Sheaff, Rod
Background Little research attention has been given to attempts to implement organisational initiatives to improve quality of care for mental health care, where there is a high level of indeterminacy and clinical judgements are often contestable. This paper explores recent efforts made at an organisational level in England to improve the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'. Methods Framework analysis, based on the Normalisation Process Model (NPM), of attempts over a five year period to develop clinical governance for primary mental health services in Primary Care Trusts (PCTs). The data come from a longitudinal qualitative multiple case-study approach in a purposive sample of 12 PCTs, chosen to reflect a maximum variety of organisational contexts for mental health care provision. Results The constant change within the English NHS provided a difficult context in which to attempt to implement 'clinical governance' or, indeed, to reconstruct primary mental health care. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, and a lack of actors with the power or skills to set about realising it, the actors in 'clinical governance' had little shared knowledge or understanding of their role in improving the quality of mental health care. There was a lack of ownership of 'mental health' as an integral, normalised part of primary care. Conclusion Despite some achievements in regard to monitoring and standardisation of prescribing practice, mental health care in primary care seems to have so far largely eluded the gaze of 'clinical governance'. Clinical governance in English primary mental health care has not yet become normalised. We make some policy recommendations which we consider would assist in the process normalisation and suggest other contexts to which our findings might apply. PMID:18366779
McKinlay, John; Piccolo, Rebecca; Marceau, Lisa
Rationale, Aims and Objectives Decades of work on health disparities have culminated in identification of three contributors to variability in diagnosis and management of disease: 1) patient attributes, 2) physician characteristics, and 3) organizational. Understanding the relative influence of different contributors to variability in diagnosis and management of diabetes is important to improving quality and reducing disparities. This study was designed to examine the influence of patient, provider, and organizational factors on the diagnosis and management of a major chronic disease: diabetes. Method A factorial experiment using video vignettes was conducted among n=192 primary care physicians. Physicians were interviewed after viewing vignettes of (1) a “patient” with symptoms strongly suggestive of diabetes and (2) an already diagnosed diabetes “patient” with emerging peripheral neuropathy. Results 60.9 percent of physicians identified diabetes as the correct diagnosis, with significant variations depending on the patients’ race/ethnicity. Many physicians offered competing diagnoses with high levels of certainty. For the “patient” with emerging peripheral neuropathy, 42.2 percent of physicians would do all essential components of a foot examination, while 21.9 percent would do none. Conclusions That half of all diabetes in the US remains undiagnosed is unsurprising given only 60.9 percent of physicians would diagnose it when the condition is strongly suggested, and nearly one quarter suspecting diabetes would not order tests necessary to confirm it. The diagnosis of diabetes is significantly influenced by a patient’s race/ethnicity and clinical management (specifically for foot neuropathy), is influenced by patient SES, physician gender, and access to clinical guidelines. PMID:23216876
Ahmed, Arif; Fincham, Jack E.
PURPOSE Retail clinics are a relatively new phenomenon in the United States, offering cheaper and convenient alternatives to physician offices for minor illness and wellness care. The objective of this study was to investigate the effects of cost of care and appointment wait time on care-seeking decisions at retail clinics or physician offices. METHODS As part of a statewide random-digit-dial survey of households, adult residents of Georgia were interviewed to conduct a discrete choice experiment with 2 levels each of 4 attributes: price ($59; $75), appointment wait time (same day; 1 day or longer), care setting–clinician combination (nurse practitioner in retail clinic; physician in private office), and acute illness (urinary tract infection [UTI]; influenza). The respondents indicated whether they would seek care under each of the 16 resulting choice scenarios. A cooperation rate of 33.1% yielded 493 completed telephone interviews. RESULTS The respondents preferred to seek care for both conditions; were less likely to seek care for UTI (β =−0.149; P = .008); preferred to seek care from a physician (β =1.067; P <.001) and receive same day care (β =−2.789; P<.001). All else equal, cost savings of $31.42 would be required for them to seek care at a retail clinic and $82.12 to wait 1 day or more. CONCLUSIONS Time and cost savings offered by retail clinics are attractive to patients, and they are likely to seek care there given sufficient cost savings. Appointment wait time is the most important factor in care-seeking decisions and should be considered carefully in setting appointment policies in primary care practices. PMID:20212298
Ambigapathy, Ranjini; Chia, Yook Chin; Ng, Chirk Jenn
Shared decision-making has been advocated as a useful model for patient management. In developing Asian countries such as Malaysia, there is a common belief that patients prefer a passive role in clinical consultation. As such, the objective of this study was to determine Malaysian patients' role preference in decision-making and the associated factors. A cross-sectional study. Study was conducted at an urban primary care clinic in Malaysia in 2012. Patients aged >21 years were chosen using systematic random sampling. Consenting patients answered a self-administered questionnaire, which included demographic data and their preferred and actual role before and after consultation. Doctors were asked to determine patients' role preference. The Control Preference Scale was used to assess patients' role preference. Prevalence of patients' preferred role in decision-making. (1) Actual role played by the patient in decision-making. (2) Sociodemographic factors associated with patients' preferred role in decision-making. (3) Doctors' perception of patients' involvement in decision-making. The response rate was 95.1% (470/494). Shared decision-making was preferred by 51.9% of patients, followed by passive (26.3%) and active (21.8%) roles in decision-making. Higher household income was significantly associated with autonomous role preference (p=0.018). Doctors' perception did not concur with patients' preferred role. Among patients whom doctors perceived to prefer a passive role, 73.5% preferred an autonomous role (p=0.900, κ=0.006). The majority of patients attending the primary care clinic preferred and played an autonomous role in decision-making. Doctors underestimated patients' preference to play an autonomous role. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Blackhall, Leslie J; Read, Paul; Stukenborg, George; Dillon, Patrick; Barclay, Joshua; Romano, Andrew; Harrison, James
Studies suggest that outpatient palliative care can reduce hospitalization and increase hospice utilization for patients with cancer, however there are insufficient resources to provide palliative care to all patients from time of diagnosis. It is also unclear whether inpatient consultation alone provides similar benefits. A better understanding of the timing, setting, and impact of palliative care for patients with cancer is needed. The purpose of this study was to measure timing of referral to outpatient palliative care and impact on end-of-life (EOL) care. The Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) program is a phased intervention integrating outpatient palliative care into cancer care. In Year 1 patients were referred at the discretion of their oncologist. Academic medical center. We compared EOL hospitalization, hospice utilization, and costs of care for CARE Track patients compared to those never seen by palliative care or seen only in hospital. Patients were referred a median of 72.5 days prior to death. CARE Track patients had few hospitalizations at end of life, were less likely to die in hospital, had increased hospice utilization, and decreased costs of care; these results were significant even after controlling for differences between groups. Inpatient consultation alone did not impact these variables. However, only approximately half of patients with incurable cancers were referred to this program. Referral outpatient palliative care within 3 months of death improved EOL care and reduced costs, benefits not seen with inpatient care only. However, many patients were never referred, and methods of systematically identifying appropriate patients are needed.
Read, Paul; Stukenborg, George; Dillon, Patrick; Barclay, Joshua; Romano, Andrew; Harrison, James
Abstract Background: Studies suggest that outpatient palliative care can reduce hospitalization and increase hospice utilization for patients with cancer, however there are insufficient resources to provide palliative care to all patients from time of diagnosis. It is also unclear whether inpatient consultation alone provides similar benefits. A better understanding of the timing, setting, and impact of palliative care for patients with cancer is needed. Objectives: The purpose of this study was to measure timing of referral to outpatient palliative care and impact on end-of-life (EOL) care. Design: The Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) program is a phased intervention integrating outpatient palliative care into cancer care. In Year 1 patients were referred at the discretion of their oncologist. Setting: Academic medical center. Measurements: We compared EOL hospitalization, hospice utilization, and costs of care for CARE Track patients compared to those never seen by palliative care or seen only in hospital. Results: Patients were referred a median of 72.5 days prior to death. CARE Track patients had few hospitalizations at end of life, were less likely to die in hospital, had increased hospice utilization, and decreased costs of care; these results were significant even after controlling for differences between groups. Inpatient consultation alone did not impact these variables. However, only approximately half of patients with incurable cancers were referred to this program. Conclusion: Referral outpatient palliative care within 3 months of death improved EOL care and reduced costs, benefits not seen with inpatient care only. However, many patients were never referred, and methods of systematically identifying appropriate patients are needed. PMID:26624851
Haas-Gehres, Anna; Sebastian, Sonya; Lamberjack, Kristen
To measure the impact of ambulatory clinical pharmacist integration in a pediatric primary care clinic on vaccination error rates and to evaluate missed opportunities. A retrospective, quasi-experimental review of electronic medical records of visit encounters during a 3-month period compared vaccine error rates and missed opportunities between two pediatric residency primary care clinics. The intervention clinic has a full-time ambulatory clinical pharmacist integrated into the health care team. Pharmacy services were not provided at the comparison clinic. A vaccine error was defined as follows: doses administered before minimum recommended age, doses administered before minimum recommended spacing from a previous dose, doses administered unnecessarily, live virus vaccination administered too close to a previous live vaccine, and doses invalid for combinations of these reasons. 900 encounters were randomly selected and reviewed. The error rate was found to be 0.28% in the intervention clinic and 2.7% in the comparison clinic. The difference in error rates was found to be significant (P = 0.0021). The number of encounters with greater than or equal to one missed opportunity was significantly higher in the comparison clinic compared with the intervention clinic (29.3% vs. 10.2%; P <0.0001). The pediatric primary care clinic with a pharmacist had reductions in vaccination errors as well as missed opportunities. Pharmacists play a key role in the pediatric primary care team to improve the appropriate use of vaccines.
Penrod, Joan D.; Pronovost, Peter J.; Livote, Elayne E.; Puntillo, Kathleen A.; Walker, Amy S.; Wallenstein, Sylvan; Mercado, Alice F.; Swoboda, Sandra M.; Ilaoa, Debra; Thompson, David A.; Nelson, Judith E.
Objectives High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance. Design Prospective, multisite, observational study of performance of key intensive care unit palliative care processes. Settings A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital. Patients Consecutive adult patients with length of intensive care unit stay ≥5 days. Interventions None. Measurements and Main Results Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care
Figueiredo, Paula Pereira de; Lunardi Filho, Wilson Danilo; Lunardi, Valéria Lerch; Pimpão, Fernanda Demutti
This review study aimed to verify how studies conducted in Brazil have related infant mortality to prenatal care and to present contributions of the clinic in the light of Canguilhem and Foucault for qualification of the care. An integrative literature review was conducted from searches in the databases SciELO, LILACS, MEDLINE and BDENF for the period 2000 to 2009. The relationship between infant mortality and prenatal care is related to the insufficient number of consultations or to the quality of the care provided. Even when the number of and routine consultations in the prenatal care were adequate, avoidable deaths were present. For the qualification of prenatal care, it is suggested that the clinical knowledge and other elements that comprise the process of human living are considered, in order that the clinical view is enlarged and articulated to the technologies available in the health system and, together, they are able to contribute to the reduction of infant mortality in Brazil.
Yehia, Baligh R; Schranz, Asher J; Momplaisir, Florence; Keller, Sara C; Gross, Robert; Frank, Ian; Metlay, Joshua P; Brady, Kathleen A
Receiving care at multiple clinics may compromise the therapeutic patient-provider alliance and adversely affect the treatment of people living with HIV. We evaluated 12,759 HIV-infected adults in Philadelphia, PA between 2008 and 2010 to determine the effects of using multiple clinics for primary HIV care. Using generalized estimating equations with logistic regression, we examined the relationship between receiving care at multiple clinics (≥ 1 visit to two or more clinics during a calendar year) and two outcomes: (1) use of ART and (2) HIV viral load ≤ 200 copies/mL for patients on ART. Overall, 986 patients (8 %) received care at multiple clinics. The likelihood of attending multiple clinics was greater for younger patients, women, blacks, persons with public insurance, and for individuals in their first year of care. Adjusting for sociodemographic factors, patients receiving care at multiple clinics were less likely to use ART (AOR = 0.62, 95 % CI 0.55-0.71) and achieve HIV viral suppression (AOR = 0.78, 95 % CI 0.66-0.94) than individuals using one clinic. Qualitative data are needed to understand the reasons for visiting multiple clinics.
Posting wait times in an urgent care center certainly can make patients happier--but don't expect it to shorten the waiting times in your ED. Patient populations in EDs and urgent care centers are entirely different, and they rarely will overlap in terms of where they seek care. Some EDs post waiting times in their lobbies, but this can be a two-edged sword as patients will take those times literally. With technology advancing and more patients becoming Internet-savvy, web postings of ED waits may be just a matter of time.
Between 4 and 22% of burn patients presenting to the emergency department are admitted to critical care. Burn injury is characterised by a hypermetabolic response with physiologic, catabolic and immune effects. Burn care has seen renewed interest in colloid resuscitation, a change in transfusion practice and the development of anti-catabolic therapies. A literature search was conducted with priority given to review articles, meta-analyses and well-designed large trials; paediatric studies were included where adult studies were lacking with the aim to review the advances in adult intensive care burn management and place them in the general context of day-to-day practical burn management. PMID:24093225
Lyons, John S; Epstein, Richard A; Jordan, Neil
The current article proposes that further specification of the system of care concept is required. Based on the assertions that the system of care concept (a) refers to an ideal as opposed to an observable phenomenon, and (b) is engaged in offering transformational experiences, the authors propose that the system of care definition must be expanded to include measurement and outcomes monitoring strategies that extend beyond current quality improvement initiatives. The authors propose that communication across multiple levels is essential if the goal of offering transformational experiences to children and families is to be realized.
Loh, Lik; Jaye, Chrystal; Dovey, Susan; Lloyd, Hywel; Rowe, Joanne
Models of care are important therapeutic modalities for achieving the goals of health care teams, but they are seldom explicitly stated or investigated. To describe the model of care at Dunedin's free clinic, and assess whether this model catered to the particular needs of enrolled patients. A mixed methods study was conducted using case study methodology to construct the clinic's model of care from multiple data sources, and to create a profile of patients' needs. A nested case study of patients with diabetes examined patients' social vulnerability characteristics. The pattern matching analytic technique was used to assess the degree of alignment between the model of care and patients' needs. Patients were not only high users of both primary and secondary health care, but also of justice and social welfare sector services. The care of patients with diabetes was complicated by coexisting social vulnerability and medical comorbidities. Surveyed patients placed high value on interpersonal dimensions of care, the Christian ethos of the clinic, and the wider range of services available. This study suggests a degree of 'fit' between the clinic's model of care and the needs of enrolled patients. A model of care that caters to the needs of patients with complex needs is important for securing their engagement in health services.
Sarabia-Cobo, Carmen María; Alconero-Camarero, Ana Rosa; Lavín-Alconero, Lucía; Ibáñez-Rementería, Isabel
Major deficiencies exist in undergraduate nursing education for Palliative Care. Opportunities to care for dying patients are often unavailable to students in traditional clinical settings. Palliative care simulation is an innovative strategy that may help to prepare undergraduate nursing students to provide quality palliative/end of life care. It is valuable to explore the student nurses' beliefs, feelings and satisfaction regarding the impact that simulation clinic applied to palliative care has and how it influenced their overall experience of caring for a dying patient and the patient's family. This study aimed to evaluate a learning intervention in palliative care using a low-fidelity clinical simulation for undergraduate nursing students from a Spanish university, based on the analytics of their expectations and learning objectives. Sixty-eight students participated in this mixed descriptive design study, they participated in a palliative care simulation scenario and completed three questionnaires which assess the knowledge and expectations before the simulation and the subsequent satisfaction with the performance and learning received. The intervention in question met students' learning expectations, singling out social abilities as important tools in palliative care training, and the students were satisfied with the presented case studies. Our results suggest that low-fidelity clinical simulation intervention training in palliative care is an appropriate and low-cost tool for acquiring competitive skills. Learning in the simulation scenarios provides a mechanism for students to improve student communication skills. Copyright © 2016 Elsevier Ltd. All rights reserved.
Lima, Juliana Vieira Figueiredo; Guedes, Maria Vilani Cavalcante; Silva, Lúcia de Fátima da; Freitas, Maria Célia de; Fialho, Ana Virgínia de Melo
The aim of this study was to evaluate the usefulness of the comfort theory for the clinical nursing care of new mothers. This is a reflexive-theoretical study conducted in November and December 2014, based on the usefulness criterion proposed in the critical analysis of the Barnum nursing theory. The comfort theory in nursing care for new mothers applied to study analysis revealed that this theory meets the criteria of usefulness because it provides applicable concepts that facilitated the clinical nursing care of women in the postpartum period and helped increase their comfort level. The verification of these concepts showed that the theory can be applied in different settings of clinical care for new mothers. The theory can be used to support and improve clinical nursing care for postpartum women, and help improve puerperal comfort.
Bender, Miriam; Williams, Marjory; Su, Wei; Hites, Lisle
To empirically validate a conceptual model of Clinical Nurse Leader integrated care delivery. There is limited evidence of frontline care delivery models that consistently achieve quality patient outcomes. Clinical Nurse Leader integrated care delivery is a promising nursing model with a growing record of success. However, theoretical clarity is necessary to generate causal evidence of effectiveness. Sequential mixed methods. A preliminary Clinical Nurse Leader practice model was refined and survey items developed to correspond with model domains, using focus groups and a Delphi process with a multi-professional expert panel. The survey was administered in 2015 to clinicians and administrators involved in Clinical Nurse Leader initiatives. Confirmatory factor analysis and structural equation modelling were used to validate the measurement and model structure. Final sample n = 518. The model incorporates 13 components organized into five conceptual domains: 'Readiness for Clinical Nurse Leader integrated care delivery'; 'Structuring Clinical Nurse Leader integrated care delivery'; 'Clinical Nurse Leader Practice: Continuous Clinical Leadership'; 'Outcomes of Clinical Nurse Leader integrated care delivery'; and 'Value'. Sample data had good fit with specified model and two-level measurement structure. All hypothesized pathways were significant, with strong coefficients suggesting good fit between theorized and observed path relationships. The validated model articulates an explanatory pathway of Clinical Nurse Leader integrated care delivery, including Clinical Nurse Leader practices that result in improved care dynamics and patient outcomes. The validated model provides a basis for testing in practice to generate evidence that can be deployed across the healthcare spectrum. © 2016 John Wiley & Sons Ltd.
Pati, Rituparna; Robbins, Rebekkah S; Braunstein, Sarah L
Improving retention in care is a key element of the National HIV/AIDS Strategy (NHAS). However, definitions for measuring retention in care are not standardized. To compare measures of retention based on both clinic visit data and HIV laboratory surveillance data. Retrospective cohort study. New York City (NYC), New York. We matched adult patients with HIV infection seen at the Spencer Cox Center for Health (SCC) in 2010 or 2011 with the NYC HIV Surveillance Registry. Retention in care was measured on the basis of SCC electronic medical record (EMR) data (≥1 medical visits in 2012) and Surveillance Registry data (≥2 CD4/viral load [VL] tests ≥90 days apart in 2012). There were 5746 adult HIV-infected patients seen at SCC between 2010 and 2011 who matched with the Surveillance Registry. Seventy-eight percent (n = 4469) had 1 or more medical visits at SCC in 2012 and were considered retained on the basis of the EMR definition, among which 3831 (86%) met the surveillance definition for retention in care. Patients who did not have a medical visit at SCC in 2012 (n = 1277) were lost to care in NYC (n = 485; 36%), engaged in care at an alternate provider (n = 622; 49%), or died after their last SCC visit (n = 197; 15%). This study is an important comparison of laboratory surveillance versus clinic visit-based measures of retention in care in an urban setting with the largest HIV epidemic in the country. Collaborative projects between local health departments and clinical care providers can help validate the care status of patients and inform the allocation of resources to reengage patients who are lost to care. The combined use of laboratory and clinic visit-based data to measure retention in care provides a more accurate representation of the care status of HIV-infected patients than use of a single data source alone. Routine sharing of data by public health institutions and clinical care providers would help target resources toward reengaging patients who are
Rojas-Fernandez, Carlos H; Patel, Tejal; Lee, Linda
Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care-based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care-based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists' activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic.
Shaw, Marta; Rypien, Candace; Drummond, Neil; Harasym, Patricia; Nixon, Lara
Primary care initiatives face an imperative to not only reduce barriers to care for their patients but also to uniquely accommodate the complex needs of at-risk patient populations. Patient-centered multidisciplinary care team models for primary care, like the Alex Seniors Clinic, are one approach for providing comprehensive care for marginalized seniors. The purpose of this qualitative study was to explore patient perspectives on the responsiveness of the Alex Seniors Clinic to their stated health needs. Themes reflected participants' perspectives on factors impacting their health needs as vulnerable seniors as well as on the measures that the Alex Seniors Clinic has taken to meet those needs. Factors impacting health included: the nature of their relationships to the physical environment in which they lived, the nature of the relationships they had to others in that environment, and independence and autonomy. Participants identified accessibility, respect and support, and advocacy as the ways in which the clinic was working to address those health needs. While respect and support, as well as advocacy, effectively addressed some patient needs, participants felt that accessibility problems continue to be health-related barriers for clinic patients. This may be due to the fact that issues of accessibility reflect larger community and social problems. Nevertheless, it is only through engaging the patient community for input on clinic approaches that an understanding can be gained of how closely a clinic's care goals are currently aligning with patient perspectives of the care and services they receive.
Goel, Hersh V; Jones, Trevor A; Skinner, David P
Clinical trials are extremely difficult to undertake and recruiting patients for these trials is one of the most significant challenges. This brief report sought to determine the suitability of an urgent care center as a research recruitment site by assessing its patients' views on participating in clinical trials. One thousand and two subjects were surveyed over a 45-day period; 9.0 % had previously participated in clinical trials while 46.6 % indicated they would be interested in participating in future clinical trials if given the opportunity. This research suggests that the urgent care venue is a viable recruitment source for clinical trials.
DeGorter, Marianne K.; Tirona, Rommel G.; Schwarz, Ute I.; Choi, Yun-Hee; Dresser, George K.; Suskin, Neville; Myers, Kathryn; Zou, GuangYong; Iwuchukwu, Otito; Wei, Wei-Qi; Wilke, Russell A.; Hegele, Robert A.; Kim, Richard B.
Background A barrier to statin therapy is myopathy associated with elevated systemic drug exposure. Our objective was to examine the association between clinical and pharmacogenetic variables and statin concentrations in patients. Methods and Results In total, 299 patients taking atorvastatin or rosuvastatin were prospectively recruited at an outpatient referral center. The contribution of clinical variables and transporter gene polymorphisms to statin concentration was assessed using multiple linear regression. We observed 45-fold variation in statin concentration among patients taking the same dose. After adjustment for gender, age, body mass index, ethnicity, dose, and time from last dose, SLCO1B1 c.521T>C (p < 0.001) and ABCG2 c.421C>A (p < 0.01) were important to rosuvastatin concentration (adjusted R2 = 0.56 for the final model). Atorvastatin concentration was associated with SLCO1B1 c.388A>G (p < 0.01) and c.521T>C (p < 0.05), and 4β-hydroxycholesterol, a CYP3A activity marker (adjusted R2 = 0.47). A second cohort of 579 patients from primary and specialty care databases were retrospectively genotyped. In this cohort, genotypes associated with statin concentration were not differently distributed among dosing groups, implying providers had not yet optimized each patient's risk-benefit ratio. Nearly 50% of patients in routine practice taking the highest doses were predicted to have statin concentrations greater than the 90th percentile. Conclusions Interindividual variability in statin exposure in patients is associated with uptake and efflux transporter polymorphisms. An algorithm incorporating genomic and clinical variables to avoid high atorvastatin and rosuvastatin levels is described; further study will determine if this approach reduces incidence of statin-myopathy. PMID:23876492
Janes, Ron; Titchener, Janet
There are many barriers to diabetes care. This paper explores whether organising these barriers to Type 2 diabetes care within the clinical framework of patient-centred medicine (PCM) enables a better appreciation and conceptualisation of these barriers. The terms 'diabetes', 'barriers to care', 'self-management', 'patient-centred care' and 'outcome assessment' were used to identify 28 articles describing multiple barriers (minimum of three) to care in Type 2 diabetes. Identified barriers were organised within the clinical framework of PCM. Barriers to diabetes care were numerous and diverse, but all could be accommodated within the PCM framework, except for one, that of patient non-compliance (non-adherence). This paternalistic concept contradicts patient autonomy, a key component of the PCM paradigm. Accepting non-adherence as a plausible barrier stops providers from recognising the actual barriers to diabetes self-management. Clinicians need to stop attributing blame for poor disease outcomes on patients, and instead to become partners in identifying and addressing their patients' real barriers to better health by using the practical clinical framework of PCM.
Tanner, Amanda E; Philbin, Morgan M; Duval, Anna; Ellen, Jonathan; Kapogiannis, Bill; Fortenberry, J Dennis
Linkage and engagement in care are critical corollaries to the health of HIV-infected adolescents. The adolescent HIV epidemic and adolescents' unique barriers to care necessitates innovation in the provision of care, including the consideration of the clinical experience. Little research has addressed how "youth friendly" clinics may influence care retention for HIV-infected youth. We conducted 124 interviews with providers, outreach workers, and case managers, at 15 Adolescent Medicine Trials Network clinics. Photographs of each clinic documented the characteristics of the physical space. Constant comparison and content and visual narrative methods were utilized for data analysis. Three elements of youth friendliness were identified for clinics serving HIV-infected youth, including: (1) role of target population (e.g., pediatric, adolescent, HIV); (2) clinics' physical environment; and (3) clinics' social environment. Working to create 'youth friendly' clinics through changes in physical (e.g., space, entertainment, and educational materials) and social (e.g., staff training related to development, gender, sexual orientation) environments may help reduce HIV-infected adolescents' unique barriers to care engagement. The integration of clinic design and staff training within the organization of a clinical program is helpful in meeting the specialized needs of HIV-infected youth.
Aitken, Elizabeth M; Powelson, Susan E; Reaume, Renée D; Ghali, William A
To measure the effect of including a clinical librarian in the health care team on medical residents and clinical clerks. In 2009, medical residents and clinical clerks were preassigned to one of two patient care teams (intervention and control). Each team had a month-long rotation on the general medicine teaching unit. The clinical librarian joined the intervention team for morning intake, clinical rounding, or an afternoon patient list review, providing immediate literature searches, formal group instruction, informal bedside teaching, and/or individual mentoring for use of preappraised resources and evidence-based medicine search techniques. Both intervention and control teams completed pre and post surveys comparing their confidence levels and awareness of resources as well as their self-reported use of evidence for making patient care decisions. The nonintervention team was surveyed as the control group. The clinical librarian intervention had a significant positive effect on medical trainees' self-reported ability to independently locate and evaluate evidence resources to support patient care decisions. Notably, 30 of 34 (88%) reported having changed a treatment plan based on skills taught by the clinical librarian, and 27 of 34 (79%) changed a treatment plan based on the librarian's mediated search support. Clinical librarians on the care team led to positive effects on self-reported provider attitudes, provider information retrieval tendencies, and, notably, clinical decision making. Future research should evaluate economic effects of widespread implementation of on-site clinical librarians.
Hieng, Yung Chun
Introduction Earlier studies have identified a gap between guidelines and actual clinical diabetes care in Malaysia. Objective We audited the quality of care for patients with type 2 diabetes mellitus (T2DM) attending our diabetes clinic at a public hospital. Methods A structured review of the outpatient clinic cards, prescriptions and laboratory results was conducted for patients attending the diabetes clinic at Sibu Hospital in October and November 2014. Results For the total of 233 patients who were audited, the levels of fasting blood sugar, blood pressure, body mass index and fasting lipid profile were satisfactory at 99.1%, 99.6%, 92.6% and 99.6% respectively. 79.7% of the subjects had had HbA1c performed at least once over the previous six months. Only 25.8% had annual foot screening, while the eye screening rate was 71.2% and the albuminuria screening rate was 93.6%. For outcome measures, the mean (SD) HbA1c level was 9.2% (1.91%), with 13 patients (6.7%) having HbA1c less than 6.5%; 36.4% of participants achieved BP < 130/80 mmHg; and 69.4% had LDL < 2.6 mmol/L. The majority of the patients were overweight or obese (91.4%). Conclusions Overall, the performance of diabetic care processes at our hospital was satisfactory, except for foot examination. The glycaemic and weight control among the subjects were suboptimal and warrant an optimised and comprehensive approach on the part of the management.
Hieng, Yung Chun
Earlier studies have identified a gap between guidelines and actual clinical diabetes care in Malaysia. We audited the quality of care for patients with type 2 diabetes mellitus (T2DM) attending our diabetes clinic at a public hospital. A structured review of the outpatient clinic cards, prescriptions and laboratory results was conducted for patients attending the diabetes clinic at Sibu Hospital in October and November 2014. For the total of 233 patients who were audited, the levels of fasting blood sugar, blood pressure, body mass index and fasting lipid profile were satisfactory at 99.1%, 99.6%, 92.6% and 99.6% respectively. 79.7% of the subjects had had HbA1c performed at least once over the previous six months. Only 25.8% had annual foot screening, while the eye screening rate was 71.2% and the albuminuria screening rate was 93.6%. For outcome measures, the mean (SD) HbA1c level was 9.2% (1.91%), with 13 patients (6.7%) having HbA1c less than 6.5%; 36.4% of participants achieved BP < 130/80 mmHg; and 69.4% had LDL < 2.6 mmol/L. The majority of the patients were overweight or obese (91.4%). Overall, the performance of diabetic care processes at our hospital was satisfactory, except for foot examination. The glycaemic and weight control among the subjects were suboptimal and warrant an optimised and comprehensive approach on the part of the management.
Hunt, Linda M; Truesdell, Nicole D; Kreiner, Meta J
Race, although an unscientific concept, remains prominent in health research and clinical guidelines, and is routinely invoked in clinical practice. In interviews with 58 primary care clinicians we explored how they understand and apply concepts of racial difference. We found wide agreement that race is important to consider in clinical care. They explained the effect of race on health, drawing on common assumptions about the biological, class, and cultural characteristics of racial minorities. They identified specific race-based clinical strategies for only a handful of conditions and were inconsistent in the details of what they said should be done for minority patients. We conclude that using race in clinical medicine promotes and maintains the illusion of inherent racial differences and may result in minority patients receiving care aimed at presumed racial group characteristics, rather than care selected as specifically appropriate for them as individuals.
Dunn, Steven P; Birtcher, Kim K; Beavers, Craig J; Baker, William L; Brouse, Sara D; Page, Robert L; Bittner, Vera; Walsh, Mary Norine
Team-based cardiovascular care, including the use of clinical pharmacists, can efficiently deliver high-quality care. This Joint Council Perspectives paper from the Cardiovascular Team and Prevention Councils of the American College of Cardiology provides background information on the clinical pharmacist's role, training, certification, and potential utilization in a variety of practice models. Selected systematic reviews and meta-analyses, highlighting the benefit of clinical pharmacy services, are summarized. Clinical pharmacists have a substantial effect in a wide variety of roles in inpatient and ambulatory settings, largely through optimization of drug use, avoidance of adverse drug events, and transitional care activities focusing on medication reconciliation and patient education. Expansion of clinical pharmacy services is often impeded by policy, legislation, and compensation barriers. Multidisciplinary organizations, including the American College of Cardiology, should support efforts to overcome these barriers, allowing pharmacists to deliver high-quality patient care to the full extent of their education and training.
Background There are numerous applications for Health Information Systems (HIS) that support specific tasks in the clinical workflow. The Lean method has been used increasingly to optimize clinical workflows, by removing waste and shortening the delivery cycle time. There are a limited number of studies on Lean applications related to HIS. Therefore, we applied the Lean method to evaluate the clinical processes related to HIS, in order to evaluate its efficiency in removing waste and optimizing the process flow. This paper presents the evaluation findings of these clinical processes, with regards to a critical care information system (CCIS), known as IntelliVue Clinical Information Portfolio (ICIP), and recommends solutions to the problems that were identified during the study. Methods We conducted a case study under actual clinical settings, to investigate how the Lean method can be used to improve the clinical process. We used observations, interviews, and document analysis, to achieve our stated goal. We also applied two tools from the Lean methodology, namely the Value Stream Mapping and the A3 problem-solving tools. We used eVSM software to plot the Value Stream Map and A3 reports. Results We identified a number of problems related to inefficiency and waste in the clinical process, and proposed an improved process model. Conclusions The case study findings show that the Value Stream Mapping and the A3 reports can be used as tools to identify waste and integrate the process steps more efficiently. We also proposed a standardized and improved clinical process model and suggested an integrated information system that combines database and software applications to reduce waste and data redundancy. PMID:23259846
Yusof, Maryati Mohd; Khodambashi, Soudabeh; Mokhtar, Ariffin Marzuki
There are numerous applications for Health Information Systems (HIS) that support specific tasks in the clinical workflow. The Lean method has been used increasingly to optimize clinical workflows, by removing waste and shortening the delivery cycle time. There are a limited number of studies on Lean applications related to HIS. Therefore, we applied the Lean method to evaluate the clinical processes related to HIS, in order to evaluate its efficiency in removing waste and optimizing the process flow. This paper presents the evaluation findings of these clinical processes, with regards to a critical care information system (CCIS), known as IntelliVue Clinical Information Portfolio (ICIP), and recommends solutions to the problems that were identified during the study. We conducted a case study under actual clinical settings, to investigate how the Lean method can be used to improve the clinical process. We used observations, interviews, and document analysis, to achieve our stated goal. We also applied two tools from the Lean methodology, namely the Value Stream Mapping and the A3 problem-solving tools. We used eVSM software to plot the Value Stream Map and A3 reports. We identified a number of problems related to inefficiency and waste in the clinical process, and proposed an improved process model. The case study findings show that the Value Stream Mapping and the A3 reports can be used as tools to identify waste and integrate the process steps more efficiently. We also proposed a standardized and improved clinical process model and suggested an integrated information system that combines database and software applications to reduce waste and data redundancy.
Houston, Thomas K; Connors, Robert L; Cutler, Naomi; Nidiry, Mary Anne
Musculoskeletal complaints are common, but are often underemphasized in residency training. We evaluated the experience of residents (12) in 4 sessions of an innovative concentrated ambulatory, community-based musculoskeletal (MS) clinic precepted by general internists with additional training in teaching MS medicine. Compared with the year long longitudinal house staff (HS) clinic experience, the mean number of musculoskeletal diagnoses per resident seen in MS clinic was higher (13.9 [standard deviation 4.0] vs 5.4 [standard deviation 4.0]; P <.01). Common diagnoses in MS clinic included shoulder, hip, and knee tendonitis/bursitis, and the majority of diagnoses in HS clinic were nonspecific arthralgia (66%). Fifty-two injections were performed in MS clinic over the year, compared with one in HS clinic.
Kaldjian, Lauris Christopher
Clinical decision making is a challenging task that requires practical wisdom-the practised ability to help patients choose wisely among available diagnostic and treatment options. But practical wisdom is not a concept one typically hears mentioned in medical training and practice. Instead, emphasis is placed on clinical judgement. The author draws from Aristotle and Aquinas to describe the virtue of practical wisdom and compare it with clinical judgement. From this comparison, the author suggests that a more complete understanding of clinical judgement requires its explicit integration with goals of care and ethical values. Although clinicians may be justified in assuming that goals of care and ethical values are implicit in routine decision making, it remains important for training purposes to encourage habits of clinical judgement that are consciously goal-directed and ethically informed. By connecting clinical judgement to patients' goals and values, clinical decisions are more likely to stay focused on the particular interests of individual patients. To cultivate wise clinical judgement among trainees, educational efforts should aim at the integration of clinical judgement, communication with patients about goals of care, and ethical reasoning. But ultimately, training in wise clinical judgement will take years of practice in the company of experienced clinicians who are able to demonstrate practical wisdom by example. By helping trainees develop clinical judgement that incorporates patients' goals of care and ethical reasoning, we may help lessen the risk that 'clinical judgement' will merely express 'the clinician's judgement.'
Eastman, Peter; Le, Brian; McCarthy, Gillian; Watt, James; Rosenthal, Mark
There has been growth in the number of clinical trials conducted in the palliative care setting. However, issues exist regarding patient acceptance and vulnerability as well as the appropriateness of conducting trials in the dying patient. This study aimed to investigate the uptake of palliative care clinical trials at the Royal Melbourne Hospital, evaluate patient demographics for those enrolled onto study and assess the proportion of patients who died within 28 days of enrolling on a palliative care clinical trial. A retrospective cohort study of all patients prescreened and enrolled onto palliative care clinical trials by the Palliative Care Clinical Trials Team (PCCTT) at the Royal Melbourne Hospital over a 27-month period was undertaken. Of 515 patients referred to the PCCTT for consideration of trial enrollment, 64 (12.4%) were subsequently enrolled onto one of six clinical trials open during the study period. About 62.5% were non-cancer patients; 81.3% of all patients completed the trial intervention and 65.6% completed trial follow-up; 28.1% of patients enrolled died within 28 days of trial commencement. More than 500 patients were referred for assessment of clinical trial participation perhaps reflecting clinician acceptance of palliative care clinical trials. A number of enrolled patients were involved in trials during their terminal phase, indicating a willingness of participants to be involved, despite poor prognosis. © 2014 Wiley Publishing Asia Pty Ltd.
Cummins, Nathan W; Badley, Andrew D; Kasten, Mary J; Sampath, Rahul; Temesgen, Zelalem; Whitaker, Jennifer A; Wilson, John W; Yao, Joseph D; Zeuli, John; Rizza, Stacey A
The Mayo human immunodeficiency virus (HIV) Clinic has been providing patient centered care for persons living with HIV in Minnesota and beyond for the past 20 years. Through multidisciplinary engagement, vital clinical outcomes such as retention in care, initiation of antiretroviral therapy and virologic suppression are maximized. In this commentary, we describe the history of the Mayo HIV Clinic and its best practices, providing a “Mayo Model” of HIV care that exceeds national outcomes and may be applicable in other settings. PMID:27175350
Williams, Cheryl-Ann N; Khanfar, Nile M; Harrington, Catherine; Loudon, David
Since their founding in 2000, retail-based health care clinics, also called convenient care clinics, have flourished but continue to generate controversy. This article examines the literature with respect to the industry's background, establishment of industry standards, types of services offered, marketing of retail health clinics, industry growth with new target markets, and patient demographics. It also examines the growing relationship with insurers and third-party payers, quality-of-care concerns by medical associations, and legal regulations and their potential impact on industry growth nationwide.
Ogrinc, Greg; Hoffman, Kimberly G.; Stevenson, Katherine M.; Shalaby, Marc; Beard, Albertine S.; Thörne, Karin E.; Coleman, Mary T.; Baum, Karyn D.
Problem Current models of health care quality improvement do not explicitly describe the role of health professions education. The authors propose the Exemplary Care and Learning Site (ECLS) model as an approach to achieving continual improvement in care and learning in the clinical setting. Approach From 2008–2012, an iterative, interactive process was used to develop the ECLS model and its core elements—patients and families informing process changes; trainees engaging both in care and the improvement of care; leaders knowing, valuing, and practicing improvement; data transforming into useful information; and health professionals competently engaging both in care improvement and teaching about care improvement. In 2012–2013, a three-part feasibility test of the model, including a site self-assessment, an independent review of each site’s ratings, and implementation case stories, was conducted at six clinical teaching sites (in the United States and Sweden). Outcomes Site leaders reported the ECLS model provided a systematic approach toward improving patient (and population) outcomes, system performance, and professional development. Most sites found it challenging to incorporate the patients and families element. The trainee element was strong at four sites. The leadership and data elements were self-assessed as the most fully developed. The health professionals element exhibited the greatest variability across sites. Next Steps The next test of the model should be prospective, linked to clinical and educa tional outcomes, to evaluate whether it helps care delivery teams, educators, and patients and families take action to achieve better patient (and population) outcomes, system performance, and professional development. PMID:26760058
Hess, Brian J; Lynn, Lorna A; Conforti, Lisa N; Holmboe, Eric S
The population of people aged 65 and older is rapidly growing. Research has demonstrated significant quality gaps in the clinical care of older patients in the United States, especially in training programs. Little is known about how older patients' experience with care delivered in residency clinics compares with that delivered by practicing physicians. Using patient surveys from the American Board of Internal Medicine Care of the Vulnerable Elderly Practice Improvement Module, the quality of care provided to adults aged 65 and older by 52 internal medicine and family medicine residency clinics and by a group of 144 practicing physicians was studied. The residency clinics received 2,213 patient surveys, and the practicing physicians received 4,204. Controlling for age and overall health status, patients from the residency clinic sample were less likely to report receiving guidance and interventions for important aspects of care for older adults than patients from the practicing physician sample. The largest difference was observed in providing ways to help patients prevent falls or treat problems with balance or walking (42.1% vs 61.8%, P<.001). Patients from the residency clinic sample were less likely to rate their overall care as high (77.5% vs 88.8%, P<.001). Patient surveys reveal important deficiencies in processes of care that are more pronounced for patients cared for in residency clinics. Quality of patient experience and communication are vital aspects of overall quality of care, especially for older adults. Physician education at all levels, faculty development, and practice system redesign are needed to ensure that the care needs of older adults are met. © 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.
Novick, Gina; Sadler, Lois S.; Knafl, Kathleen A.; Groce, Nora Ellen; Kennedy, Holly Powell
Women from vulnerable populations encounter challenging circumstances that generate stress and may adversely affect their health. Group prenatal care (GPNC) incorporates features which address social stressors, and has been demonstrated to improve pregnancy outcomes and prenatal care experiences. In this qualitative study, we describe the complex circumstances in the lives of women receiving care in two urban clinics and how GPNC attenuated them. Stressors included problems with transportation and child care, demanding jobs, poverty, homelessness, difficult relationships with partners, limited family support, and frustrating health care experiences. Receiving prenatal care in groups allowed women to strengthen relationships with significant others, gain social support, and develop meaningful relationships with group leaders. By eliminating waits and providing the opportunity to participate in care, GPNC also offered sanctuary from frustrations encountered in receiving individual care. Reducing such stressors may help improve pregnancy outcomes; however, more evidence is needed on mechanisms underlying these effects. PMID:22643609
Shibata, Hiroko; Matsunaga, Kyoko
We taught fourth-year students in a university about patient education using the diabetes retinopathy model in adult nursing practice. We analyzed teacher's student guidance plans and the guidance process using a clinical training education analysis form from the viewpoint of qualitative interpretation. We evaluated the degree of achievement of the students' goal for practice and the training subject. Consequently, the teacher developed training guidance as a class.
Farraye, Francis A; Melmed, Gil Y; Lichtenstein, Gary R; Kane, Sunanda V
Recent data suggest that inflammatory bowel disease (IBD) patients do not receive preventive services at the same rate as general medical patients. Patients with IBD often consider their gastroenterologist to be the primary provider of care. To improve the care delivered to IBD patients, health maintenance issues need to be co-managed by both the gastroenterologist and primary care team. Gastroenterologists need to explicitly inform the primary care provider of the unique needs of the IBD patient, especially those on immunomodulators and biologics or being considered for such therapy. In particular, documentation of up to date vaccinations are crucial as IBD patients are often treated with long-term immune-suppressive therapies and may be at increased risk for infections, many of which are preventable with vaccinations. Health maintenance issues addressed in this guideline include identification, safety and appropriate timing of vaccinations, screening for osteoporosis, cervical cancer, melanoma and non-melanoma skin cancer as well as identification of depression and anxiety and smoking cessation. To accomplish these health maintenance goals, coordination between the primary care provider, gastroenterology team and other specialists is necessary.
Aschkenasy-Steuer, Gabriella; Shamir, Micha; Rivkind, Avraham; Mosheiff, Rami; Shushan, Yigal; Rosenthal, Guy; Mintz, Yoav; Weissman, Charles; Sprung, Charles L; Weiss, Yoram G
Over the past four years there have been 93 multiple-casualty terrorist attacks in Israel, 33 of them in Jerusalem. The Hadassah-Hebrew University Medical Center is the only Level I trauma center in Jerusalem and has therefore gained important experience in caring for critically injured patients. To do so we have developed a highly flexible operational system for managing the general intensive care unit (GICU). The focus of this review will be on the organizational steps needed to provide operational flexibility, emphasizing the importance of forward deployment of intensive care unit personnel to the trauma bay and emergency room and the existence of a chain of command to limit chaos. A retrospective review of the hospital's response to multiple-casualty terror incidents occurring between 1 October 2000 and 1 September 2004 was performed. Information was assembled from the medical center's trauma registry and from GICU patient admission and discharge records. Patients are described with regard to the severity and type of injury. The organizational work within intensive care is described. Finally, specific issues related to the diagnosis and management of lung, brain, orthopedic and abdominal injuries, caused by bomb blast events associated with shrapnel, are described. This review emphasizes the importance of a multidisciplinary team approach in caring for these patients. PMID:16277738
Mikuni, Masahiko; Kurihara, Chieko; Miyaoka, Hitoshi
In May 2011, the Japanese Society of Psychiatry and Neurology released their Guidelines on Conflict of Interest (COI) in Clinical Research and detailed regulations. These guidelines cover clinical research, although each committee of the society may have a policy to cover basic research as well as clinical research. The COI Committee implemented the guidelines, including a one-year trial period. According to the guidelines, members of the society have to disclose their COIs at the time of presentations, manuscript submissions, and publications; the board and committees members have to submit their COIs to the president of the society. During the trial period, the latter was limited to the four committees involved in the development of the guidelines: Conflict of Interest; Pharmaceutical Affairs; Research Ethics; and Editorial Committees. The COI Committee reviewed the COIs submitted by the board and committee members. The COI Committee found that, among the 382 board and committee members, 298 were without COI; 31 COIs were regarded by one committee member as not necessary to be circulated to all the attending members (total of these 2 categories: 329, 87%); 31 COIs (8%) were regarded as necessary to be circulated; and 18 cases (4.7%) were problematic: not submitted or explicit rejection of submission. Considering the seriousness of scientific misconduct by a researcher in another disease area who resigned his professorship and is now under investigation, we should further discuss the implementation of our COI guidelines.
Wolfenden, Luke; Wiggers, John; Knight, Jenny; Campbell, Elizabeth; Spigelman, Allan; Kerridge, Ross; Moore, Karen
Evidence suggests that preoperative clinics, like other hospital outpatient clinics and inpatient wards, fail to systematically provide smoking cessation care to patients having planned surgery. The aim of the study was to assess the efficacy, acceptability, and cost of a multifaceted intervention to facilitate the provision of comprehensive smoking cessation care to patients attending a preoperative clinic. Two hundred ten smoking patients attending a preoperative clinic at a major teaching hospital in Australia took part in the study. One hundred twenty-four patients were randomly assigned to an experimental group and 86 patients to a usual cessation care group. A multifaceted intervention was developed that included the use of opinion leaders, consensus processes, computer-delivered cessation care, computer-generated prompts for care provision by clinic staff, staff training, and performance feedback. Ninety-six percent of experimental group patients received behavioral counseling and tailored self-help material. Experimental group patients were significantly more likely than usual care patients to report receiving brief advice by nursing (79% vs. 47%; P < 0.01) and anaesthetic (60% vs. 39%; P < 0.01) staff. Experimental group patients who were nicotine dependent were also more likely to be offered preoperative nicotine replacement therapy (NRT) (82% vs. 8%; P < 0.01) and be prescribed postoperative NRT (86% vs. 0%; P < 0.01). The multifaceted intervention was found to be acceptable by staff. A multifaceted clinical practice change intervention may be effective in improving the delivery of smoking cessation care to preoperative surgical patients.
Lemire, Joe; Budgell, Brian
It appears that a great many chiropractors and chiropractic institutions are involved in health care initiatives in developing countries. Developing nations present extraordinary opportunities to do good, but also carry risks, for practitioners and organizations, which may not be obvious prior to actual local engagement. This paper describes the guiding principles under which one international collaboration has evolved in rural Tanzania, a so-called 'low resource' setting where the majority of families subsist in extreme poverty. Several challenges to effective care are also identified.
Lemire, Joe; Budgell, Brian
It appears that a great many chiropractors and chiropractic institutions are involved in health care initiatives in developing countries. Developing nations present extraordinary opportunities to do good, but also carry risks, for practitioners and organizations, which may not be obvious prior to actual local engagement. This paper describes the guiding principles under which one international collaboration has evolved in rural Tanzania, a so-called ‘low resource’ setting where the majority of families subsist in extreme poverty. Several challenges to effective care are also identified. PMID:27385832
Bakula, Dana M; Sharkey, Christina M; Wolfe-Christensen, Cortney; Mullins, Alexandria J; Meyer, Jonathan; Mullins, Larry L; Wisniewski, Amy B
Provide recommendations for the development of an interdisciplinary care (IDC) clinic for the treatment of youth with disorders/differences of sex development (DSD). DSD consist of a group of complex congenital medical disorders in which the development of chromosomal, gonadal, or anatomical sex is atypical. Youth with DSD require care from multiple specialized healthcare disciplines, including several medical specialties, surgery, nursing, and mental health. Recommendations are based on an interdisciplinary care clinic model that allows for a team of relevant professionals who share knowledge, ideas, and responsibility of care. The framework established in this article is based largely on experiences at an established DSD clinic, as well as observations of multiple clinics across the United States. Preliminary outcome data on clinic adherence to treatment protocol under an IDC model are provided. To meet the diverse healthcare needs of youth with DSD, comprehensive care clinics are recommended; however, few such clinics exist in the United States. Establishing new comprehensive DSD clinics can be challenging due to the highly unique treatment of DSD, but the current paper expands the literature available to guide clinic development in the United States. Copyright © 2017 Elsevier Inc. All rights reserved.
Fortney, John C.; Pyne, Jeffrey M.; Steven, Christopher A.; Williams, J. Silas; Hedrick, Richard G.; Lunsford, Amanda K.; Raney, William N.; Ackerman, Betty A.; Ducker, Loretta O.; Bonner, Laura M.; Smith, Jeffrey L.
Objective To inform the design of future informatics systems that support the chronic care model. Study Design We describe the development and functionality of a decision support system for the chronic care model of depression treatment, known as collaborative care. Dissemination of evidence-based collaborative care models has been slow, and fidelity to the evidence base has been poor during implementation initiatives. Implementation could be facilitated by a decision support system for depression care managers, the cornerstone of the collaborative care model. The Net Decision Support System (https://www.netdss.net/) is a free Web-based system that was developed to support depression care manager activities and to facilitate the dissemination of collaborative care models that maintain high fidelity to the evidence base. Methods The NetDSS was based on intervention materials used for a randomized trial of depression care management that improved clinical outcomes compared with usual care. The NetDSS was developed jointly by a cross-functional design team of psychiatrists, depression care managers, information technology specialists, technical writers, and researchers. Results The NetDSS has the following functional capabilities: patient registry, patient encounter scheduler, trial management, clinical decision support, progress note generator, and workload and outcomes report generator. The NetDSS guides the care manager through a self-documenting patient encounter using evidence-based scripts and self-scoring instruments. The NetDSS has been used to provide evidence-based depression care management to more than 1700 primary care patients. Conclusion Intervention protocols can be successfully converted to Web-based decision support systems that facilitate the implementation of evidence-based chronic care models into routine care with high fidelity. PMID:21348556
Taylor, Cathy R; Hepworth, Joseph T; Buerhaus, Peter I; Dittus, Robert; Speroff, Theodore
Background Diabetes care in our inner‐city primary care clinic was suboptimal, despite provider education and performance feedback targeting improved adherence to evidence‐based clinical guidelines. A crew resource management (CRM) intervention (communication and teamwork, process and workflow organisation, and standardised information debriefings) was implemented to improve diabetes care and patient outcomes. Objective To assess the effect of the CRM intervention on adherence to evidence‐based diabetes care standards, work processes, standardised clinical communication and patient outcomes. Methods Time‐series analysis was used to assess the effect on the delivery of standard diabetes services and patient outcomes among medically indigent adults (n = 619). Results The CRM principles were translated into useful process redesign and standardised care approaches. Significant improvements in microalbumin testing and associated patient outcome measures were attributed to the intervention. Conclusions The CRM approach provided tools for management that, in the short term, enabled reorganisation and prevention of service omissions and, in the long term, can produce change in the organisational culture for continuous improvement. PMID:17693668
Taylor, Cathy R; Hepworth, Joseph T; Buerhaus, Peter I; Dittus, Robert; Speroff, Theodore
Diabetes care in our inner-city primary care clinic was suboptimal, despite provider education and performance feedback targeting improved adherence to evidence-based clinical guidelines. A crew resource management (CRM) intervention (communication and teamwork, process and workflow organisation, and standardised information debriefings) was implemented to improve diabetes care and patient outcomes. To assess the effect of the CRM intervention on adherence to evidence-based diabetes care standards, work processes, standardised clinical communication and patient outcomes. Time-series analysis was used to assess the effect on the delivery of standard diabetes services and patient outcomes among medically indigent adults (n = 619). The CRM principles were translated into useful process redesign and standardised care approaches. Significant improvements in microalbumin testing and associated patient outcome measures were attributed to the intervention. The CRM approach provided tools for management that, in the short term, enabled reorganisation and prevention of service omissions and, in the long term, can produce change in the organisational culture for continuous improvement.
Gardner, Lytt I; Marks, Gary; Wilson, Tracey E; Giordano, Thomas P; Sullivan, Meg; Raper, James L; Rodriguez, Allan E; Keruly, Jeanne; Malitz, Faye
: We calculated the financial impact in 6 HIV clinics of a low-effort retention in care intervention involving brief motivational messages from providers, patient brochures, and posters. We used a linear regression model to calculate absolute changes in kept primary care visits from the preintervention year (2008-2009) to the intervention year (2009-2010). Revenue from patients' insurance was also assessed by clinic. Kept visits improved significantly in the intervention year versus the preintervention year (P < 0.0001). We found a net-positive effect on clinic revenue of +$24,000/year for an average-size clinic (7400 scheduled visits/year). We encourage HIV clinic administrators to consider implementing this low-effort intervention.
Gardner, Lytt I.; Marks, Gary; Wilson, Tracey E.; Giordano, Thomas P.; Sullivan, Meg; Raper, James L.; Rodriguez, Allan E.; Keruly, Jeanne; Malitz, Faye
We calculated the financial impact in 6 HIV clinics of a low-effort retention in care intervention involving brief motivational messages from providers, patient brochures, and posters. We used a linear regression model to calculate absolute changes in kept primary care visits from the preintervention year (2008–2009) to the intervention year (2009–2010). Revenue from patients’ insurance was also assessed by clinic. Kept visits improved significantly in the intervention year versus the preintervention year (P < 0.0001). We found a net-positive effect on clinic revenue of +$24,000/year for an average-size clinic (7400 scheduled visits/year). We encourage HIV clinic administrators to consider implementing this low-effort intervention. PMID:25559605
Moylan, J A
This report reviews the history of the development of civilian helicopter ambulance program as a component of a total emergency medical services (EMS) system. Current literature demonstrates significant reduction in trauma mortality for those patients transported by air either from the scene of the accident or from an outlying hospital to a trauma center. The primary factor is not the speed of the transport but administration of life-saving care by the helicopter medical crew at the scene of the accident or at the outlying hospital. Regulations have been developed to assure proper patient selection, quality care, safety, and minimization of misuse of this expensive resource. Images Fig. 1. PMID:3058056
Locke, Amanda; Kamo, Norifumi
Access to mental health providers has become an increasingly common challenge for many patients with depression and anxiety disorders. Primary care providers often manage this gap in care and currently provide solo care without the assistance of other team members. In order to provide quality care that aligns with best practice, we developed a depression and anxiety disorder treatment pathway utilizing a multidisciplinary team based on each members' individual skill set, or skill-task alignment. The main change to treatment implemented by the pathway was the addition of a clinical pharmacist in the management of patient care. This pathway was trialed over five months targeting two adult primary care teams (approximately 34 physicians and Advanced Registered Nurse Practitioners [ARNPs]) while the other five teams continued with current practice standards. Post-implementation metrics indicated that clinical pharmacists successfully contacted 55% (406 of 738) of patients started on medication or who had a medication changed. Of these patients reached, 82 (20%) had an intervention completed. In addition, all physician leaders on the planning team (n=6) stated the new pathway was well received and delivered positive feedback from team members.
Fadlalla, Adam M A; Golob, Joseph F; Claridge, Jeffrey A
Infections in the surgical and trauma intensive care