Douw, Karla; Nielsen, Camilla Palmhøj; Pedersen, Camilla Riis
In May 2012, one of Denmark's five health care regions mandated a reform of stroke care. The purpose of the reform was to save costs, while at the same time improving quality of care. It included (1) centralisation of acute stroke treatment at specialised hospitals, (2) a reduced length of hospital stay, and (3) a shift from inpatient rehabilitation programmes to community-based rehabilitation programmes. Patients would benefit from a more integrated care pathway between hospital and municipality, being supported by early discharge teams at hospitals. A formal policy tool, consisting of a health care agreement between the region and municipalities, was used to implement the changes. The implementation was carried out in a top-down manner by a committee, in which the hospital sector--organised by regions--was better represented than the primary care sector-organised by municipalities. The idea of centralisation of acute care was supported by all stakeholders, but municipalities opposed the hospital-based early discharge teams as they perceived this to be interfering with their core tasks. Municipalities would have liked more influence on the design of the reform. Preliminary data suggest good quality of acute care. Cost savings have been achieved in the region by means of closure of beds and a reduction of hospital length of stay. The realisation of the objective of achieving integrated rehabilitation care between hospitals and municipalities has been less successful. It is likely that greater involvement of municipalities in the design phase and better representation of health care professionals in all phases would have led to more successful implementation of the reform.
The purpose of this scoping review was to survey the most recent (5 years) acute care, community health, and mental health nursing workload literature to understand themes and research avenues that may be applicable to school nursing workload research. The search for empirical and nonempirical literature was conducted using search engines such as…
Bowblis, John R; McHone, Heather S
For the affluent elderly, continuing care retirement communities (CCRCs) have become a popular option for long term care and other health care needs related to aging. While CCRCs have experienced significant growth over the last few decades, very little is known about the quality of care CCRCs provide. This paper is the first to rigorously study CCRCs on a national scale and the only study that focuses on nursing home quality. Using a national sample from 2005, we determine if the quality of post-acute care provided by CCRC nursing homes is superior to traditional nursing homes. To mimic randomization of patients, instrumental variables analysis is used with relative distance as an exclusion restriction to handle the endogeneity of the type of facility where care is provided. After adjusting for endogeniety, we find that CCRC nursing homes provide post-acute care quality that is similar or lower to traditional nursing homes, depending on the quality measure.
A service led by acute care surgeons managing trauma, critically ill surgical, and emergency general surgery patients via an acute care surgery model of patient care improves hospital efficiency and patient outcomes at university-affiliated hospitals and American College of Surgeons-verified trauma centers. Our goal was to determine whether an acute care surgeon led service, entitled the Surgical Trauma and Acute Resuscitative Service (STARS) that implemented an acute care surgery model of patient care, could improve hospital efficiency and patient outcomes at a community hospital. A total of 492 patient charts were reviewed, which included 230 before the implementation of the STARS [pre-STARS (control)] and 262 after the implementation of the STARS [post-STARS (study)]. Demographics included age, gender, Acute Physiology and Chronic Health Evaluation 2 score, and medical comorbidities. Efficiency data included length of stay in emergency department (ED-LOS), length of stay in surgical intensive care unit (SICU-LOS), and length of stay in hospital (H-LOS), and total in hospital charges. Average age was 64.1 + 16.4 years, 255 males (51.83%) and 237 females (48.17%). Average Acute Physiology and Chronic Health Evaluation 2 score was 11.9 + 5.8. No significant differences in demographics were observed. Average decreases in ED-LOS (9.7 + 9.6 hours, pre-STARS versus 6.6 + 4.5 hours, post-STARS), SICU-LOS (5.3 + 9.6 days, pre-STARS versus 3.5 + 4.8 days, post-STARS), H-LOS (12.4 + 12.7 days, pre-STARS versus 11.4 + 11.3 days, post-STARS), and total in hospital charges ($419,602.6 + $519,523.0 pre-STARS to $374,816.7 + $411,935.8 post-STARS) post-STARS. Regression analysis revealed decreased ED-LOS-2.9 hours [P = 0.17; 95% confidence interval (CI): -7.0, 1.2], SICU-LOS-6.3 days (P < 0.001; 95% CI: -9.3, -3.2), H-LOS-7.6 days (P = 0.001; 95% CI: -12.1, -3.1), and 3.4 times greater odds of survival (P = 0.04; 95% CI: 1.1, 10.7) post-STARS. In conclusion, implementation of
... providing important healthcare or personal care support. Adult Day Care Adult day care is a community-based option that has become ... support services in a group setting. Most adult day care centers are either in churches or community centers. ...
O'Reilly, Jacqueline; Lowson, Karin; Young, John; Forster, Anne; Green, John; Small, Neil
Objective To assess the cost effectiveness of post-acute care for older people in a locality based community hospital compared with a department for care of elderly people in a district general hospital, which admits patients aged over 76 years with acute medical conditions. Design Cost effectiveness analysis within a randomised controlled trial. Setting Community hospital and district general hospital in Yorkshire, England. Participants 220 patients needing rehabilitation after an acute illness for which they required admission to hospital. Interventions Multidisciplinary care in the district general hospital or prompt transfer to the community hospital. Main outcome measures EuroQol EQ-5D scores transformed into quality adjusted life years (QALYs), and health and social service costs over six months from randomisation. Results The mean QALY score for the community hospital group was marginally non-significantly higher than that for the district general hospital group (0.38 v 0.35) at six months after recruitment. The mean (standard deviation) costs per patient of the health and social services resources used were similar for both groups: community hospital group £7233 (euros 10 567; $13 341) (£5031), district general hospital group £7351 (£6229), and these findings were robust to several sensitivity analyses. The incremental cost effectiveness ratio for community hospital care dominated. A cost effectiveness acceptability curve, based on bootstrapped simulations, suggests that at a willingness to pay threshold of £10 000 per QALY, 51% of community hospital cases will be cost effective, which rises to 53% of cases when the threshold is £30 000 per QALY. Conclusion Post-acute care for older people in a locality based community hospital is of similar cost effectiveness to that of an elderly care department in a district general hospital. PMID:16861254
Davis, Kimberly A; Rozycki, Grace S
At the center of the development of acute care surgery is the growing difficulty in caring for patients with acute surgical conditions. Care demands continue to grow in the face of an escalating crisis in emergency care access and the decreasing availability of surgeons to cover emergency calls. To compound this problem, there is an ever-growing shortage of general surgeons as technological advances have encouraged subspecialization. Developed by the leadership of the American Association for the Surgery of Trauma, the specialty of acute care surgery offers a training model that would produce a new breed of specialist with expertise in trauma surgery, surgical critical care, and elective and emergency general surgery. This article highlights the evolution of the specialty in hope that these acute care surgeons, along with practicing general surgeons, will bring us closer to providing superb and timely care for patients with acute surgical conditions.
Levy, Matthew E; Watson, Christopher Chauncey; Glick, Sara Nelson; Kuo, Irene; Wilton, Leo; Brewer, Russell A; Fields, Sheldon D; Criss, Vittoria; Magnus, Manya
Characterization of structural barriers that impede the receipt of HIV prevention and care services is critical to addressing the HIV epidemic among Black men who have sex with men (BMSM). This study investigated the utilization of HIV prevention and general care services among a non-clinic-based sample of BMSM who reported at least one structural barrier to engagement in care. Proportions of participants who had received HIV prevention services and general care services in different settings were compared using Fisher's exact test and correlates of service receipt were assessed using logistic regression. Among 75 BMSM, 60% had accessed a community-based clinic, 21% had accessed a primary care setting, and 36% had accessed an acute care setting in the last 6 months. Greater proportions of participants who had accessed community-based clinics received HIV prevention services during these visits (90%) compared to those who had accessed primary care (53%) and acute care (44%) settings (p = .005). Opportunities for BMSM to receive HIV prevention interventions differed by care setting. Having access to health care did not necessarily facilitate the uptake of HIV prevention interventions. Further investigation of the structurally rooted reasons why BMSM are often unable to access HIV prevention services is warranted.
Califf, R.M.; Wagner, G.S.
This book contains 22 chapters. Some of the titles are: The measurement of acute myocardial infarct size by CT; Magnetic resonance imaging for evaluation of myocardial ischemia and infarction; Poistron imaging in the evaluation of ischemia and myocardial infarction; and New inotropic agents.
Russell, J S
In the last few years, much medical-facility construction has been driven by what insurers want. Hospitals have built facilities for well-reimbursed procedures and closed money-losing ones. Health-maintenance organizations increasingly expect to hold down costs by making prepayment arrangements with doctors and their hospitals. President Clinton has pledged early action on health-care reform, which will likely change planners' priorities. Whether the nation goes to Clintonian "managed competition" or a Canadian-style nationwide single-payer system (the two most likely options), the projects on these pages reflect two large-scale trends that are likely to continue: the movement of more procedures from inpatient to outpatient facilities and the separation of treatment functions from ordinary office and administrative tasks so that the latter are not performed in the same high-cost buildings as technology-intensive procedures. Various schemes that make care more "patient-centered" have been tried and been shown to speed healing, even for outpatients, but such hard-to-quantify issues get short shrift in an era of knee-jerk cost containment. The challenge in tomorrow's healthcare universe--whatever it becomes--will be to keep these issues on the table.
The aim of community care is to enable people with various types of disability to live in their own homes, rather than in institutions. This involves the provision of support and services at home by various agencies. After a critical report in 1986 identified problems with coordination and flexibility of community care services, the white paper Caring for People (1989) stated the government's aim to provide a "needs led," responsive range of services, promoting maximum independence of those wishing to live at home rather than enter institutional care. New arrangements were introduced in 1993, involving a formal assessment procedure and the production of a personalized care plan for each individual, incorporating services provided by private and voluntary agencies as well as by social services departments. This article describes the components of community care services supplied by local social services authorities, including housing adaptations, equipment, telephones and alarms, home care, meals, and respite care. Images p871-a PMID:8870580
Daly, Donnelle; Matzel, Stephen Chavez
A transdisciplinary team is an essential component of palliative and end-of-life care. This article will demonstrate how to develop a transdisciplinary approach to palliative care, incorporating nursing, social work, spiritual care, and pharmacy in an acute care setting. Objectives included: identifying transdisciplinary roles contributing to care in the acute care setting; defining the palliative care model and mission; identifying patient/family and institutional needs; and developing palliative care tools. Methods included a needs assessment and the development of assessment tools, an education program, community resources, and a patient satisfaction survey. After 1 year of implementation, the transdisciplinary palliative care team consisted of seven palliative care physicians, two social workers, two chaplains, a pharmacist, and End-of-Life Nursing Consortium (ELNEC) trained nurses. Palomar Health now has a palliative care service with a consistent process for transdisciplinary communication and intervention for adult critical care patients with advanced, chronic illness.
Planning for patient discharge is an essential element of any admission to an acute setting, but may often be left until the patient is almost ready to leave hospital. This article emphasises why discharge planning is important and lists the essential principles that should be addressed to ensure that patients leave at an optimum time, feeling confident and safe to do so. Early assessment, early planning and co-ordination of all the teams involved in the patient's care are essential. Effective communication between the various teams and with the patient and their family or carer(s) is necessary. Patients should leave hospital with all the information, medications and equipment they require. Appropriate plans should have been developed and communicated to the receiving community or non-acute team. When patient discharge is effective, complications as a result of extended lengths of hospital stay are prevented, hospital beds are used efficiently and readmissions are reduced.
Dean, Marleah; Oetzel, John; Sklar, David P
Effective communication has been linked to better health outcomes, higher patient satisfaction, and treatment adherence. Communication in ambulatory care contexts is even more crucial, as providers typically do not know patients' medical histories or have established relationships, conversations are time constrained, interruptions are frequent, and the seriousness of patients' medical conditions may create additional tension during interactions. Yet, health communication often unduly emphasizes information exchange-the transmission and receipt of messages leading to a mutual understanding of a patient's condition, needs, and treatments. This approach does not take into account the importance of rapport building and contextual issues, and may ultimately limit the amount of information exchanged.The authors share the perspective of communication scientists to enrich the current approach to medical communication in ambulatory health care contexts, broadening the under standing of medical communication beyond information exchange to a more holistic, multilayered viewpoint, which includes rapport and contextual issues. The authors propose a socio-ecological model for understanding communication in acute ambulatory care. This model recognizes the relationship of individuals to their environment and emphasizes the importance of individual and contextual factors that influence patient-provider interactions. Its key elements include message exchange and individual, organizational, societal, and cultural factors. Using this model, and following the authors' recommendations, providers and medical educators can treat communication as a holistic process shaped by multiple layers. This is a step toward being able to negotiate conflicting demands, resolve tensions, and create encounters that lead to positive health outcomes.
Goodman, Melody S.; Gonzalez, Maria; Gil, Sandra; Si, Xuemei; Pashoukos, Judith L.; Stafford, Jewel D.; Ford, Elsa; Pashoukos, Dennis A.
Background The Community Alliance for Research Empowering Social Change (CARES) is an academic–community research partnership designed to train community members on research methods and develop the infrastructure for community-based participatory research (CBPR) to examine and address racial/ethnic health disparities. The Brentwood Community Health Assessment (BCHA) was developed through a CBPR pilot project grant from CARES. Objectives The purpose of the BCHA is to assess health care utilization and identify existing barriers to health care access among a multi-ethnic community in the Hamlet of Brentwood, New York. Methods Using CBPR approaches, the community–academic research partnership develop the study design and survey instrument. Trained Bilingual (English/Spanish) data collectors verbally administered surveys door-to-door to residents of Brentwood from October 2010 to May 2011. Inclusion criteria required participants to be at least 18 years of age and speak either English or Spanish. Results Overall, 232 residents completed the BCHA; 49% were male, 66% Hispanic, 13% non-Hispanic White, 13% non-Hispanic Black, 29% had less than a high school education, and 33% were born in United States. The assessment results revealed that most residents are able to access health care when needed and the most significant barriers to health care access are insurance and cost. Conclusions We describe the community–academic partnered process used to develop and implement the BCHA and report assessment findings; the community-partnered approach improved data collection and allowed access into one of Suffolk County’s most vulnerable communities. PMID:24859100
Roth, Sean M; Keyser, Gabrielle; Winfield, Michelle; McNeil, Julie; Simko, Leslie; Price, Karen; Moffa, Donald; Hussain, Muhammad Shazam; Peacock, W Frank; Katzan, Irene L
The Acute Care Team Educational Initiative (ACTEI) was developed as a quality improvement initiative for the recognition and initial management of time-sensitive medical conditions. For our first time-sensitive disease process, we focused on acute stroke [acute stroke initiative (ASI)]. As part of the larger ACTEI, the ASI included creating an ACT that responds to all suspected emergency department stroke patients. In this article, we describe the planning, process, and development of the ACTEI/ASI as well as how we created an acute response team for the diagnosis and management of suspected acute stroke.
Brown, S.; Hine, N.; Sixsmith, A.; Garner, P.
The UK population is ageing. At the time of the 2001 census there were 8.1 million people aged over 65 living in the UK, 3.1 million of them living alone. By 2011 the number of over 65s is projected to reach just under 12 million, and by 2026 over 13 million . The extra workload this will place on health and care services will be compounded by political ambitions aimed at meeting the challenges of rising patient expectations . In addition to this, the Department of Health aims to promote the independence of older people by providing enhanced services from the National Health Service (NHS) and councils to prevent unnecessary hospital admission . As a result we can expect to see a continuing rise in the number of elderly people living at home and requiring good-quality health and social care services.
Ahmad, Waqar I. U., Ed.; Atkin, Karl, Ed.
This collection offers a wide-ranging introduction to contemporary issues surrounding the health care needs of members of minority ethnic communities within the framework of community care in Britain. The following chapters consider state welfare, minority communities, family structures, and social change: (1) "'Race' and Community Care: An…
Background Intermittent treatment of acute lower acuity situations has come to be defined as urgent rather than emergent care. The location of urgent care delivery has been shifting from exclusively hospital or office settings to other community locales. Aims To review the concept of urgent care and the new models of health care delivery in the niche between hospitals and primary care. To highlight the roles of urgent care in Israel and compare these roles with those in other countries. Method Narrative review of the literature. Main findings The new models of community based urgent care include 1) the urgent care center; 2) the retail or convenience clinic, 3) the free standing emergency center, and 4) the walk-in clinic. These models fall on a continuum of comprehensiveness. They offer care at a lower cost than hospital-based emergency departments and greater temporal convenience than primary care physicians. However, their impact on emergency department utilization and overcrowding or primary care physician overload is unclear. Israel has integrated its urgent care centers into its national health system by encouraging the use of urgent care centers and by requiring all health insurance funds to reimburse patients who use these centers. This integration is similar to the approach in England; however, the type of service is different in that the service in England is provided by nurses. It is different from most other countries where urgent care facilities are primarily private ventures. Conclusions Community-based acute care facilities are becoming a part of the medical landscape in a number of countries. Still, they remain primarily on the fringe of organized medicine. Despite the important role of community-based acute care facilities in Israel, no nationwide study has been done in two decades. Health policy planning in Israel necessitates further study of urgent care use and its clinical outcomes. PMID:24152917
Castle, Bryan W; Shapiro, Susan E
Accountable Care Units are a disruptive innovation that has moved care on acute care units from a traditional silo model, in which each discipline works separately from all others, to one in which multiple disciplines work together with patients and their families to move patients safely through their hospital stay. This article describes the "what," "how," and "why" of the Accountable Care Units model as it has evolved in different locations across a single health system and includes the lessons learned as different units and hospitals continue working to implement the model in their complex care environments.
Horwitz, Rany J.; And Others
The University of Illinois' medical school has a third-year program of weekly role-playing exercises focusing on management of acute medical problems. Students are responsible for creating the cases, complete with scenarios and treatment teams, simulating them, and successfully treating or reaching an impasse. Little teacher preparation time is…
Shitole, Sanyog G; Kayo, Noel; Srinivas, Vankeepuram; Alapati, Venkatesh; Nordin, Charles; Southern, William; Christia, Panagiota; Faillace, Robert T; Scheuer, James; Kizer, Jorge R
Although cocaine is a well-recognized risk factor for coronary disease, detailed information is lacking regarding related behavioral and clinical features of cocaine-associated ST-segment elevation myocardial infarction (STEMI), particularly in socioeconomically disadvantaged urban settings. Nor are systematic or extended follow-up data available on outcomes for cocaine-associated STEMI in the contemporary era of percutaneous coronary intervention. We leveraged a prospective STEMI registry from a large health system serving an inner-city community to characterize the clinical features, acute management, and middle-term outcomes of cocaine-related versus cocaine-unrelated STEMI. Of the 1,003 patients included, 60% were black or Hispanic. Compared with cocaine-unrelated STEMI, cocaine-related STEMI (n = 58) was associated with younger age, male gender, lower socioeconomic score, current smoking, high alcohol consumption, and human immunodeficiency virus seropositivity but less commonly with diabetes or hypertension. Cocaine users less often received drug-eluting stents or β blockers at discharge. During median follow-up of 2.7 years, rates of death, death or any rehospitalization, and death or cardiovascular rehospitalization did not differ significantly between cocaine users and nonusers but were especially high for death or any hospitalization in the 2 groups (31.4 vs 32.4 per 100 person-years, p = 0.887). Adjusted hazard ratios for outcomes were likewise not significantly different. In conclusion, in this low-income community, cocaine use occurred in a substantial fraction of STEMI cases, who were younger than their nonuser counterparts but had more prevalent high-risk habits and exhibited similarly high rates of adverse outcomes. These data suggest that programs targeting cocaine abuse and related behaviors could contribute importantly to disease prevention in disadvantaged communities.
Background Seniors with chronic diseases such as heart failure have complex care needs. They are vulnerable to their condition deteriorating and, without timely intervention, may require multiple emergency department visits and/or repeated hospitalizations. Upon discharge, the transition from the emergency department to home can be a vulnerable time for recovering patients with disruptions in the continuity of care. Remote monitoring of heart failure patients using home telemonitoring, coupled with clear communication protocols between health care professionals, can be effective in increasing the safety and quality of care for seniors with heart failure discharged from the emergency department. Objective The aim of the Telehealth for Emergency-Community Continuity of Care Connectivity via Home Telemonitoring (TEC4Home) study is to generate evidence through a programmatic evaluation and a clinical trial to determine how home telemonitoring may improve care and increase patient safety during the transition of care and determine how it is best implemented to support patients with heart failure within this context. Methods This 4-year project consists of 3 studies to comprehensively evaluate the outcomes and effectiveness of TEC4Home. Study 1 is a feasibility study with 90 patients recruited from 2 emergency department sites to test implementation and evaluation procedures. Findings from the feasibility study will be used to refine protocols for the larger trial. Study 2 is a cluster randomized controlled trial that will include 30 emergency department sites and 900 patients across British Columbia. The primary outcome of the randomized controlled trial will be emergency department revisits and hospital readmission rates. Secondary outcomes include health care resource utilization/costs, communication between members of the care team, and patient quality of life. Study 3 will run concurrently to study 2 and test the effectiveness of predictive analytic software to
... AFFAIRS 38 CFR Part 17 RIN 2900-AO62 Community Residential Care AGENCY: Department of Veterans Affairs... concerning approval of non-VA community residential care facilities to allow VA to waive such facilities... cannot be corrected, and into more restrictive and/or costly care. In addition, we make a technical...
Quinn Griffin, Mary T; Klein, Deborah; Winkelman, Chris
As genomic health care becomes commonplace, nurses will be asked to provide genomic care in all health care settings including acute care and critical care. Three common cardiac conditions are reviewed, Marfan syndrome, bicuspid aortic valve, and hypertrophic cardiomyopathy, to provide acute care and critical care nurses with an overview of these pathologies through the lens of genomics and relevant case studies. This information will help critical care nursing leaders become familiar with genetics related to common cardiac conditions and prepare acute care and critical care nurses for a new phase in patient diagnostics, with greater emphasis on early diagnosis and recognition of conditions before sudden cardiac death.
Sathe, Prachee M.; Patwa, Urvil D.
Pulmonary embolism, Deep Vein Thrombosis (DVT) and Disseminated intravascular coagulation (DIC) are important sources of mortality and morbidity in intensive care unit (ICU). And every time D-dimer remains the the commonest investigation. Many times D-dimer is erroneously considered as a diagnostic test in above mentioned conditions. Its interpretation requires cautions. To circumvent this source of error it is necessary to understand D-dimer test and its significance in various disorder. This article review some basic details of D-dimer, condition associated with its increased level and some prognostic value in intracranial hemorrhage and gastrointestinal (GI) bleed. PMID:25337485
Davidson, Patricia M; Introna, Kate; Cockburn, Jill; Daly, John; Dunford, Mary; Paull, Glenn; Dracup, Kathleen
Advances in the practice of medicine and nursing science have increased survival for patients with chronic cardiorespiratory disease. Parallel to this positive outcome is a societal expectation of longevity and cure of disease. Chronic disease and the inevitability of death creates a dilemma, more than ever before, for the health care professional, who is committed to the delivery of quality care to patients and their families. The appropriate time for broaching the issue of dying and determining when palliative care is required is problematic. Dilemmas occur with a perceived dissonance between acute and palliative care and difficulties in determining prognosis. Palliative care must be integrated within the health care continuum, rather than being a discrete entity at the end of life, in order to achieve optimal patient outcomes. Anecdotally, acute and critical care nurses experience frustration from the tensions that arise between acute and palliative care philosophies. Many clinicians are concerned that patients are denied a good death and yet the moment when care should be oriented toward palliation rather than aggressive management is usually unclear. Clearly this has implications for the type and quality of care that patients receive. This paper provides a review of the extant literature and identifies issues in the end of life care for patients with chronic cardiorespiratory diseases within acute and critical care environments. Issues for refinement of acute and critical care nursing practice and research priorities are identified to create a synergy between these philosophical perspectives.
A negative image of community care prevails. This method of care is perceived to be a relatively novel phenomenon and has received mixed media coverage. The negative image of community care has led to the growing belief that this care method has failed. This failure has largely been ascribed to the lack of powers available to control patients in the community and to the method's relative novelty. However, this paper contends that there are two flaws to the above assertion: first, community care is far from new, and second, the inherent problem is not the lack of powers available to control patients in the community, but, essentially, the absence of a secure and stable environment within the community. PMID:9800590
Rochon, Andrea; Heale, Roberta; Hunt, Elena; Parent, Michele
The literature suggests that effective teamwork among patient care teams can positively impact work environment, job satisfaction and quality of patient care. The purpose of this study was to determine the perceived level of nursing teamwork by registered nurses, registered practical nurses, personal support workers and unit clerks working on patient care teams in one acute care hospital in northern Ontario, Canada, and to determine if a relationship exists between the staff scores on the Nursing Teamwork Survey (NTS) and participant perception of adequate staffing. Using a descriptive cross-sectional research design, 600 staff members were invited to complete the NTS and a 33% response rate was achieved (N=200). The participants from the critical care unit reported the highest scores on the NTS, whereas participants from the inpatient surgical (IPS) unit reported the lowest scores. Participants from the IPS unit also reported having less experience, being younger, having less satisfaction in their current position and having a higher intention to leave. A high rate of intention to leave in the next year was found among all participants. No statistically significant correlation was found between overall scores on the NTS and the perception of adequate staffing. Strategies to increase teamwork, such as staff education, among patient care teams may positively influence job satisfaction and patient care on patient care units.
Ellerbeck, Edward F.; Bhimaraj, Arvind; Perpich, Denise
One in 4 Americans lives in a rural community and relies on rural hospitals and medical systems for emergent care of acute myocardial infarctions (AMI). The infrastructure and organization of AMI care in rural and urban Kansas hospitals was examined. Using a nominal group process, key elements within hospitals that might influence quality of AMI…
Pichichero, Michael E.; Casey, Janet R.; Almudevar, Anthony
Objective We sought to determine if use of more stringent diagnostic criteria for acute otitis media (AOM) than currently advocated by the American Academy of Pediatrics (AAP), tympanocentesis and pathogen-specific antibiotic treatment (individualized care) would result in reducing the incidence of recurrent AOM and consequent tympanostomy tube surgery. Methods A 5 year longitudinal, prospective study in Rochester NY was conducted from July 2006 – July 2011 involving 254 individualized care children. When this individualized care group developed symptoms of AOM, strict diagnostic criteria were applied and a tympanocentesis was performed. Pathogen resistance to empiric high dose amoxicillin/clavulanate (80mg/kg of amoxicillin component) caused a change in antibiotic to an optimized choice. Legacy controls (n=208) were diagnosed with the same diagnostic criteria by the same physicians as the individualized care group and received the same empiric amoxicillin/clavulanate (80mg/kg of Amoxicillin component) but no tympanocentesis or change in antibiotic. Community control children (n=1020) were diagnosed according to current AAP guidelines and treated with high dose amoxicillin (80 mg/kg) without tympanocentesis as guideline recommended. Results 5.9% of children of the individualized care group compared to 14.4% of Legacy controls and 27.3% of community controls became otitis prone (OP), defined as 3 episodes of AOM within a 6-month time span or 4 AOM episodes within a 12-month time span (p<0.0001). 2.4% of the individualized care group compared to 6.3% of Legacy controls, and 14.8% of community controls received tympanostomy tubes (p<0.0001). Conclusions Individualized care of AOM significantly reduces the frequency of AOM and tympanostomy tube surgery. Use of strict diagnostic criteria for AOM and empiric antibiotic treatment using evidence-based knowledge of circulating otopathogens and their antimicrobial susceptibility profile also produces improved outcomes
Smith, Veronica M
There has been little research that explores the interaction between community pharmacists and community nurses and how this interaction could benefit people affected by dementia. Using information taken from a larger study, this article presents the views of community pharmacists and one community nurse on how their communication, information sharing and team integration may improve care for this patient group. The community pharmacists reported positive attitudes to supporting people affected by dementia, but they highlighted barriers to integrated team working. In contrast, the community nurse conveyed the belief that the community pharmacist was an integrated member of the community health team. Community pharmacists and community nurses are keen to interact with each other to support people affected by dementia, but this interaction stops short of collaborative, integrated team working. Further research is needed to address this issue.
Sfakianaki, Efrosyni; Sfakianakis, George N; Georgiou, Mike; Hsiao, Bernard
Renal scintigraphy is a powerful imaging method that provides both functional and anatomic information, which is particularly useful in the acute care setting. In our institution, for the past 2 decades, we have used a 25-minute renal diuretic protocol, technetium-99m ((99m)Tc) mercaptoacetyltriglycine with simultaneous intravenous injection of furosemide, for all ages and indications, including both native and transplant kidneys. As such, this protocol has been widely used in the workup of acutely ill patients. In this setting, there are common clinical entities which affect patients with native and transplant kidneys. In adult patients with native kidneys one of the most frequent reasons for emergency room visits is renal colic due to urolithiasis. Although unenhanced computed tomography is useful to assess the anatomy in cases of renal colic, it does not provide functional information. Time zero furosemide renal scintigraphy can do both and we have shown that it can effectively stratify patients with renal colic. To this end, 4 characteristic patterns of scintirenography have been identified, standardized, and consistently applied: no obstruction, partial obstruction (mild vs high grade), complete obstruction, and stunned (postdecompressed) kidney. With the extensive use of this protocol over the past 2 decades, a pattern of "regional parenchymal dysfunction" indicative of acute pyelonephritis has also been delineated. This information has proved to be useful for patients presenting with urinary tract infection and suspected pyelonephritis, as well as for patients who were referred for workup of renal colic but were found to have acute pyelonephritis instead. In instances of abdominal trauma, renal scintigraphy is uniquely suited to identify urine leaks. This is also true in cases of suspected leak following renal transplant or from other iatrogenic/postsurgical causes. Patients presenting with acute renal failure can be evaluated with renal scintigraphy. A
McWilliams, J Michael; Chernew, Michael E; Zaslavsky, Alan M; Landon, Bruce E
Objective To determine how the inclusion of post-acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs). Data Sources Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Association Group Practice data identifying provider groups sufficiently large to be eligible for ACO program participation. Study Design We calculated the fraction of community-dwelling beneficiaries whose assignment shifted, as a consequence of including post-acute E&M services, from the group providing their outpatient primary care to a different group providing their inpatient post-acute care. Principal Findings Assignment shifts occurred for 27.6 percent of 25,992 community-dwelling beneficiaries with at least one post-acute skilled nursing facility stay, and they were more common for those incurring higher Medicare spending. Those whose assignment shifted constituted only 1.3 percent of all community-dwelling beneficiaries cared for by large ACO-eligible organizations (n = 535,138), but they accounted for 8.4 percent of total Medicare spending for this population. Conclusions Under current Medicare assignment rules, ACOs may not be accountable for an influential group of post-acute patients, suggesting missed opportunities to improve care coordination and reduce inappropriate readmissions. PMID:23350910
Pines, Jesse M; Lotrecchiano, Gaetano R; Zocchi, Mark S; Lazar, Danielle; Leedekerken, Jacob B; Margolis, Gregg S; Carr, Brendan G
We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts' comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery.
Pulikottil-Jacob, Ruth; Marshall, Fiona; Montgomery, Alan; Tan, Wei; Sach, Tracey; Logan, Pip; Kendrick, Denise; Watson, Alison; Walker, Maria; Waring, Justin
Abstract Objective to compare the clinical and cost-effectiveness of a Community In-reach Rehabilitation and Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service. Design pragmatic randomised controlled trial with an integral health economic study. Settings large UK teaching hospital, with community follow-up. Subjects frail older people aged 70 years and older admitted to hospital as an acute medical emergency. Measurements Primary outcome: hospital length of stay; secondary outcomes: readmission, day 91-super spell bed days, functional ability, co-morbidity and health-related quality of life; cost-effectiveness analysis. Results a total of 250 participants were randomised. There was no significant difference in length of stay between the CIRACT and THB-Rehab service (median 8 versus 9 days; geometric mean 7.8 versus 8.7 days, mean ratio 0.90, 95% confidence interval (CI) 0.74–1.10). Of the participants who were discharged from hospital, 17% and 13% were readmitted within 28 days from the CIRACT and THB-Rehab services, respectively (risk difference 3.8%, 95% CI −5.8% to 13.4%). There were no other significant differences in any of the other secondary outcomes between the two groups. The mean costs (including NHS and personal social service) of the CIRACT and THB-Rehab service were £3,744 and £3,603, respectively (mean cost difference £144; 95% CI −1,645 to 1,934). Conclusion the CIRACT service does not reduce major hospital length of stay nor reduce short-term readmission rates, compared to the standard THB-Rehab service; however, a modest (<2.3 days) effect cannot be excluded. Further studies are necessary powered with larger sample sizes and cluster randomisation. Trial registration ISRCTN 94393315, 25th April 2013 PMID:28180236
hospital acute care capacity is measured in patient beds and utilization is measured and projected in terms of patient days or admissions times length...the Community Served by Kimbrough Army Comunity Hospital , Ft. Meade, Maryland 12. PERSONAL AUITHOR(S) Captain Donald C. Curry, Jr., 13a. TYPE OF REPORT...COMMUNITY SERVED BY KIMBROUGH ARMY COMMUNITY HOSPITAL FORT MEADE, MARYLAND A Problem Solving Project Submitted to the Faculty of Baylor University In
Sorensen, Ros; Iedema, Rick
The care of people who die in hospitals is often suboptimal. Involving patients in decisions about their care is seen as one way to improve care outcomes. Federal and state government policymakers in Australia are promoting shared decision making in acute care hospitals as a means to improve the quality of end-of-life care. If policy is to be…
Dilwali, Prashant K
The responsibility of hospitals is changing. Those activities that were once confined within the walls of the medical facility have largely shifted outside them, yet the requirements for hospitals have only grown in scope. With the passage of the Patient Protection and Affordable Care Act (ACA) and the development of accountable care organizations, financial incentives are focused on care coordination, and a hospital's responsibility now includes postdischarge outcomes. As a result, hospitals need to adjust their business model to accommodate their increased need to impact post-acute care settings. A home care service line can fulfill this role for hospitals, serving as an effective conduit to the postdischarge realm-serving as both a potential profit center and a risk mitigation offering. An alliance between home care agencies and hospitals can help improve clinical outcomes, provide the necessary care for communities, and establish a potentially profitable product line.
Salazar, Amy M; Haggerty, Kevin P; de Haan, Benjamin; Catalano, Richard F; Vann, Terri; Vinson, Jean; Lansing, Michaele
The prevention of mental, emotional, and behavioral (MEB) disorders among children and adolescents is a national priority. One mode of implementing community-wide MEB prevention efforts is through evidence-based community mobilization approaches such as Communities That Care (CTC). This article provides an overview of the CTC framework and discusses the adaptation process of CTC to prevent development of MEBs through preventing child abuse and neglect and bolstering child well-being in children aged 0 to 10. Adaptations include those to the intervention itself as well as those to the evaluation approach. Preliminary findings from the Keeping Families Together pilot study of this evolving approach suggest that the implementation was manageable for sites, and community board functioning and community adoption of a science-based approach to prevention in pilot sites looks promising. Implications and next steps are outlined. (PsycINFO Database Record
Lymbery, M; Millward, A
This paper examines the establishment of social work within primary health care settings in Great Britain, following the passage of the National Health Service and Community Care Act in 1990. Although the improvement of relationships between social workers and primary health care teams has been promoted for a number of years, the advent of formal policies for community care has made this a priority for both social services and health. This paper presents interim findings from the evaluation of three pilot projects in Nottinghamshire, Great Britain. These findings are analysed from three linked perspectives. The first is the extent to which structures and organisations have worked effectively together to promote the location of social workers within health care settings. The second is the impact of professional and cultural factors on the work of the social worker in these settings. The third is the effect of interpersonal relationships on the success of the project. The paper will conclude that there is significant learning from each of these perspectives which can be applied to the future location of social workers to primary health care.
Yeaman, Brian; Ko, Kelly J; Alvarez del Castillo, Rodolfo
Care transitions between settings are a well-known cause of medical errors. A key component of transition is information exchange, especially in long-term care (LTC). However, LTC is behind other settings in adoption of health information technologies (HIT). In this article, we provide some brief background information about care transitions in LTC and concerns related to technology. We describe a pilot project using HIT and secure messaging in LTC to facilitate electronic information exchange during care transitions. Five LTC facilities were included, all located within Oklahoma and serviced by the same regional health system. The study duration was 20 months. Both inpatient readmission and return emergency department (ED) visit rates were lower than baseline following implementation. We provide discussion of positive outcomes, lessons learned, and limitations. Finally, we offer implications for practice and research for implementation of HIT and information exchange across care settings that may contribute to reduction in readmission rates in acute care and ED settings.
Califf, R.M.; Wagner, G.S.
This book contains 58 chapters. Some of the chapter titles are: Radionuclide Techniques for Diagnosing and Sizing of Myocardial Infarction; The Use of Serial Radionuclide Angiography for Monitoring Function during Acute Myocardial Infarction; Hemodynamic Monitoring in Acute Myocardial Infarction; and The Valve of Radionuclide Angiography for Risk Assessment of Patients following Acute Myocardial Infarction.
Steiner, Beat D; Denham, Amy C; Ashkin, Evan; Newton, Warren P; Wroth, Thomas; Dobson, L Allen
The United States leads the world in health care costs but ranks far below many developed countries in health outcomes. Finding ways to narrow this gap remains elusive. This article describes the response of one state to establish community health networks to achieve quality, utilization, and cost objectives for the care of its Medicaid recipients. The program, known as Community Care of North Carolina, is an innovative effort organized and operated by practicing community physicians. In partnership with hospitals, health departments, and departments of social services, these community networks have improved quality and reduced cost since their inception a decade ago. The program is now saving the State of North Carolina at least $160 million annually. A description of this experience and the lessons learned from it can inform others seeking to implement effective systems of care for patients with chronic illness.
Bond, Penny; Goudie, Karen
Delirium is an acute medical emergency affecting about one in eight acute hospital inpatients. It is associated with poor outcomes, is more prevalent in older people and it is estimated that half of all patients receiving intensive care or surgery for a hip fracture will be affected. Despite its prevalence and impact, delirium is not reliably identified or well managed. Improving the identification and management of patients with delirium has been a focus for the national improving older people's acute care work programme in NHS Scotland. A delirium toolkit has been developed, which includes the 4AT rapid assessment test, information for patients and carers and a care bundle for managing delirium based on existing guidance. This toolkit has been tested and implemented by teams from a range of acute care settings to support improvements in the identification and immediate management of delirium.
Shah, Manish N; Gillespie, Suzanne M; Wood, Nancy; Wasserman, Erin B; Nelson, Dallas L; Dozier, Ann; McConnochie, Kenneth M
Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models.
Kaye, Erica C; Rubenstein, Jared; Levine, Deena; Baker, Justin N; Dabbs, Devon; Friebert, Sarah E
Early integration of pediatric palliative care (PPC) for children with life-threatening conditions and their families enhances the provision of holistic care, addressing psychological, social, spiritual, and physical concerns, without precluding treatment with the goal of cure. PPC involvement ideally extends throughout the illness trajectory to improve continuity of care for patients and families. Although current PPC models focus primarily on the hospital setting, community-based PPC (CBPPC) programs are increasingly integral to the coordination, continuity, and provision of quality care. In this review, the authors examine the purpose, design, and infrastructure of CBPPC in the United States, highlighting eligibility criteria, optimal referral models to enhance early involvement, and fundamental tenets of CBPPC. This article also appraises the role of CBPPC in promoting family-centered care. This model strives to enhance shared decision making, facilitate seamless handoffs of care, maintain desired locations of care, and ease the end of life for children who die at home. The effect of legislation on the advent and evolution of CBPPC also is discussed, as is an assessment of the current status of state-specific CBPPC programs and barriers to implementation of CBPPC. Finally, strategies and resources for designing, implementing, and maintaining quality standards in CBPPC programs are reviewed.
Collins, Courtney E.; Pringle, Patricia L.; Santry, Heena P.
Background Patterns of adoption of acute care surgery (ACS) as a strategy for emergency general surgery (EGS) care are unknown. Methods We conducted a qualitative study comprising face-to-face interviews with senior surgeons responsible for ACS at 18 teaching hospitals chosen to ensure diversity of opinions and practice environment (three practice types [community, public/charity, university] in each of six geographic regions [Mid-Atlantic, Midwest, New England, Northeast, South, West]). Interviews were recorded, transcribed, and analyzed using NVivo (QSR International, Melbourne, Australia). We applied the methods of investigator triangulation using an inductive approach to develop a final taxonomy of codes organized by themes related to respondents’ views on the future of ACS as a strategy for EGS. We applied our findings to a conceptual model on diffusion of innovation. Results We found a paradox between ACS viewed as a healthcare delivery innovation versus a rebranding of comprehensive general surgery. Optimism for the future of ACS due to increased desirability for trauma/critical care careers and improved outcomes for EGS was tempered by fear over lack of continuity, poor institutional resources and uncertainty regarding financial viability. Our analysis suggests that the implementation of ACS, whether a true healthcare delivery innovation or an innovative rebranding, fits into the Rogers’ Diffusion of Innovation Theory. Conclusions Despite concerns over resource allocation and the definition of the specialty, from the perspective of senior surgeons deeply entrenched in executing this care-delivery model, ACS represents the new face of general surgery that will likely continue to diffuse from these early adopters. PMID:25891673
Dummit, Laura A
Fee-for-service Medicare, in which a separate payment is made for each service, rewards health care providers for delivering more services, but not necessarily coordinating those services over time or across settings. To help address these concerns, the Patient Protection and Affordable Care Act of 2010 requires Medicare to experiment with making a bundled payment for a hospitalization plus post-acute care, that is, the recuperative or rehabilitative care following a hospital discharge. This bundled payment approach is intended to promote more efficient care across the acute/post-acute episode because the entity that receives the payment has financial incentives to keep episode costs below the payment. Although the entity is expected to control costs through improved care coordination and efficiency, it could stint on care or avoid expensive patients instead. This issue brief focuses on the unique challenges posed by the inclusion of post-acute care services in a payment bundle and special considerations in implementing and evaluating the episode payment approach.
Feo, Rebecca; Kitson, Alison
Meeting patients' fundamental care needs is essential for optimal safety and recovery and positive experiences within any healthcare setting. There is growing international evidence, however, that these fundamentals are often poorly executed in acute care settings, resulting in patient safety threats, poorer and costly care outcomes, and dehumanising experiences for patients and families. Whilst care standards and policy initiatives are attempting to address these issues, their impact has been limited. This discussion paper explores, through a series of propositions, why fundamental care can be overlooked in sophisticated, high technology acute care settings. We argue that the central problem lies in the invisibility and subsequent devaluing of fundamental care. Such care is perceived to involve simple tasks that require little skill to execute and have minimal impact on patient outcomes. The propositions explore the potential origins of this prevailing perception, focusing upon the impact of the biomedical model, the consequences of managerial approaches that drive healthcare cultures, and the devaluing of fundamental care by nurses themselves. These multiple sources of invisibility and devaluing surrounding fundamental care have rendered the concept underdeveloped and misunderstood both conceptually and theoretically. Likewise, there remains minimal role clarification around who should be responsible for and deliver such care, and a dearth of empirical evidence and evidence-based metrics. In explicating these propositions, we argue that key to transforming the delivery of acute healthcare is a substantial shift in the conceptualisation of fundamental care. The propositions present a cogent argument that counters the prevailing perception that fundamental care is basic and does not require systematic investigation. We conclude by calling for the explicit valuing and embedding of fundamental care in healthcare education, research, practice and policy. Without this
Kang, Raymond; Hasnain-Wynia, Romana
We examine the association between hospital community orientation and quality-of-care measures, which include process measures for patients admitted for acute myocardial infarction, heart failure, and pneumonia as well as measures of patient experience. The community orientation measure is obtained from the 2009 American Hospital Association's Annual Survey Database. Information on hospital quality of care and patient experience comes from 2009 Hospital Quality Alliance data and results from the 2009 Hospital Consumer Assessment of Healthcare Providers and Systems (Medicare.gov, 2009). To evaluate the relationship between community orientation and measures of quality and patient experience, we used multivariate linear regressions. Organizational and market control variables included bed size, ownership, teaching status, safety net status, number of nurses per patient day, multihospital system status, network status, extent of reliance on managed care, market competition, and location within an Aligning Forces for Quality community (these communities have multistakeholder alliances and focus on improving quality of care at the community level). After controlling for organizational factors, we found that hospitals with a stronger commitment to community orientation perform better on process measures for all three conditions, and they report higher patient experience of care scores for one measure, than do those demonstrating weaker commitment. Hospital commitment to community orientation is significantly related to the provision of high-quality care and to one measure of patient experience of care.
Smallwood, Nicholas; Dachsel, Martin; Matsa, Ramprasad; Tabiowo, Eugene; Walden, Andrew
Point of care ultrasound (POCU) is becoming increasingly popular as an extension to clinical examination techniques. Specific POCU training pathways have been developed in specialties such as Emergency and Intensive Care Medicine (CORE Emergency Ultrasound and Core UltraSound Intensive Care, for example), but until this time there has not been a curriculum for the acutely unwell medical patient outside of Critical Care. We describe the development of Focused Acute Medicine Ultrasound (FAMUS), a curriculum designed specifically for the Acute Physician to learn ultrasound techniques to aid in the management of the unwell adult patient. We detail both the outline of the curriculum and the process involved for a candidate to achieve FAMUS accreditation. It is anticipated this will appeal to both Acute Medical Unit (AMU) clinicians and general physicians who deal with the unwell or deteriorating medical or surgical patient. In time, the aspiration is for FAMUS to become a core part of the AIM curriculum.
Thornhill, Lee; Klein, Pamela
Partnerships between transgender individuals and community health nurses have been a primary source of monitoring and responding to the impact of the HIV epidemic on transgender communities, specifically transgender women. This article provides two perspectives: first, from a transgender service provider, and second, from a public health nurse, on forming partnerships that brought consumers and providers together to create environments of care in which many transgender persons living with and at high risk of HIV were able to engage with medical providers who believed in their right to self-determination. The process led to an increased understanding of HIV prevention and treatment needs, better individual-level health outcomes, and institutional change, including the creation of a transgender medical clinic serving homeless transgender individuals in greater Boston.
Zazworsky, Donna; Johnson, Nancy
Population health management calls for hospitals and health care entities to better align their strategies in order to deliver quality care more efficiently. Although these efforts tend to be addressed with insured populations, the homeless demand a very intentional focus. The issue of homelessness has adverse effects on the health care system, resulting in the inefficient use of resources. Community-wide efforts must be mobilized to address this inefficiency and need for preventative care and self-management education for this population. Carondelet Health Network, in partnership with El Rio Community Health Center, a federally qualified health center, along with other health care and social service providers, has established the Southern Arizona Health Village for the Homeless, providing a health care delivery system to ensure the best functional and clinical outcomes. This system includes a van (the Van of Hope), licensed as a health center, and staffed with an El Rio Community Health Center nurse practitioner and a medical assistant partnering with a Carondelet Health Network behavioral health specialist and a community outreach worker. Clinical patient information is managed via an electronic health record inclusive of clinical data, number of visits, referrals, self-management education, hospitalizations, and follow-up care. A post-hospital program with shelters and an Emergency Room Navigation Program are additional components of the village that provide a comprehensive pre-acute and post-acute effort to support the homeless. Financial impact is measured by reductions in hospitalizations and average length of stay.
These materials have been prepared to help communities identify child care needs and appropriate services or policies for meeting those needs. The materials can be used by community groups to answer two questions: (1) Is there a need for child care in a specific community? (2) What kinds of child care services or policies would be most useful for…
This is a retrospective report on the importance of Kark and Cassel's 1952 paper on community-oriented primary care (COPC). In 1978, WHO and UNICEF endorsed COPC. However, the ideas girding and framing this approach had first been given full expression in practice some four decades earlier. In Depression-Era South Africa, Sidney Kark, a leader of the National Department of Health, converted the emergent discipline of social medicine into a unique form of comprehensive practice and established the Pholela Health Center, which was the explicit model for COPC. COPC as founded and practiced by Kark was a community, family and personal practice; it also was a multidisciplinary and team practice. Furthermore, the innovations of COPC entailed monitoring, evaluation, and research. Evaluation is the essence of Kark and Kassel's paper, which offers a convincing demonstration of the effects of COPC. Its key findings include the following: 1) that there was a decline in the incidence of syphilis in the area served by the health center; 2) that diet and nutrition improved; and 3) that the crude mortality rate as well as the infant mortality rate--the standard marker--declined in Pholela. In the succeeding decades, OPC had an international legacy (through WHO and H. Jack Geiger's influence in the US Office of Economic Opportunity), which came full circle in the 1980s, when a young generation of South Africans began to search their history for models for their health care programs at the dawn of the post-Apartheid Era.
Alonso de Leciñana-Cases, María; Gil-Núñez, Antonio; Díez-Tejedor, Exuperio
Stroke is a neurological emergency. The early administration of specific treatment improves the prognosis of the patients. Emergency care systems with early warning for the hospital regarding patients who are candidates for this treatment (stroke code) increases the number of patients treated. Currently, reperfusion via thrombolysis for ischemic stroke and attention in stroke units are the bases of treatment. Healthcare professionals and health provision authorities need to work together to organize systems that ensure continuous quality care for the patients during the whole process of their disease. To implement this, there needs to be an appropriate analysis of the requirements and resources with the objective of their adjustment for efficient use. It is necessary to provide adequate information and continuous training for all professionals who are involved in stroke care, including primary care physicians, extrahospital emergency teams and all physicians involved in the care of stroke patients within the hospital. The neurologist has the function of coordinating the protocols of intrahospital care. These organizational plans should also take into account the process beyond the acute phase, to ensure the appropriate application of measures of secondary prevention, rehabilitation, and chronic care of the patients that remain in a dependent state. We describe here the stroke care program in the Community of Madrid (Spain).
O'Connor, Moira; Pugh, Judith; Jiwa, Moyez; Hughes, Jeff; Fisher, Colleen
Palliative care emphasizes an interdisciplinary approach to care to improve quality of life and relieve symptoms. Palliative care is provided in many ways; in hospices, hospital units, and the community. However, the greatest proportion of palliative care is in the community. In hospice and palliative care units in hospitals, clinical pharmacists are part of the interdisciplinary team and work closely with other health care professionals. Their expertise in the therapeutic use of medications is highly regarded, particularly as many palliative care patients have complex medication regimens, involving off-label or off-license prescribing that increases their risk for drug-related problems. However, this active involvement in the palliative care team is not reflected in the community setting, despite the community pharmacist being one of the most accessible professionals in the community, and visiting a community pharmacist is convenient for most people, even those who have limited access to private or public transport. This may be due to a general lack of understanding of skills and knowledge that particular health professionals bring to the interdisciplinary team, a lack of rigorous research supporting the necessity for the community pharmacist's involvement in the team, or it could be due to professional tensions. If these barriers can be overcome, community pharmacists are well positioned to become active members of the community palliative care interdisciplinary team and respond to the palliative care needs of patients with whom they often have a primary relationship.
Khodyakov, Dmitry; Mendel, Peter; Dixon, Elizabeth; Jones, Andrea; Masongsong, Zoe; Wells, Kenneth
Research suggests that the quality and outcomes of depression treatment for adults can be substantially improved through “collaborative care” programs. However, there is a lack of resources required to implement such programs in vulnerable communities. Our paper examines the planning phase of the Community Partners in Care (CPIC) initiative, which addresses this problem through a unique approach in which academic institutions partner directly with a wide range of community-based and service organizations in all phases of the project fielded in two underserved communities in Los Angeles. CPIC offers a unique opportunity to understand how diverse organizations can work together to address community depression care needs and to analyze the potential strengths and tradeoffs of coordinating among such varied entities. This article focuses on intra-group dynamics that surround the process of participatory research and reports results of the first wave of process evaluation of the planning phase of the CPIC initiative. Our analysis explores two main themes: Community-Partnered Participatory Research and benefits and challenges of collaboration in diverse groups. PMID:21528111
Jha, Vivekanand; Parameswaran, Sreejith
Community-acquired acute kidney injury (AKI) in developing tropical countries is markedly different from AKI in developed countries with a temperate climate, which exemplifies the influence that environment can have on the epidemiology of human diseases. The aetiology and presentation of AKI reflect the ethnicity, socioeconomic factors, climatic and ecological characteristics in tropical countries. Tropical zones are characterized by high year-round temperatures and the absence of frost, which supports the propagation of infections that can cause AKI, including malaria, leptospirosis, HIV and diarrhoeal diseases. Other major causes of AKI in tropical countries are envenomation; ingestion of toxic herbs or chemicals; poisoning; and obstetric complications. These factors are associated with low levels of income, poor access to treatment, and social or cultural practices (such as the use of traditional herbal medicines and treatments) that contribute to poor outcomes of patients with AKI. Most causes of AKI in developing tropical countries are preventable, but strategies to improve the outcomes and reduce the burden of tropical AKI require both improvements in basic public health, achieved through effective interventions, and increased access to effective medical care (especially for patients with established AKI).
Puett, Chloe; Sadler, Kate; Alderman, Harold; Coates, Jennifer; Fiedler, John L; Myatt, Mark
This study assessed the cost-effectiveness of adding the community-based management of severe acute malnutrition (CMAM) to a community-based health and nutrition programme delivered by community health workers (CHWs) in southern Bangladesh. The cost-effectiveness of this model of treatment for severe acute malnutrition (SAM) was compared with the cost-effectiveness of the 'standard of care' for SAM (i.e. inpatient treatment), augmented with community surveillance by CHWs to detect cases, in a neighbouring area. An activity-based cost model was used, and a societal perspective taken, to include all costs incurred in the programme by providers and participants for the management of SAM in both areas. Cost data were coupled with programme effectiveness data. The community-based strategy cost US$26 per disability-adjusted life year (DALY) averted, compared with US$1344 per DALY averted for inpatient treatment. The average cost to participant households for their child to recover from SAM in community treatment was one-sixth that of inpatient treatment. These results suggest that this model of treatment for SAM is highly cost-effective and that CHWs, given adequate supervision and training, can be employed effectively to expand access to treatment for SAM in Bangladesh.
Connolly, V; Hamad, M; Scott, Y; Bramble, M
Acute Assessment Units (AAUs) have been developed to meet the demand for emergency care. Traditionally, AAUs have been an admission route to secondary care but the role is now evolving to assessment. AAUs are complex and have many interactions both in hospitals and the community. The effective functioning of an AAU requires excellent clinical leadership, appropriate facilities, timely access to diagnostics and input from the multi-disciplinary team. Increasingly, AAUs will have to develop services which are not dependent on using hospital beds. A variety of emergency medical presentations can, with the appropriate resources, be delivered in an out-patient setting.
... multiple chronic conditions better manage their health care. Definitions Residential care communities : Includes assisted-living facilities and ... a unit or wing that met the above definition and residents could be enumerated separately. The 2010 ...
Van Vorst, Rebecca F.; Crane, Lori A.; Barton, Phoebe Lindsey; Kutner, Jean S.; Kallail, K. James; Westfall, John M.
Context: Barriers to providing optimal palliative care in rural communities are not well understood. Purpose: To identify health care personnel's perceptions of the care provided to dying patients in rural Kansas and Colorado and to identify barriers to providing optimal care. Methods: An anonymous self-administered survey was sent to health care…
Darvas, Katalin; Futó, Judit; Okrös, Ilona; Gondos, Tibor; Csomós, Akos; Kupcsulik, Péter
Acute pancreatitis is a dynamic, often progressive disease; 14-20% require intensive care in its severe form due to multiorgan dysfunction and/or failure. This review was created using systematic literature review of articles published on this subject in the last 5 years. The outcome of severe acute pancreatitis is determined by the inflammatory response and multiorgan dysfunction - the prognostic scores (Acute Physiology and Chronic Health Evaluation, Glasgow Prognostic Index, Sepsis-related Organ Failure Assessment, Multi Organ Dysfunction Syndrome Scale, Ranson Scale) can be used to determine outcome. Clinical signs (age, coexisting diseases, confusion, obesity) and biochemistry values (serum amylase, lipase, C-reactive protein, procalcitonin, creatinine, urea, calcium) have important prognostic roles as well. Early organ failure increases the risk of late abdominal complications and mortality. Intensive care can provide appropriate multi-function patient monitoring which helps in early recognition of complications and appropriate target-controlled treatment. Treatment of severe acute pancreatitis aims at reducing systemic inflammatory response and multiorgan dysfunction and, on the other side, at increasing the anti-inflammatory response. Oral starvation for 24-48 hours is effective in reducing the exocrine activity of the pancreas; the efficacy of protease inhibitors is questionable. Early intravascular volume resuscitation and stable haemodynamics improve microcirculation. Early oxygen therapy and mechanical ventilation provide adequate oxygenation. Electrolyte and acid-base control can be as important as tight glucose control. Adequate pain relief can be achieved by thoracic epidural catheterization. Early enteral nutrition with immunonutrition should be used. There is evidence that affecting the coagulation cascade by activated protein C can play a role in reducing the inflammatory response. The complex therapy of acute pancreatitis includes appropriate
Lazzeri, Chiara; Picariello, Claudio; Dini, Carlotta Sorini; Gensini, Gian Franco; Valente, Serafina
Hyperlactataemia is commonly used as a diagnostic and prognostic tool in intensive care settings. Recent studies documented that serial lactate measurements over time (or lactate clearance), may be clinically more reliable than lactate absolute value for risk stratification in different pathological conditions. While the negative prognostic role of hyperlactataemia in several critical ill diseases (such as sepsis and trauma) is well established, data in patients with acute cardiac conditions (i.e. acute coronary syndromes) are scarce and controversial. The present paper provides an overview of the current available evidence on the clinical role of lactic acid levels and lactate clearance in acute cardiac settings (acute coronary syndromes, cardiogenic shock, cardiac surgery), focusing on its prognostic role. PMID:24062898
Wheeler, Erlinda C; Plowfield, Lisa
With greater numbers of chronically ill clients cared for in their homes rather than in acute care hospitals, nursing schools need to create and implement innovative strategies for experiences in the community setting. A telephone intervention program was initiated in the last semester of the medical-surgical clinical course to promote the health of patients with congestive heart failure and provide meaningful community experiences for senior nursing students. Students' journals from this semester-long clinical experience were analyzed and showed outcome benefits to both patients and students.
Mullen-Fortino, Margaret; Sites, Frank D; Soisson, Michael; Galen, Julie
Tele-intensive care units (ICUs) typically provide remote monitoring for ICUs of acute care, short-stay hospitals. As part of a joint venture project to establish a long-term acute level of care, Good Shepherd Penn Partners became the first facility to use tele-ICU technology in a nontraditional setting. Long-term acute care hospitals care for patients with complex medical problems. We describe describes the benefits and challenges of integrating a tele-ICU program into a long-term acute care setting and the impact this model of care has on patient care outcomes.
Hernández-Fabà, Eva; Sanfeliu-Julià, Cristina
Since 2008, the Institut Catala de la Salut (ICS) introduced the nurses management plan for acute pathology, in primary care centres. In the implementation of this system of organization, the ICS introduced various diseases protocols with performance algorithms. To raise awareness of the the practice of acute pathology, we present a clinical case. An urgent consultation of a 30 year-old male, with fever, sore throat and cough, which was managed and resolved by a nurse. The aim of this new management plan is that nursing is the first health professional to take care of patient coming to primary care centre without a scheduled visit, to avoid saturating the general clinic or hospital emergencies. This new organisational system involves an increase in the responsibilities of nursing in the diagnosis and treatment of patients.
Kivlin, Jude; Altemimi, Harith
The Queen Elizabeth Hospital in King's Lynn, Norfolk is a 488 bed hospital providing services to approximately 331,000 people across 750 square miles. In 2012 a need was recognised for documentation (pathways) in a practical format to increase usage of national guidelines and facilitate adherence to best practice (gold standards of care) that could be easily version controlled, auditable and provide support in clinical decision-making by junior doctors. BMJ Action Sets fulfilled the brief with expert knowledge, version control and support, though they were deemed too lengthy and unworkable in fast paced settings like the medical assessment unit; they formed the base creation of concise care bundles (CCB). CCB were introduced for 21 clinical presentations and one procedure. Outcomes were fully audited and showed significant improvement in a range of measures, including an increase in completions of CHADVASC score in atrial fibrillation, antibiotics prescribed per protocol in chronic obstructive pulmonary disease (COPD), and Blatchford score recorded for patients presenting with upper gastrointestinal bleed. PMID:26734437
De Luca, C; Valentino, M; Rimondi, M R; Branchini, M; Baleni, M Casadio; Barozzi, L
Diagnosis of acute lung disease is a daily challenge for radiologists working in acute-care areas. It is generally based on the results of chest radiography performed under technically unfavorable conditions. Computed tomography (CT) is undoubtedly more accurate in these cases, but it cannot always be performed on critically ill patients who need continuous care.The use of thoracic ultrasonography (US) has recently been proposed for the study of acute lung disease. It can be carried out rapidly at the bedside and does not require any particularly sophisticated equipment. This report analyzes our experience with chest sonography as a supplement to chest radiography in an Emergency Radiology Unit. We performed chest sonography - as an adjunct to chest radiography - on 168 patients with acute chest pathology. Static and dynamic US signs were analyzed in light of radiographic findings and, when possible, CT. The use of chest US improved the authors' ability to provide confident diagnoses of acute disease of the chest and lungs.
Moseley, Charles B; Shen, Jay J; Ginn, Gregory O
Hospitals provide diversity activities for a number of reasons. The authors examined community demand, resource availability, managed care, institutional pressure, and external orientation related variables that were associated with acute care hospital diversity plans and translation services. The authors used multiple logistic regression to analyze the data for 478 hospitals in the 2006 National Inpatient Sample (NIS) dataset that had available data on the racial and ethnic status of their discharges. We also used 2004 and 2006 American Hospital Association (AHA) data to measure the two dependent diversity variables and the other independent variables. We found that resource, managed care, and external orientation variables were associated with having a diversity plan and that resource, managed care, institutional, and external orientation variables were associated with providing translation services. The authors concluded that more evidence for diversity's impact, additional resources, and more institutional pressure may be needed to motivate more hospitals to provide diversity planning and translation services.
Syre, Thomas R.; Wilson, Richard W.
This article discusses role delineation in the health education profession, defines and presents principles of health care marketing, describes marketing plan development, and examines major ethical issues associated with health care marketing when utilized by community health educators. A marketing plan format for community health education is…
Scott, Shylan E.
The focus of this study was the experience of students who had successfully achieved the transition from foster care to enrollment in Virginia Community Colleges. The following questions guided the inquiry: How do students who are emancipating from foster care describe their transition to enrollment at one of the Virginia Community Colleges? What…
Changes in British social policy regarding community health care has implications for local education agency (LEA) providers of adult continuing education. LEAs will either have a role in providing staff training and other learning opportunities, will be forced to provide cheaper forms of community care, or will be ignored altogether. (SK)
Warnock, Mary M.
A rural community established an after-school child care program by forming a community coalition, acquiring funding, obtaining space, and arranging for children's transportation. The program enriched the quality of life for children, parents, and staff. Children's grades improved and the number of mothers satisfied with child care services…
Ekerstad, Niklas; Karlson, Björn W; Dahlin Ivanoff, Synneve; Landahl, Sten; Andersson, David; Heintz, Emelie; Husberg, Magnus; Alwin, Jenny
Objective The aim of this study was to investigate whether the acute care of frail elderly patients in a comprehensive geriatric assessment (CGA) unit is superior to the care in a conventional acute medical care unit. Design This is a clinical, prospective, randomized, controlled, one-center intervention study. Setting This study was conducted in a large county hospital in western Sweden. Participants The study included 408 frail elderly patients, aged ≥75 years, in need of acute in-hospital treatment. The patients were allocated to the intervention group (n=206) or control group (n=202). Mean age of the patients was 85.7 years, and 56% were female. Intervention This organizational form of care is characterized by a structured, systematic interdisciplinary CGA-based care at an acute elderly care unit. Measurements The primary outcome was the change in health-related quality of life (HRQoL) 3 months after discharge from hospital, measured by the Health Utilities Index-3 (HUI-3). Secondary outcomes were all-cause mortality, rehospitalizations, and hospital care costs. Results After adjustment by regression analysis, patients in the intervention group were less likely to present with decline in HRQoL after 3 months for the following dimensions: vision (odds ratio [OR] =0.33, 95% confidence interval [CI] =0.14–0.79), ambulation (OR =0.19, 95% CI =0.1–0.37), dexterity (OR =0.38, 95% CI =0.19–0.75), emotion (OR =0.43, 95% CI =0.22–0.84), cognition (OR = 0.076, 95% CI =0.033–0.18) and pain (OR =0.28, 95% CI =0.15–0.50). Treatment in a CGA unit was independently associated with lower 3-month mortality adjusted by Cox regression analysis (hazard ratio [HR] =0.55, 95% CI =0.32–0.96), and the two groups did not differ significantly in terms of hospital care costs (P>0.05). Conclusion Patients in an acute CGA unit were less likely to present with decline in HRQoL after 3 months, and the care in a CGA unit was also independently associated with lower mortality
Caffrey, Rosalie A
Rural elderly individuals are an underserved population with limited access to health care. There is an increasing need for independent community care nurses to provide assistance to home-based elderly individuals with chronic illnesses to prevent unnecessary medical and placement decisions and, thus, allow them to maintain independence and quality of life. This article describes the rural setting and why community care nurses are needed, and explores strategies for implementing the role of the independent nurse entrepreneur in caring for community-based elderly individuals in rural settings.
Quillian, J P
Community participation and utilization of community health workers (CHWs) are essential components of the primary health care model. The success of CHWs is dependent on their training and subsequent community support. Community-prepared nurses are ideal CHW educators. A training program for CHWs was implemented in Honduras emphasizing the principles of adult learning and problem-based learning. Following a 4-month program of training a primary health care clinic was opened and managed by CHWs for a population over 10,000. Approximately 80% of local health problems were managed by the CHWs proving that well-trained CHWs can have a significant impact on the delivery of health care.
Noureddine, Samar; Dumit, Nuhad Y; Saab, Mohammad
The purpose of this qualitative descriptive study was to explore how patients who experience acute myocardial infarction (AMI) decide to seek emergency care. Fifty patients with AMI were interviewed at two hospitals in Lebanon. The perspective of 22 witnesses of the attack was also sought about the cardiac event. The themes that transpired from the data were as follows: making sense of the symptoms, waiting to see what happens, deciding to come to the hospital, and the family influenced the decision to seek care. The witnesses of the cardiac event, mostly family members, supported the decision to seek emergency care. Deciding to seek emergency care for AMI is complex. Nurses must solicit their patients' perception of the cardiac event to provide them with tailored education and counseling about heart attack symptoms and how to respond to them in case they recur. Family members must be included in the education process.
Mueller, Christian; Christ, Michael; Cowie, Martin; Cullen, Louise; Maisel, Alan S; Masip, Josep; Miro, Oscar; McMurray, John; Peacock, Frank W; Price, Susanna; DiSomma, Salvatore; Bueno, Hector; Zeymer, Uwe; Mebazaa, Alexandre
Acute heart failure (AHF) continues to have unacceptably high rates of mortality and morbidity. This position paper highlights the need for more intense interdisciplinary cooperation as one key element to overcome the challenges associated with fragmentation in the care of AHF patients. Additional aspects discussed include the importance of early diagnosis and treatment, options for initial treatment, referral bias as a potential cause for treatment preferences among experts, considerable uncertainty regarding patient disposition, the diagnosis of accompanying acute myocardial infarction, the need for antibiotic therapy, as well as assessment of intravascular volume status.
Green, Janette P; McNamee, Jennifer P; Kobel, Conrad; Seraji, Md Habibur R; Lawrence, Suanne J
Objective The aim of the present study was to develop a robust model that uses the concept of 'rehabilitation-sensitive' Diagnosis Related Groups (DRGs) in predicting demand for rehabilitation and geriatric evaluation and management (GEM) care following acute in-patient episodes provided in Australian hospitals.Methods The model was developed using statistical analyses of national datasets, informed by a panel of expert clinicians and jurisdictional advice. Logistic regression analysis was undertaken using acute in-patient data, published national hospital statistics and data from the Australasian Rehabilitation Outcomes Centre.Results The predictive model comprises tables of probabilities that patients will require rehabilitation or GEM care after an acute episode, with columns defined by age group and rows defined by grouped Australian Refined (AR)-DRGs.Conclusions The existing concept of rehabilitation-sensitive DRGs was revised and extended. When applied to national data, the model provided a conservative estimate of 83% of the activity actually provided. An example demonstrates the application of the model for service planning.What is known about the topic? Health service planning is core business for jurisdictions and local areas. With populations ageing and an acknowledgement of the underservicing of subacute care, it is timely to find improved methods of estimating demand for this type of care. Traditionally, age-sex standardised utilisation rates for individual DRGs have been applied to Australian Bureau of Statistics (ABS) population projections to predict the future need for subacute services. Improved predictions became possible when some AR-DRGs were designated 'rehabilitation-sensitive'. This improved methodology has been used in several Australian jurisdictions.What does this paper add? This paper presents a new tool, or model, to predict demand for rehabilitation and GEM services based on in-patient acute activity. In this model, the methodology
Ltaief, Z; Ben-Hamouda, N; Suys, T; Daniel, R T; Rossetti, A O; Oddo, M
Management of neurocritical care patients is focused on the prevention and treatment of secondary brain injury, i.e. the number of pathophysiological intracerebral (edema, ischemia, energy dysfunction, seizures) and systemic (hyperthermia, disorders of glucose homeostasis) events that occur following the initial insult (stroke, hemorrhage, head trauma, brain anoxia) that may aggravate patient outcome. The current therapeutic paradigm is based on multimodal neuromonitoring, including invasive (intracranial pressure, brain oxygen, cerebral microdialysis) and non-invasive (transcranial doppler, near-infrared spectroscopy, EEG) tools that allows targeted individualized management of acute coma in the early phase. The aim of this review is to describe the utility of multimodal neuromonitoring for the critical care management of acute coma.
Albeit the considerable progress that has been made both in our understanding of the pathophysiology of acute renal failure (ARF) and in its treatment (continuous renal replacement therapies), the morbidity of this complex syndrome remains unacceptably high. The current review focuses on recent developments concerning the definition of ARF, new strategies for the prevention and pharmacological treatment of specific causes of ARF, dialysis treatment in the intensive care setting and provides an update on critical care issues relevant to the clinical nephrologist. PMID:21897760
Palliative care is expanding out of the hospice, and out of the narrow confines of its association with cancer. It should be a part of all care. District nurses are ideally placed to implement and coordinate palliative care in the community, making use of the talents of many other agencies and professionals. However, because of a lack of communication between these agencies, there is confusion about their roles, and many patients may not be receiving optimal care. This article argues that by promoting interagency and interprofessional communication and cooperation, district nurses can strengthen their role at the heart of palliative care provision in the community.
Availability of nursing home beds was a strong predictor of institutional care. Higher rates of community care occurred where there were greater expenditures for protective, legal, chore, day care and social/recreation services and, in which there were more older persons in poverty and fewer women working. (Author)
Tilson, Elizabeth Cuervo
Community Care of North Carolina (CCNC) takes a comprehensive approach to asthma management. Support from CCNC helps providers follow evidence-based practice guidelines; data guide continuous quality improvement initiatives and inform the care of individual patients and populations; and care managers work with high-risk patients.
Rowan, Leslie; Veenema, Tener Goodwin
Falls in acute care medical patients are a complex problem impacted by the constantly changing risk factors affecting this population. This integrative literature review analyzes current evidence to determine factors that continue to make falls a top patient safety problem within the medical unit microsystem. The goal of this review is to develop an evidence-based structure to guide process improvement and effective use of organization resources.
Schiele, Francois; Gale, Chris P; Bonnefoy, Eric; Capuano, Frederic; Claeys, Marc J; Danchin, Nicolas; Fox, Keith Aa; Huber, Kurt; Iakobishvili, Zaza; Lettino, Maddalena; Quinn, Tom; Rubini Gimenez, Maria; Bøtker, Hans E; Swahn, Eva; Timmis, Adam; Tubaro, Marco; Vrints, Christiaan; Walker, David; Zahger, Doron; Zeymer, Uwe; Bueno, Hector
Evaluation of quality of care is an integral part of modern healthcare, and has become an indispensable tool for health authorities, the public, the press and patients. However, measuring quality of care is difficult, because it is a multifactorial and multidimensional concept that cannot be estimated solely on the basis of patients' clinical outcomes. Thus, measuring the process of care through quality indicators (QIs) has become a widely used practice in this context. Other professional societies have published QIs for the evaluation of quality of care in the context of acute myocardial infarction (AMI), but no such indicators exist in Europe. In this context, the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) has reflected on the measurement of quality of care in the context of AMI (ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI)) and created a set of QIs, with a view to developing programmes to improve quality of care for the management of AMI across Europe. We present here the list of QIs defined by the ACCA, with explanations of the methodology used, scientific justification and reasons for the choice for each measure.
... Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY... Rehabilitation and Respiratory Care Services; Medicaid Program: Accreditation for Providers of Inpatient... ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the...
McConnell, Eleanor S; Karel, Michele J
As the prevalence of Alzheimer disease and related dementias increases, dementia-related behavioral symptoms present growing threats to care quality and safety of older adults across care settings. Behavioral and psychological symptoms of dementia (BPSD) such as agitation, aggression, and resistance to care occur in nearly all individuals over the course of their illness. In inpatient care settings, if not appropriately treated, BPSD can result in care complications, increased length of stay, dissatisfaction with care, and caregiver stress and injury. Although evidence-based, nonpharmacological approaches to treating BPSD exist, their implementation into acute care has been thwarted by limited nursing staff expertise in behavioral health, and a lack of consistent approaches to integrate behavioral health expertise into medically focused inpatient care settings. This article describes the core components of one evidence-based approach to integrating behavioral health expertise into dementia care. This approach, called STAR-VA, was implemented in Veterans' Health Administration community living centers (nursing homes). It has demonstrated effectiveness in reducing the severity and frequency of BPSD, while improving staff knowledge and skills in caring for people with dementia. The potential for adapting this approach in acute care settings is discussed, along with key lessons learned regarding opportunities for nursing leadership to ensure consistent implementation and sustainability.
Skerritt, Louise; Moore, Zena
This study aimed to establish the prevalence and aetiology of wounds, allowing an insight into the management of wound care, the use of dressings and the nursing time allocated to the provision of wound care in a community setting in Ireland. A cross-sectional survey was used, with data collected on all clients in the community who received treatment from public health nurses or community registered general nurses for wound care over a 1-week period in April 2013. A 98.9% response rate was realised, and 188 people were identified as having wounds, equating to a crude prevalence of 5% of the active community nursing caseload. A total of 60% (n=112) had leg ulcers, 22% (n=42) had pressure ulcers, 16% (n=30) had an acute wound (surgical or traumatic wounds), 1% (n=2) had a diabetic foot wound and a further 1% (n=2) had wounds of other aetiologies. The mean duration of wounds was 5.41 months. A total of 18% of wounds were identified as infected; however, 60% (n=112) of wounds had antimicrobial products in use as either a primary or secondary dressing. The study established that there is a significant prevalence of wounds in this community care area. There was absence of a clinical diagnosis in many cases, and evidence of inappropriate dressing use, risking an increase in costs and a decrease in good clinical outcomes. It also highlighted the importance of ongoing education and auditing in the provision of wound care.
Televisitation is the virtual transportation of a patient's family to the bedside, regardless of the patient's location within an acute care setting. This innovation in the Telemedicine Program at Thunder Bay Regional Health Sciences Centre (TBRHSC) in Ontario, Canada, embraces the concept of patient- and family-centered care and has been identified as a leading practice by Accreditation Canada. The need to find creative ways to link patients to their family and friend supports hundreds of miles away was identified more than ten years ago. The important relationship between health outcomes and the psychosocial needs of patients and families has been recognized more recently. TBRHSC's patient- and family-centered model of care focuses on connecting patients with their families. First Nations renal patients with family in remote communities were some of the earliest users of videoconferencing technology for this purpose.
Björkdahl, A; Palmstierna, T; Hansebo, G
Demanding conditions in acute psychiatric wards inhibit provision of safe, therapeutic care and leave nurses torn between humanistic ideals and the harsh reality of their daily work. The aim of this study was to describe nurses' caring approaches within this context. Data were collected from interviews with nurses working in acute psychiatric intensive care. Data were analysed using qualitative analysis, based on interpretive description. Results revealed a caring-approach continuum on which two approaches formed the main themes: the bulldozer and the ballet dancer. The bulldozer approach functioned as a shield of power that protected the ward from chaos. The ballet dancer approach functioned as a means of initiating relationships with patients. When examining the data from a theoretical perspective of caring and uncaring encounters in nursing, the ballet dancer approach was consistent with a caring approach, while the bulldozer approach was more complex and somewhat aligned with uncaring approaches. Conclusions drawn from the study are that although the bulldozer approach involves a risk for uncaring and harming actions, it also brings a potential for caring. This potential needs to be further explored and nurses should be encouraged to reflect on how they integrate paternalistic nursing styles with person-centred care.
This paper examines the impact of the changes to health and social care on enteral feeding in the community, outlines implications for practice and offers recommendations to ameliorate the challenges. It is now clear that there have been significant changes especially in the last 10 years in health and social care provisions in the UK with an overarching effect on enteral nutrition in the community. Advances in technology, increasing demand and treatment costs, the need for improvement in quality, economic challenges, market forces, political influences and more choices for patients are some of the factors driving the change. Government’s vision of a modern system of health and social care is based on initiatives such as clinically led commissioning, establishment of Monitor, shifting care from acute hospitals to community settings, integrating health and social care provisions, Quality, Innovation, Productivity and Prevention (QIPP) program and the concept of “Big Society”. These strategies which are encapsulated in various guidelines, policies and legislation, including the health and social care Act, 2012 are clarified. The future challenges and opportunities brought on by these changes for healthcare professionals and patients who access enteral nutrition in the community are discussed and recommendations to improve practice are outlined.
This paper examines the impact of the changes to health and social care on enteral feeding in the community, outlines implications for practice and offers recommendations to ameliorate the challenges. It is now clear that there have been significant changes especially in the last 10 years in health and social care provisions in the UK with an overarching effect on enteral nutrition in the community. Advances in technology, increasing demand and treatment costs, the need for improvement in quality, economic challenges, market forces, political influences and more choices for patients are some of the factors driving the change. Government’s vision of a modern system of health and social care is based on initiatives such as clinically led commissioning, establishment of Monitor, shifting care from acute hospitals to community settings, integrating health and social care provisions, Quality, Innovation, Productivity and Prevention (QIPP) program and the concept of “Big Society”. These strategies which are encapsulated in various guidelines, policies and legislation, including the health and social care Act, 2012 are clarified. The future challenges and opportunities brought on by these changes for healthcare professionals and patients who access enteral nutrition in the community are discussed and recommendations to improve practice are outlined. PMID:23201842
Caffrey, Christine; Harris-Kojetin, Lauren; Rome, Vincent; Sengupta, Manisha
In 2012, the majority of residential care communities had 4–25 beds, yet 71% of residents lived in communities with more than 50 beds. A lower percentage of communities with 4–25 beds were chain-affiliated, nonprofit, and in operation 10 years or more, compared with communities with 26–50 and more than 50 beds. Dementia-exclusive care or dementia care units were more common as community size increased. A higher percentage of communities with more than 50 beds screened for cognitive impairment and offered dementia-specific programming compared with communities with 4–25 and 26–50 beds. A higher percentage of communities with more than 50 beds screened for depression compared with communities with 4–25 beds. Compared with communities with 4–25 beds, a higher percentage of communities with 26–50 beds and more than 50 beds provided therapeutic, hospice, mental health, and dental services; but a lower percentage of communities with more than 50 beds provided skilled nursing services than did smaller communities. This report presents national estimates of residential care communities, using data from the first wave of NSLTCP. This brief profile of residential care communities provides useful information to policymakers, providers, researchers, and consumer advocates as they plan to meet the needs of an aging population. The findings also highlight the diversity of residential care communities across different sizes. Corresponding state estimates and their standard errors for the national figures in this data brief can be found on the NSLTCP website at http://www.cdc.gov/nchs/nsltcp/ nsltcp_products.htm. These national and state estimates establish a baseline for monitoring trends among residents living in residential care.
Günzel, F; Theiss, S; Knüppel, P; Halberstadt, S; Rose, G; Raith, M
Specialized stroke units offer optimal treatment of patients with an acute stroke. Unfortunately, their installation is limited by an acute lack of experienced neurologists and the small number of stroke patients in sparsely populated rural areas. This problem is increasingly being solved by the use of telemedicine, so that neurological expertise is made available to basic and regular care. It has been demonstrated by national and international pilot studies that solidly based and rapid decisions can be made by telemedicine regrading the use of thrombolysis, as the most important acute treatment, but also of other interventions. So far studies have only evaluated improvement in the quality of care achieved by networking, but not of any lasting effect on any economic benefit. Complementary to a medical evaluation, the qualitative economic assessment presented here of German and American concepts of telemetric care indicate no difference in efficacy between various ways of networking. Most noteworthy, when comparing two large American and German studies, is the difference in their priorities. While the American networks achieved targeted improvements in efficacy of care that go beyond the immediate wishes of the doctors involved, this was of only secondary importance in the German studies. Also, in contrast to several American networks, the German telemetry networks have not tended to be organized for future growth. In terms of economic benefits, decentralized organized networks offer a greater potential of efficacy than purely local ones. Furthermore, the integration of inducements into the design of business models is a fundamental factor for achieving successful and lasting existence, especially within a highly competitive market.
Giffords, Elissa D.; Wenze, Linda; Weiss, David M.; Kass, Donna; Guercia, Rosemarie
The present study explored hospital community benefits and free care programs at seven hospitals in Nassau and Suffolk counties in Long Island, New York. There were two components to this project: (1) assessment of information regarding the availability of free care and (2) an analysis of the community benefits information filed with state…
Georges, C Alicia; Bolton, Linda Burnes; Bennett, Crystal
The National Black Nurses Foundation commissioned a research project to determine the effect of the nursing shortage on African-American communities. The W.K. Kellogg Foundation funded the project as part of a multiphase project aimed at identifying issues related to the nursing shortage among ethnic people of color communities and developing policy recommendations around the supply of nurses to serve those communities. The study was conducted over a six-month period by the nursing research investigative team at Cedars-Sinai Medical Center and Burns and Allen Research Institute in Los Angeles, California. One hundred (N=100) nurse leaders from communities across the United States participated in the research. Each leader completed a questionnaire regarding the existence of the nursing shortage in their community and the effect of the shortage on access to services, clinical quality and the retention and recruitment of nurses. Leaders were queried on nurse vacancy and turnover within their communities, incidence of adverse events and the ability of institutions to meet the demands for nursing and health services in their communities. Forty-five percent of the organizations in the study were reported to be single facilities and 55% consisted of integrated health systems. Respondents identified five major issues resulting from nurse vacancies in their communities: closure of acute care beds or clinical services, delays in providing treatment to patients, inability to retain nurses due to increased workload and decreased nurse satisfaction, diminished capacity to address chronic health problems in their communities and increased incidence of adverse patient events. African-American nurse leaders reported higher rates of nurse vacancy and turnover; higher incidence of adverse events and greater difficulty providing access to health care than was reported in the literature. Nurse vacancy and turnover rates are higher than reported national averages. The study suggests
Plescia, M; Koontz, S; Laurent, S
OBJECTIVES: In this report, the authors present a representative case of the implementation of community assessment and the subsequent application of findings by a large, vertically integrated health care system. METHODS: Geographic information systems technology was used to access and analyze secondary data for a geographically defined community. Primary data included a community survey and asset maps. RESULTS: In this case presentation, information has been collected on demographics, prevalent health problems, access to health care, citizens' perceptions, and community assets. The assessment has been used to plan services for a new health center and to engage community members in health promotion interventions. CONCLUSIONS: Geographically focused assessments help target specific community needs and promote community participation. This project provides a practical application for integrating aspects of medicine and public health. PMID:11344895
Arthur, Michael W.; Briney, John S.; Hawkins, J. David; Abbott, Robert D.; Brooke-Weiss, Blair L.; Catalano, Richard F.
The Communities That Care Youth Survey measures risk and protective factors shown in prior studies to predict adolescent problem behaviors such as drug use, delinquency, and violence. This paper describes the development and validation of cut points for the risk and protective factor scales in the Communities That Care Youth Survey that…
Clean Air Communities (CAC) is the recipient of a Level II CARE cooperative agreement to implement recommendations by the state’s Environmental Justice Task Force and the Air Toxics Pilot Project to reduce environmental risks.
Barbaro, Ellen L.; Noyes, Lin E.
Describes a health education program at a life care community, based on Knowles' theory of androgyny. The program significantly affected participants' health behavior which reduced the effects of aging. Planning guidelines, audiovisual considerations, format, and cost are discussed. (JAC)
Burke, Triona; O'Neill, Catherine
Primary care health services in the Irish Republic have undergone fundamental transformation with the establishment of multidisciplinary primary care teams nationwide. Primary care teams provide a community-based health service delivered through a range of health professionals in an integrated way. As part of this initiative ten pilot teams were established in 2003. This research was undertaken in order to gain an understanding of nurse's experiences of working in a piloted primary care team. The methodology used was a focus group approach. The findings from this study illustrated how community nurse's roles and responsibilities have expanded within the team. The findings also highlighted the benefits and challenges of working as a team with various other community-based health-care disciplines.
Kally, Zina; Cherry, Debra L; Howland, Susan; Villarruel, Monica
This study presents the results of the work of the Asian Pacific Islander Dementia Care Network (APIDCN)--a collaborative model of care created to develop community capacity to deliver dementia capable services, build community awareness about Alzheimer's disease and other dementias, and offer direct services to caregivers in the API community in Los Angeles. Through trainings, mentoring, and outreach campaigns, the APIDCN expanded the availability of culturally competent services in the API community. The knowledge that was embedded within partner organizations and in the community at large assures sustainability of the services after the project ended.
Tichnor-Wagner, Ariel; Allen, Danielle
This comparative case study examines the prevalence of caring practices in two higher performing and two lower performing urban high schools and the contextual factors that helped or hindered the extent to which students felt cared for. We found that higher performing schools demonstrated caring communities, where interpersonal relationships and…
Brownhill, Suzanne; Chang, Esther; Bidewell, John; Johnson, Amanda
Community (district) nurses play a significant role in assisting and supporting bereaved informal carers (family members and friends) of recently decease clients of palliative care. Bereavement care demands a wide range of competencies including clinical decision-making. To date, little has been known about the decision-making role of community nurses in Australia. The aim of this study was to conduct in-depth examination of an existing data set generated from semi-structured interviews of 10 community nurses providing follow-up bereavement care home visits within an area health service of a metropolitan region of Sydney, Australia. A grounded theory approach to data analysis generated a model, which highlights an interaction between 'the relationship','the circumstances' (surrounding the bereavement),'the psychosocial variant', 'the mix of nurses', 'the workload', and 'the support' available for the bereaved and for community nurses, and elements of 'the visit' (central to bereavement care). The role of community nurses in bereavement care is complex, particularly where decision-making is discretionary and contingent on multiple variables that effect the course of the family's grief. The decision model has the potential to inform community nurses in their support of informal carers, to promote reflective practice and professional accountability, ensuring continuing competence in bereavement care.
... 0938-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident... Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term...
Schoenman, Julie A.; Mueller, Curt D.
Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the…
A community practice framework is presented as the synthesis of research findings from the analysis of a critical ethnonursing study of women in recovery from chemical dependence. Critical Social Theory is used to examine the paradoxical experiences of women from their lifeworld and system within the community. The framework focuses on the mutual moral caring actions of the community nurse and the women in the recovery. It is supported by the concepts of transcultural nursing ethics. The utility of the framework is to promote clarity of speech and parity of community membership for women in recovery from chemical dependence and their return to the community.
Introduction: Internet point of care (PoC) learning is a relatively new method for obtaining continuing medical education credits. Few data are available to describe physician utilization of this CME activity. Methods: We describe the Internet point of care system we developed at a medium-sized community hospital and report on its first year of…
The rapid increase in Colorado's population has created a huge demand for allied health care providers. This increase, coupled with the aging baby boomer population, has created a near-crisis situation in many Colorado communities. The U.S. Department of Labor predicts severe shortages of allied health care workers for the next several years. The…
The state of Indiana took a unique approach to developing a statewide plan to improve perinatal health outcomes by engaging parents in a series of focus groups, called Community Conversations in Perinatal Care (CCPC), to hear directly from consumers about their health care experiences and needs. Recognizing that disparities exist among different…
van Loon, Jos; Knibbe, Jeroen; Van Hove, Geert
Background: Concerns have been raised about the quality of medical care available for people with intellectual disabilities in community-based services. The aims of this study were to evaluate a model of medical care developed during a programme of deinstitutionalization, based on a specialist physician supporting general practitioners (GPs).…
The author argues that the importance of primary health care, with emphasis on preventive aspects of care, requires a socioeconomic and health survey of each community and that the nurse-epidemiologist would be the most effective compiler of such surveys. (MF) Baganda in Uganda was interviewed concerning perceptions of loneliness and social…
Martin, J B; Dahlstrom, G A; Johnston, C M
This article reports an evaluation of the impact of three administrative technologies--Admission Scheduling (AS) Systems, Outpatient Surgery (OPS) Programs, and Preadmission Testing (PAT) Programs--on the number of acute care beds required by a hospital. The evaluation mechanism reported here is called the ADTECH Computerized Planning Model. ADTECH uses parameters of each technology, identified from previous literature and discussions with health care professionals, to predict the changes in bed requirements resulting from implementation of these programs. Data from eight hospitals of various characteristics and sizes were run to test the ADTECH model. The results from these test runs indicate that the proper implementation of AS, OPS, and PAT can significantly influence a hospital's required bed complement. PMID:3988530
Doctors must frequently make decisions during medical treatment, whether in an acute care facility, such as an Intensive Care Unit (ICU), or in an operating room. These decisions rely on a various information sources, such as the patient's medical history, preoperative images, and general medical knowledge. Decision support systems can assist by facilitating access to this information when and where it is needed. This paper presents some research eorts that address the integration of information with clinical practice. The example systems include a clinical decision support system (CDSS) for pediatric traumatic brain injury, an augmented reality head- mounted display for neurosurgery, and an augmented reality telerobotic system for minimally-invasive surgery. While these are dierent systems and applications, they share the common theme of providing information to support clinical decisions and actions, whether the actions are performed with the surgeon's own hands or with robotic assistance.
Administration QASP quality assurance surveillance plan This is a work of the U.S. government and is not subject to copyright protection in the...Community Care Credentials important means by which health care organizations gain assurance that patients receive safe, high quality care.2 VA... quality of health care. URAC has over 30 accreditation and certification programs, some of which are related to physician credentialing. URAC was
Pickkers, Peter; Ostermann, Marlies; Joannidis, Michael; Zarbock, Alexander; Hoste, Eric; Bellomo, Rinaldo; Prowle, John; Darmon, Michael; Bonventre, Joseph V; Forni, Lui; Bagshaw, Sean M; Schetz, Miet
Acute kidney injury (AKI) is a common complication in the critically ill. Current standard of care mainly relies on identification of patients at risk, haemodynamic optimization, avoidance of nephrotoxicity and the use of renal replacement therapy (RRT) in established AKI. The detection of early biomarkers of renal tissue damage is a recent development that allows amending the late and insensitive diagnosis with current AKI criteria. Increasing evidence suggests that the consequences of an episode of AKI extend long beyond the acute hospitalization. Citrate has been established as the anticoagulant of choice for continuous RRT. Conflicting results have been published on the optimal timing of RRT and on the renoprotective effect of remote ischaemic preconditioning. Recent research has contradicted that acute tubular necrosis is the common pathology in AKI, that septic AKI is due to global kidney hypoperfusion, that aggressive fluid therapy benefits the kidney, that vasopressor therapy harms the kidney and that high doses of RRT improve outcome. Remaining uncertainties include the impact of aetiology and clinical context on pathophysiology, therapy and prognosis, the clinical benefit of biomarker-driven interventions, the optimal mode of RRT to improve short- and long-term patient and kidney outcomes, the contribution of AKI to failure of other organs and the optimal approach for assessing and promoting renal recovery. Based on the established gaps in current knowledge the trials that must have priority in the coming 10 years are proposed together with the definition of appropriate clinical endpoints.
You, Emily Chuanmei; Dunt, David; Doyle, Colleen
Case management has been widely implemented in the community aged care setting. In this study, we aimed to explore influences on case-managed community aged care practice from the perspectives of community aged care case managers. We conducted 33 semistructured interviews with 47 participants. We drew these participants from a list of all case managers working in aged care organizations that provided publicly funded case management program(s)/packages in Victoria, Australia. We used a multilevel framework that included such broad categories of factors as structural, organizational, case manager, client, and practice factors to guide the data analysis. Through thematic analysis, we found that policy change, organizational culture and policies, case managers' professional backgrounds, clients with culturally and linguistically diverse backgrounds, and case management models stood out as key influences on case managers' practice. In the future, researchers can use the multilevel framework to undertake implementation research in similar health contexts.
Sulaiman, Kadhim J.; Panduranga, Prashanth; Al-Zakwani, Ibrahim; Alsheikh-Ali, Alawi; Al-Habib, Khalid; Al-Suwaidi, Jassim; Al-Mahmeed, Wael; Al-Faleh, Husam; El-Asfar, Abdelfatah; Al-Motarreb, Ahmed; Ridha, Mustafa; Bulbanat, Bassam; Al-Jarallah, Mohammed; Bazargani, Nooshin; Asaad, Nidal; Amin, Haitham
Background: There is paucity of data on heart failure (HF) in the Gulf Middle East. The present paper describes the rationale, design, methodology and hospital characteristics of the first Gulf acute heart failure registry (Gulf CARE). Materials and Methods: Gulf CARE is a prospective, multicenter, multinational registry of patients >18 year of age admitted with diagnosis of acute HF (AHF). The data collected included demographics, clinical characteristics, etiology, precipitating factors, management and outcomes of patients admitted with AHF. In addition, data about hospital readmission rates, procedures and mortality at 3 months and 1-year follow-up were recorded. Hospital characteristics and care provider details were collected. Data were entered in a dedicated website using an electronic case record form. Results: A total of 5005 consecutive patients were enrolled from February 14, 2012 to November 13, 2012. Forty-seven hospitals in 7 Gulf States (Oman, Saudi Arabia, Yemen, Kuwait, United Gulf Emirates, Qatar and Bahrain) participated in the project. The majority of hospitals were community hospitals (46%; 22/47) followed by non-University teaching (32%; 15/47 and University hospitals (17%). Most of the hospitals had intensive or coronary care unit facilities (93%; 44/47) with 59% (28/47) having catheterization laboratory facilities. However, only 29% (14/47) had a dedicated HF clinic facility. Most patients (71%) were cared for by a cardiologist. Conclusions: Gulf CARE is the first prospective registry of AHF in the Middle East, intending to provide a unique insight into the demographics, etiology, management and outcomes of AHF in the Middle East. HF management in the Middle East is predominantly provided by cardiologists. The data obtained from this registry will help the local clinicians to identify the deficiencies in HF management as well as provide a platform to implement evidence based preventive and treatment strategies to reduce the burden of HF in
Puett, Chloe; Alderman, Harold; Sadler, Kate; Coates, Jennifer
Community health workers (CHWs) have strong potential to extend health and nutrition services to underserved populations. However, CHWs face complex challenges when working within weak health systems and among communities with limited abilities to access and utilise CHW services. It is crucial to understand these challenges to improve programme support mechanisms. This study describes the results of qualitative investigations into CHW perceptions of barriers to quality of care among two groups of workers implementing community case management of acute respiratory infection, diarrhoea and severe acute malnutrition in southern Bangladesh. We explored systemic barriers to service delivery, pertaining to communities and health systems, which limited the usefulness and effectiveness of CHW services. Focus group discussions (n = 10) were conducted in March 2010. Discussions were analysed for themes related to CHWs' work challenges. Findings highlight several perceived barriers to effective service provision, including community poverty constraining uptake of recommended practices, irregular supplies of medicine from the health facility and poor quality of care for CHW referrals sent there. This study further documents interactions between demand-side and supply-side constraints including the influence of health system resource constraints on community trust in CHW services, and the influence of community resource constraints on the utilisation and effectiveness of CHW services. By documenting service delivery challenges from the perspective of the frontline workers themselves, this article contributes evidence to help identify appropriate support mechanisms for these workers, in order to develop scalable and sustainable CHW programmes in countries with under-resourced public health care infrastructure.
Adams, Rose; White, Barb; Beckett, Cynthia
Background Pain management remains a critical issue for hospitals and is receiving the attention of hospital accreditation organizations. The acute care setting of the hospital provides an excellent opportunity for the integration of massage therapy for pain management into the team-centered approach of patient care. Purpose and Setting This preliminary study evaluated the effect of the use of massage therapy on inpatient pain levels in the acute care setting. The study was conducted at Flagstaff Medical Center in Flagstaff, Arizona—a nonprofit community hospital serving a large rural area of northern Arizona. Method A convenience sample was used to identify research participants. Pain levels before and after massage therapy were recorded using a 0 – 10 visual analog scale. Quantitative and qualitative methods were used for analysis of this descriptive study. Participants Hospital inpatients (n = 53) from medical, surgical, and obstetrics units participated in the current research by each receiving one or more massage therapy sessions averaging 30 minutes each. The number of sessions received depended on the length of the hospital stay. Result Before massage, the mean pain level recorded by the patients was 5.18 [standard deviation (SD): 2.01]. After massage, the mean pain level was 2.33 (SD: 2.10). The observed reduction in pain was statistically significant: paired samples t52 = 12.43, r = .67, d = 1.38, p < .001. Qualitative data illustrated improvement in all areas, with the most significant areas of impact reported being overall pain level, emotional well-being, relaxation, and ability to sleep. Conclusions This study shows that integration of massage therapy into the acute care setting creates overall positive results in the patient’s ability to deal with the challenging physical and psychological aspects of their health condition. The study demonstrated not only significant reduction in pain levels, but also the interrelatedness of pain, relaxation
Ghoshal, Arunangshu; Damani, Anuja; Salins, Naveen; Deodhar, Jayita; Muckaden, Mary Ann
Levofloxacin is a commonly prescribed antibiotic for managing chest and urinary tract infections in a palliative care setting. Incidence of Levofloxacin-associated anaphylaxis is rare and delirium secondary to Levofloxacin is a seldom occurrence with only few published case reports. It is an extremely rare occurrence to see this phenomenon in combination. Early identification and prompt intervention reduces both mortality and morbidity. A 17-year-old male with synovial sarcoma of right thigh with chest wall and lung metastasis and with no prior psychiatric morbidity presented to palliative medicine outpatient department with community-acquired pneumonia. He was initiated on intravenous (IV) Ceftriaxone and IV Levofloxacin. Post IV Levofloxacin patient developed anaphylaxis and acute delirium necessitating IV Hydrocortisone, IV Chlorpheneramine, Oxygen and IV Haloperidol. Early detection and prompt intervention helped in complete recovery. Patient was discharged to hospice for respite after 2 days of hospitalization and then discharged home. Acute palliative care approach facilitated management of two life-threatening medical complications in a palliative care setting improving both quality and length of life. PMID:25709191
Creating an environment in which patient's responsibility for self is fostered and nurses can practice professional and autonomous nursing practice is a challenge in today's hospitals. Innovative systems and structures need to be developed to assure quality of patient care and a high quality work environment. Newark Beth Israel Medical Center responded to the many demands of the mid-1980s, including increasing acuity of patients hospitalized, personnel shortages in nursing, physical therapy and other disciplines, and diminishing dollars available to the health care institution, through the creation of Self-Care Units. This article reviews how they came about, the way in which Self-Care Units function within the acute care setting and the management philosophy and structure which make them work. The experience at Newark Beth Israel Medical Center demonstrates that the potential exists to put control back at the bedside with the patient and the health care team working with the patient to achieve mutual goals. The focus of care has shifted from a "doing for" to a "working with" patients to identify interventions which promote active participation in hospitalization and a sense of self responsibility.
The pregnant migrant farm worker faces many barriers to accessing healthcare in the United States due to poverty, language/literacy issues, transportation difficulties, and geographic isolation. The advanced practice nurse has the opportunity to contribute solutions to the problems of lack of adequate prenatal care among the migrant farm worker community, if he/she is aware of the need and can institute novel models of care. This article describes the problem of migrant farm worker health and suggests ways that advanced practice nurses can provide cost effective, competent professional care to reduce or eliminate the obstacles to care for this population.
Green, John; Young, John; Forster, Anne; Mallinder, Karen; Bogle, Sue; Lowson, Karin; Small, Neil
Objective To determine the effects on independence in older people needing rehabilitation in a locality based community hospital compared with care on a ward for elderly people in a district general hospital. Design Randomised controlled trial. Setting Care in a community hospital and district general hospital in Bradford, England. Participants 220 patients needing rehabilitation after an acute illness that required hospital admission. Interventions Patients were randomly allocated to a locality based community hospital or to remain within a department for the care of elderly people in a district general hospital. Main outcome measures Primary outcomes were Nottingham extended activities of daily living scale and general health questionnaire 28 (carer). Secondary outcomes were activities of daily living (Barthel index), Nottingham health profile, hospital anxiety and depression scale, mortality, destination after discharge, satisfaction with services, carer strain index, and carer's satisfaction with services. Results The median length of stay was 15 days for both the community hospital and the district general hospital groups (interquartile range: community hospital 9-25 days; district general hospital 9-24 days). Independence at six months was greater in the community hospital group (adjusted mean difference 5.30, 95% confidence interval 0.64 to 9.96). Results for the secondary outcome measures, including care satisfaction and measures of carer burden, were similar for both groups. Conclusions Care in a locality based community hospital is associated with greater independence for older people than care in wards for elderly people in a district general hospital. PMID:15994660
To improve the nursing care quality in acute care hospitals in Taiwan after the 2003 SARS epidemic, the Taipei City Government Department of Health has allocated about US dollars 6 million for nurse aides' salaries and costs for recruitment, training, and administration of this program. Yet, there have been no corresponding changes in payments for nursing services by the National Health Insurance system in Taiwan such as increasing nurse fees for inpatient services. This article examines the roles of nurse aides and family members in providing acute patient care in Taiwan and discusses issues of nursing care quality as related to nurse staffing in acute care hospitals.
Gordon, Janet; Kirlew, Mike; Schreiber, Yoko; Saginur, Raphael; Bocking, Natalie; Blakelock, Brittany; Haavaldsrud, Michelle; Kennedy, Christine; Farrell, Terri; Douglas, Lloyd; Kelly, Len
Abstract Objective To document a case series of 8 young First Nations patients diagnosed with acute rheumatic fever (ARF), a preventable disease that resulted in the death of 2 patients, in northwestern Ontario in the context of late diagnosis, overcrowded housing, and inadequate public health response. Design Retrospective case series over an 18-month period. Setting Remote First Nations communities in northwestern Ontario. Participants Eight patients with ARF. Main outcome measures Incidence, mortality, residual rheumatic heart disease, time to diagnosis, barriers to diagnosis and treatment, housing situation of patients, patient demographic characteristics (age, sex), and investigation results. Results The incidence of ARF in this population was 21.3 per 100 000, which is 75 times greater than the overall Canadian estimated incidence. The average patient age was 9.4 years. Most cases developed joint findings, and 5 of the surviving patients had rheumatic heart disease when they received echocardiography. The average time to diagnosis was 88 days. Two 4-year-old children died from ARF. Most patients lived in inadequate and crowded housing. Conclusion This rare disease still exists in remote First Nations communities. These communities demonstrate an incidence equal to that in aboriginal communities in Australia and New Zealand, which have among the highest international incidence of ARF. Primordial prevention, including improved on-reserve housing, is urgently needed. Case detection and ongoing surveillance for primary and secondary prophylaxis requires a well resourced regional strategy. PMID:26759842
Hadley, H. Roger; Rutherford, Harold G.; Smith, Louis L.; Briggs, Burton A.; Neilsen, Ivan R.; Rau, Richard
The need exists for a simplified and ecomonical computer based monitoring system for critically ill surgical patients. Such a system would enjoy widespread use in surgical intensive care units in regional, as well as larger community hospitals. We have assembled such a system which provides digital readout of the usual physiologic parameters, and also provide computer storage of accumulated data for review and evaluation of patient care. The computer provides graphic and digital display and digital printout for subsequent inclusion in the patient records. Most frequent indications for this system include the development of acute respiratory insufficiency or acute circulatory failure due to invasive sepsis and/or severe arteriosclerotic cardiovascular disease. Information most beneficial in patient care included measurement of cardiac output;alveolar arterial oxygen gradient. ImagesFigure 1Figure 5Figure 9Figure 11
Rohde, J E
Infections pose a nutritional stress on the growing child. No therapeutic goal is as important as the rapid recovery of preillness weight after acute infections. Successful convalescence, with supernormal growth rates, can be achieved with relatively brief periods of intensive refeeding, offsetting any tendency toward reduced immune defenses or other nutritionally determined susceptibilities to further infection. Since the mother is the only person who can effectively manage convalescent care, she must be given specific tasks with measurable targets in order to reliably oversee the child's rehabilitation. Not generally considered in the realm of preventive medicine, effective home-based convalencent care is the first crucial step in preventing the next round of illness. An approach to the widespread mobilization of mothers to monitor and sustain their children's growth is proposed in this paper. Rather than a passive recipient of health services, the mother becomes the basic health worker, providing diagnostic and therapeutic primary care for her child. Only the mother can break the malnutrition-infection cycle.
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
Kruse, Barbara G; Melhado, Lolita W; Convertine, Linda; Stecher, Jo
Providing quality care to the dying has become a primary concern in the United States. Eighty percent of deaths still occur in the hospital even though nurses report they do not think that good deaths are routinely possible within a hospital setting due to lack of appropriate education on end-of-life care. The aim of this pilot study was to test the best method for changing acute nurse's perceptions about end-of-life care. A 3-group experimental design tested the efficacy of a nurse-led hospice collaborative. Hypotheses were: (1) nurses who receive classroom instruction will have greater change in perceptions than the control group and (2) nurses who receive a combination of classroom and hospice experiences will demonstrate greater changes than the classroom or control group. No significant differences were found among the 3 groups. However, the intervention group showed increased guilt about not having enough time to spend with the dying.
Kidman, R; Petrow, S E; Heymann, S J
The AIDS epidemic has created a crisis for children, severely threatening the health and development of children whose parents are ill, have died and whose communities have lost a large percentage of their adults. Even when extended family can serve as guardians, their need to work in the context of widespread poverty decreases the amount of time they are able to spend with children. Other children live in child-headed households or with seniors unable to provide adequate care. Relative to the size of the need there are few interventions that provide support to orphans in sub-Saharan Africa. We report on two different models of community-based care that have emerged to fill this caregiving gap, and highlight the relative advantages of each. These programmes, one centralized and the other decentralized, are an effective means of caring for orphans and could be scaled up in other communities to meet the magnitude of the crisis.
Kirkhart, Kathryn A.; And Others
The Ventilator Assisted Care Program provides centralized case management services to ventilator-using youths and their families in Louisiana. Case managers develop individualized, comprehensive plans to be implemented locally using community resources; plans are based on needs identified by tertiary care providers and family members and are…
Gates, Michael G; Mark, Barbara A
Nursing scholars and healthcare administrators often assume that a more diverse nursing workforce will lead to better patient and nurse outcomes, but this assumption has not been subject to rigorous empirical testing. In a study of nursing units in acute care hospitals, the influence of age, gender, education, race/ethnicity, and perceived value diversity on nurse job satisfaction, nurse intent to stay, and patient satisfaction were examined. Support was found for a negative relationship between perceived value diversity and all outcomes and for a negative relationship between education diversity and intent to stay. Additionally, positive relationships were found between race/ethnicity diversity and nurse job satisfaction as well as between age diversity and intent to stay. From a practice perspective, the findings suggest that implementing retention, recruitment, and management practices that foster a strong shared value system among nurses may lead to better workplace outcomes.
Vujanovic, Anka A; Dutcher, Christina D; Berenz, Erin C
Distress tolerance (DT), the actual or perceived capacity to withstand negative internal states, has received increasing scholarly attention due to its theoretical and clinical relevance to posttraumatic stress disorder (PTSD). Past studies have indicated that lower self-reported - but not behaviorally observed - DT is associated with greater PTSD symptoms; however, studies in racially and socioeconomically diverse clinical samples are lacking. The current study evaluated associations between multiple measures of DT (self-report and behavioral) and PTSD symptoms in an urban, racially and socioeconomically diverse, acute-care psychiatric inpatient sample. It was hypothesized that lower self-reported DT (Distress Tolerance Scale [DTS]), but not behavioral DT (breath-holding task [BH]; mirror-tracing persistence task [MT]), would be associated with greater PTSD symptoms, above and beyond the variance contributed by trauma load, substance use, gender, race/ethnicity, and subjective social status. Participants were 103 (41.7% women, Mage=33.5) acute-care psychiatric inpatients who endorsed exposure to potentially traumatic events consistent with DSM-5 PTSD Criterion A. Results of hierarchical regression analyses indicated that DTS was negatively associated with PTSD symptom severity (PCL-5 Total) as well as with each of the four DSM-5 PTSD symptom clusters (p's<0.001), contributing between 5.0%-11.1% of unique variance in PTSD symptoms across models. BH duration was positively associated with PTSD arousal symptom severity (p<0.05). Covariates contributed between 21.3%-40.0% of significant variance to the models. Associations between DT and PTSD in this sample of acute-care psychiatric inpatients are largely consistent with those observed in community samples.
Kapoor, Kapil; Gupta, Shalu
Acute kidney injury (AKI) is a serious complication of malaria which has a very high mortality rate. A retrospective analysis of medical record data of children treated for malarial AKI in a paediatric intensive care unit (PICU) was performed in order to evaluate the incidence, poor prognostic factors and outcome of AKI with malaria. Eighteen (48.6%) malarial patients had AKI (11 Plasmodium vivax positive, six P. falciparum positive and one mixed infection) with a male-to-female ratio of 1:2. The mean age was 75 ± 32 months (range, 1 month to 10 years). Oliguria was present in 61.1% and 55.5% required renal replacement therapy. Mortality was noted in 33.3% of patients and full recovery was achieved in 50% of patients. Oliguria, shock, central nervous system involvement, jaundice, disseminated intravascular coagulopathy and acute respiratory distress syndrome emerged as bad prognostic factors in simple univariate analysis. Malaria patients with and without AKI differ significantly in terms of shock, ventilator requirement, mortality and length of PICU stay.
..., 2010 unless otherwise footnoted).'' c. Third column, the title, ``Table 4J.--Out-Migration Adjustment...) Out-Migration Adjustment for Acute Care Hospitals--FY 2010 (April 1, 2010 through September 30, 2010...: Table 4J--(Abbreviated) Out-Migration Adjustment for Acute Care Hospitals--FY 2010 (April 1,...
Walsh, Mary E.; Buchanan, Marla J.
A large body of research provides evidence of workplace injuries to those in the nursing profession. Research on workplace stress and burnout among medical professionals is also well known; however, the profession of acute care nursing has not been examined with regards to work-related stress. This qualitative study focused on acute care nurses'…
Johnson, Diane; Saavedra, Patricia; Sun, Eugene; Stageman, Ann; Grovet, Dodie; Alfero, Charles; Maynes, Carmen; Skipper, Betty; Powell, Wayne; Kaufman, Arthur
We describe the impact of community health workers (CHWs) providing community-based support services to enrollees who are high consumers of health resources in a Medicaid managed care system. We conducted a retrospective study on a sample of 448 enrollees who were assigned to field-based CHWs in 11 of New Mexico's 33 counties. The CHWs provided patients education, advocacy and social support for a period up to 6 months. Data was collected on services provided, and community resources accessed. Utilization and payments in the emergency department, inpatient service, non-narcotic and narcotic prescriptions as well as outpatient primary care and specialty care were collected on each patient for a 6 month period before, for 6 months during and for 6 months after the intervention. For comparison, data was collected on another group of 448 enrollees who were also high consumers of health resources but who did not receive CHW intervention. For all measures, there was a significant reduction in both numbers of claims and payments after the community health worker intervention. Costs also declined in the non-CHW group on all measures, but to a more modest degree, with a greater reduction than in the CHW group in use of ambulatory services. The incorporation of field-based, community health workers as part of Medicaid managed care to provide supportive services to high resource-consuming enrollees can improve access to preventive and social services and may reduce resource utilization and cost.
Burke, Robert E.; Whitfield, Emily A.; Hittle, David; Min, Sung-joon; Levy, Cari; Prochazka, Allan V.; Coleman, Eric A.; Schwartz, Robert; Ginde, Adit A.
Objectives Hospital discharges to post-acute care (PAC) facilities have increased rapidly. This increase may lead to more hospital readmissions from PAC facilities, which are common and poorly understood. We sought to determine the risk factors and timing for hospital readmission from PAC facilities and evaluate the impact of readmission on patient outcomes. Design Retrospective analysis of Medicare Current Beneficiary Survey (MCBS) from 2003–2009. Setting The MCBS is a nationally-representative survey of beneficiaries matched with claims data. Participants Community-dwelling beneficiaries who were hospitalized and discharged to a PAC facility for rehabilitation. Intervention/Exposure Potential readmission risk factors included patient demographics, health utilization, active medical conditions at time of PAC admission, and PAC characteristics. Measurements Hospital readmission during the PAC stay, return to community residence, and all-cause mortality. Results Of 3246 acute hospitalizations followed by PAC facility stays, 739 (22.8%) included at least 1 hospital readmission. The strongest risk factors for readmission included impaired functional status (HR 4.78, 95% CI 3.21–7.10), markers of increased acuity such as need for intravenous medications in PAC (1.63, 1.39–1.92), and for-profit PAC ownership (1.43, 1.21–1.69). Readmitted patients had a higher mortality rate at both 30 days (18.9 vs. 8.6%, p<0.001) and 100 days (39.9 vs. 14.5%, p<0.001) even after adjusting for age, comorbidities, and prior health care utilization (30 days: OR 2.01, 95% CI 1.60–2.54; 100 days: OR 3.79, 95% CI 3.13–4.59). Conclusions Hospital readmission from PAC facilities is common and associated with a high mortality rate. Readmission risk factors may signify inadequate transitional care processes or a mismatch between patient needs and PAC resources. PMID:26715357
Robison, Julie; Shugrue, Noreen; Porter, Martha; Fortinsky, Richard H; Curry, Leslie A
A major effort is under way nationally to shift long-term care services from institutional to home- and community-based settings. This article employs quantitative and qualitative methods to identify unmet needs of consumers who transition from a statewide home- and community-based service program for older adults to long-term nursing home residence. Administrative data, care manager notes, and focus group discussions identified program service gaps that inadequately accommodated acute health problems, mental health issues, and stressed family caregivers; additional unmet needs highlighted an inadequate workforce, transportation barriers, and limited supportive housing options. National and state-level policy implications are considered.
Murphy, Andrea L.; Gardner, David M.; Martin-Misener, Ruth; Naylor, Ted; Kutcher, Stan P.
Background: Community pharmacists care for and support people with lived experience of mental illness in their communities. We developed a program called More Than Meds to facilitate enhancing capacity of community pharmacists’ roles in mental health care. Methods: We conducted a qualitative study and used a directed content analysis with application of the Theoretical Domains Framework as part of our underlying theory of behaviour change and our analytic framework. Results: Ten interviews (n = 6 pharmacists, n = 4 community members) were conducted with participants from the More Than Meds program. Three key themes were identified from the experiences of More Than Meds participants: networking and bridging, stigma, and expectations and permissions. The most frequently coded domains in the data from the Theoretical Domains Framework were social/professional role, skills, beliefs about capabilities, knowledge and environmental context and resources. Conclusions: The More than Meds Program enabled community pharmacists to increase their capabilities, opportunities and motivation in providing mental health care and support. Involving community pharmacists together with people with lived experience of mental illness was identified as an innovative component of the program. PMID:26600823
Ariza, Adolfo J; Hartman, Jennifer; Grodecki, Jennifer; Clavier, Alejandro; Ghaey, Kamala; Elsner, Mary; Moore, Chantal; Reina, Olga Ochoa; Binns, Helen J
Guidelines for obesity management in primary care call for linking to community services. The Promoting Health Project (PHP) was a multi-component, practice-based intervention aimed at improving care of obese children, including referrals to community services. Promoting Health Project staff identified and interviewed representatives of 40 nutrition or physical activity services/programs. Quality improvement (QI) teams at three practices worked to improve overweight/obesity identification and care and implement practice-to-community connections that used the information gathered from the programs/ services. A practice community coordinator (PCC) facilitated interactions between practices, community programs and families. Researchers tracked patients referred, PCC to family interactions, and time spent. They surveyed parents of referred patients and interviewed key clinicians. Forty-six patients participated in programs. Substantial efforts were necessary to create smooth referral systems. Family motivation was perceived as a limiting factor in program attendance. Clinicians were satisfied with systems established. Effectively linking practitioners to community programs requires the use of additional resources.
Chen, Serene I; Fox, Erin R; Hall, M Kennedy; Ross, Joseph S; Bucholz, Emily M; Krumholz, Harlan M; Venkatesh, Arjun K
Early evidence suggests that provisions of the Food and Drug Administration Safety and Innovation Act of 2012 are associated with reductions in the total number of new national drug shortages. However, drugs frequently used in acute unscheduled care such as the care delivered in emergency departments may be increasingly affected by shortages. Our estimates, based on reported national drug shortages from 2001 to 2014 collected by the University of Utah's Drug Information Service, show that although the number of new annual shortages has decreased since the act's passage, half of all drug shortages in the study period involved acute care drugs. Shortages affecting acute care drugs became increasingly frequent and prolonged compared with non-acute care drugs (median duration of 242 versus 173 days, respectively). These results suggest that the drug supply for many acutely and critically ill patients in the United States remains vulnerable despite federal efforts.
Dickey, B; Fisher, W; Siegel, C; Altaffer, F; Azeni, H
OBJECTIVE: To examine the cost-effectiveness of community-based mental health care. DATA SOURCES/STUDY SETTING: Administrative data from Medicaid and the Massachusetts Department of Mental Health; primary data from 144 psychiatrically disabled adult Medicaid beneficiaries who lived in Boston, central Massachusetts, and western Massachusetts. STUDY DESIGN: A cross-sectional observational study compared the costs and outcomes of treatment in three different types of public mental health service systems. DATA COLLECTION/EXTRACTION METHODS: Beneficiaries, randomly sampled from outpatient mental health programs, were interviewed about their mental health status. All their acute treatment and long-term continuing care for the preceding year were abstracted from Medicaid and Department of Mental Health files. Costs were extracted from Medicaid paid claims and from Department of Mental Health contracts and other financial documents. PRINCIPAL FINDINGS: Clients in the region allocating a greater proportion of its Department of Mental Health budget to community support services used far fewer hospital days, resulting in lower per person treatment expenditures. Outcomes, however, were not significantly different from outcomes of clients in the other regions. For all regions, substance abuse comorbidity increased hospitalization and total treatment costs. An individual-level cost-effectiveness analysis identified western Massachusetts (community-based care) as significantly more cost effective than the other two regions. CONCLUSIONS: Systems with stronger community-based orientation are more cost effective. PMID:9402903
Piredda, M; Ghezzi, V; De Marinis, M G; Palese, A
Longitudinal three-time point study, addressing how neurological adult patient care dependency varies from the admission time to the 3rd day of acute hospitalization. Nursing care dependency was measured with the Care Dependency Scale (CDS) and a Latent Growth Modeling approach was used to analyse the CDS trend in 124 neurosurgical and stroke inpatients. Care dependence followed a decreasing linear trend. Results can help nurse-managers planning an appropriate amount of nursing care for acute neurological patients during their initial stage of hospitalization. Further studies are needed aimed at investigating the determinants of nursing care dependence during the entire in-hospital stay.
Lilford, Richard J.
Objective To examine the independent contribution of individual, community and state-level factors to health care service utilization for children with acute childhood illnesses in Nigeria. Materials and methods The study was based on secondary analyses of cross-sectional population-based data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel logistic regression models were applied to the data on 6,427 under-five children who used or did not use health care service when they were sick (level 1), nested within 896 communities (level 2) from 37 states (level 3). Results About one-quarter of the mothers were between 15 and 24 years old and almost half of them did not have formal education (47%). While only 30% of the children utilized health service when they were sick, close to 67% lived in the rural area. In the fully adjusted model, mothers with higher education attainment (Adjusted odds ratio [aOR] = 1.63; 95% credible interval [CrI] = 1.31–2.03), from rich households (aOR = 1.76; 95% CrI = 1.35–2.25), with access to media (radio, television or magazine) (aOR = 1.18; 95% CrI = 1.08–1.29), and engaging in employment (aOR = 1.18; 95% CrI = 1.02–1.37) were significantly more likely to have used healthcare services for acute childhood illnesses. On the other hand, women who experienced difficulty getting to health facilities (aOR = 0.87; 95% CrI = 0.75–0.99) were less likely to have used health service for their children. Conclusions Our findings highlight that utilization of healthcare service for acute childhood illnesses was influenced by not only maternal factors but also community-level factors, suggesting that public health strategies should recognise this complex web of individual composition and contextual composition factors to guide provision of healthcare services. Such interventions could include: increase in female school enrolment, provision of interest-free loans for small and medium scale enterprises, introduction of
Choo, Janet; Johnston, Linda; Manias, Elizabeth
This study examined registered nurses' overall compliance with accepted medication administration procedures, and explored the distractions they faced during medication administration at two acute care hospitals in Singapore. A total of 140 registered nurses, 70 from each hospital, participated in the study. At both hospitals, nurses were distracted by personnel, such as physicians, radiographers, patients not under their care, and telephone calls, during medication rounds. Deviations from accepted medication procedures were observed. At one hospital, the use of a vest during medication administration alone was not effective in avoiding distractions during medication administration. Environmental factors and distractions can impact on the safe administration of medications, because they not only impair nurses' level of concentration, but also add to their work pressure. Attention should be placed on eliminating distractions through the use of appropriate strategies. Strategies that could be considered include the conduct of education sessions with health professionals and patients about the importance of not interrupting nurses while they are administering medications, and changes in work design.
Fukuda, Risa; Shimizu, Yasuko
Objective Dementia is a major public health problem. More and more patients with dementia are being admitted to acute care hospitals for treatment of comorbidities. Issues associated with care of patients with dementia in acute care hospitals have not been adequately clarified. This study aimed to explore the challenges nurses face in providing care to patients with dementia in acute care hospitals in Japan. Methods This was a qualitative study using focus group interviews (FGIs). The setting was six acute hospitals with surgical and medical wards in the western region of Japan. Participants were nurses in surgical and internal medicine wards, excluding intensive care units. Nurses with less than 3 years working experience, those without experience in dementia patient care in their currently assigned ward, and head nurses were excluded from participation. FGIs were used to collect data from February to December 2008. Interviews were scheduled for 1–1.5 h. The qualitative synthesis method was used for data analysis. Results In total, 50 nurses with an average experience of 9.8 years participated. Eight focus groups were formed. Issues in administering care to patients with dementia at acute care hospitals were divided into seven groups. Three of these groups, that is, problematic patient behaviors, recurrent problem, and problems affecting many people equally, interact to result in a burdensome cycle. This cycle is exacerbated by lack of nursing experience and lack of organization in hospitals. In coping with this cycle, the nurses develop protection plans for themselves and for the hospital. Conclusions The two main issues experienced by nurses while administering care to patients with dementia in acute care hospitals were as follows: (a) the various problems and difficulties faced by nurses were interactive and caused a burdensome cycle, and (b) nurses do their best to adapt to these conditions despite feeling conflicted. PMID:25716983
Kossaify, Antoine; Garcia, Annie; Succar, Sami; Ibrahim, Antoine; Moussallem, Nicolas; Kossaify, Mikhael; Grollier, Gilles
Biomarkers in acute cardiac care are gaining increasing interest given their clinical benefits. This study is a review of the major conditions in acute cardiac care, with a focus on biomarkers for diagnostic and prognostic assessment. Through a PubMed search, 110 relevant articles were selected. The most commonly used cardiac biomarkers (cardiac troponin, natriuretic peptides, and C-reactive protein) are presented first, followed by a description of variable acute cardiac conditions with their relevant biomarkers. In addition to the conventional use of natriuretic peptides, cardiac troponin, and C-reactive protein, other biomarkers are outlined in variable critical conditions that may be related to acute cardiac illness. These include ST2 and chromogranin A in acute dyspnea and acute heart failure, matrix metalloproteinase in acute chest pain, heart-type fatty acid binding protein in acute coronary syndrome, CD40 ligand and interleukin-6 in acute myocardial infarction, blood ammonia and lactate in cardiac arrest, as well as tumor necrosis factor-alpha in atrial fibrillation. Endothelial dysfunction, oxidative stress and inflammation are involved in the physiopathology of most cardiac diseases, whether acute or chronic. In summary, natriuretic peptides, cardiac troponin, C-reactive protein are currently the most relevant biomarkers in acute cardiac care. Point-of-care testing and multi-markers use are essential for prompt diagnostic approach and tailored strategic management. PMID:24046510
Glimmerveen, Ludo; Nies, Henk
This article gives an in-depth description of the service delivery model of Geriant, a Dutch organization providing community-based care services for people suffering from dementia. Core to its model is the provision of clinical case management, embedded in multidisciplinary dementia care teams. As Geriant's client group includes people from the first presumption of dementia until they can no longer live at home, its care model provides valuable lessons about how different mechanisms of integration are flexibly put to use if the complexity of clients” care needs increases. It showcases how the integration of services for a specific sub-population is combined with alignment of these services with generalist network partners. After a detailed description of the programme and its results, this article builds on the work of Walter Leutz for a conceptual discussion of Geriant's approach to care integration. PMID:26528095
Giffords, Elissa D; Wenze, Linda; Weiss, David M; Kass, Donna; Guercia, Rosemarie
The present study explored hospital community benefits and free care programs at seven hospitals in Nassau and Suffolk counties in Long Island, NewYork. There were two components to this project: (1) assessment of information regarding the availability of free care and (2) an analysis of the community benefits information filed with state regulatory offices. Results show that not one of the seven hospitals consistently informed surveyors that free care was available to low-income, uninsured people. Surveyors had difficulty obtaining written free care policies. The article concludes with suggestions for government agencies, hospital administrators, social workers, and other advocates on how to get involved in efforts to increase access to health care for the uninsured population.
Payne, Julianne; Razi, Sima; Emery, Kyle; Quattrone, Westleigh; Tardif-Douglin, Miriam
Health care organizations increasingly employ community health workers (CHWs) to help address growing provider shortages, improve patient outcomes, and increase access to culturally sensitive care among traditionally inaccessible or disenfranchised patient populations. Scholarly interest in CHWs has grown in recent decades, but researchers tend to focus on how CHWs affect patient outcomes rather than whether and how CHWs fit into the existing health care workforce. This paper focuses on the factors that facilitate and impede the integration of the CHWs into health care organizations, and strategies that organizations and their staff develop to overcome barriers to CHW integration. We use qualitative evaluation data from 13 awardees that received Health Care Innovation Awards from the Centers of Medicare and Medicaid Innovation to enhance the quality of health care, improve health outcomes, and reduce the cost of care using programs involving CHWs. We find that organizational capacity, support for CHWs, clarity about health care roles, and clinical workflow drive CHW integration. We conclude with practical recommendations for health care organizations interested in employing CHWs.
Chapman, Colin A; van Bavel, Bianca; Boodman, Carl; Ghai, Ria R; Gogarten, Jan F; Hartter, Joel; Mechak, Lauren E; Omeja, Patrick A; Poonawala, Sofia; Tuli, Dan; Goldberg, Tony L
Impoverished communities often turn to illegal extraction of resources from protected areas to alleviate economic pressures or to make monetary gains. Such practices can cause ecological damage and threaten animal populations. These communities also often face a high disease burden and typically do not have access to affordable health care. Here we argue that these two seemingly separate challenges may have a common solution. In particular, providing health care to communities adjacent to protected areas may be an efficient and effective way to reduce the disease burden while also improving local perceptions about protected areas, potentially reducing illegal extraction. We present a case study of a health centre on the edge of Kibale National Park, Uganda. The centre has provided care to c. 7,200 people since 2008 and its outreach programme extends to c. 4,500 schoolchildren each year. Contrasting the provision of health care to other means of improving community perceptions of protected areas suggests that health clinics have potential as a conservation tool in some situations and should be considered in future efforts to manage protected areas.
Campion, William J.; Kyle, Marybeth
Community colleges are uniquely positioned and well suited to assist in meeting the increasing demand for child care programs. Although a number of colleges have been reluctant to institute these programs due to the problems of liability, operating expenses, and allegations of child abuse, there are a number of advantages to having on-campus child…
New Jersey State Dept. of Education, Trenton. Div. of School Programs.
The purpose of this guide is to assist child care personnel in finding and working with community resources. Aspects of setting up a resource system are discussed, including establishing responsibilities, identifying needs, locating resources, cooperating with other centers, and contacting resource agencies. Suggestions are made for keeping…
Nakamura, Naoki; Nakayama, Masaharu; Nakaya, Jun; Tominaga, Teiji; Suganuma, Takuo; Shiratori, Norio
After the Great East Japan Earthquake we constructed a community health care information network system. Focusing on the authentication server and portal server capable of SAML&ID-WSF, we proposed an audit trail management system to look over audit events in a comprehensive manner. Through implementation and experimentation, we verified the effectiveness of our proposed audit trail management system.
Murphy, Joseph; Holste, Linda
This article explains how communities of pastoral care work. It presents an empirically forged theory in action. We examined theoretical and empirical work across the targeted area of personalization for students. We also completed what Hallinger (2012) refers to as "exhaustive review" of the field of school improvement writ large. We…
van Bavel, Bianca; Boodman, Carl; Ghai, Ria R.; Gogarten, Jan F.; Hartter, Joel; Mechak, Lauren E.; Omeja, Patrick A.; Poonawala, Sofia; Tuli, Dan; Goldberg, Tony L.
Impoverished communities often turn to illegal extraction of resources from protected areas to alleviate economic pressures or to make monetary gains. Such practices can cause ecological damage and threaten animal populations. These communities also often face a high disease burden and typically do not have access to affordable health care. Here we argue that these two seemingly separate challenges may have a common solution. In particular, providing health care to communities adjacent to protected areas may be an efficient and effective way to reduce the disease burden while also improving local perceptions about protected areas, potentially reducing illegal extraction. We present a case study of a health centre on the edge of Kibale National Park, Uganda. The centre has provided care to c. 7,200 people since 2008 and its outreach programme extends to c. 4,500 schoolchildren each year. Contrasting the provision of health care to other means of improving community perceptions of protected areas suggests that health clinics have potential as a conservation tool in some situations and should be considered in future efforts to manage protected areas. PMID:26456977
Anker, L; Rose, R; Watson, R F
The growing number of vulnerable people, such as the elderly and people with long-term disabilities, calls for healthcare providers to offer more programs to ensure a continuum of care. Client-focused care management programs offer access to such a continuum. Care managers understand services and reimbursement and can pull it all together for the client. The Sisters of Charity Health Care Systems, Cincinnati, have two models of care management. St. Joseph Coordinated Care provides extensive outreach to a large, culturally diverse New Mexico community, serving urban and rural clients. Penrose-St. Francis Healthcare System offers inpatient medical care management in Colorado. Coordinated Care at St. Joseph Healthcare System in Albuquerque is comprehensive, covering a wide spectrum of client needs--medical, social, and psychological. The program's central goal is to help individuals remain safely at home. Persistence and devotion to the client are the hallmarks of effective care management and the foundation of the new geriatric care management program at Penrose-St. Francis Healthcare System in Colorado Springs, CO. The program's goals are to improve inpatient geriatric care, smooth the patient's transition to alternative care settings, and ensure efficient and effective resource use during the patient's hospital stay.
Piquette, Dominique; Moulton, Carol-Anne; LeBlanc, Vicki R
Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.
The aging of the elderly population is of crucial importance as people who are over 80 make far greater use of health and social services than any other age group. Government guidelines on the provision of services, which are generally related to the whole population aged 65 and over, fail to take account of this change in the age structure of the elderly population and are no longer appropriate. Recent trends in the provision of domiciliary services, day care, specialist housing for the elderly, and residential care have been related to changes in the number of potential consumers. Ironically, despite the government's stated commitment to "community care," the chief growth area has been private institutional care. The number of day care places and sheltered housing units has also increased in real terms, but the provision of domiciliary services, such as home help and health visitor visits to the elderly, has either fallen behind or barely matched the increase in the number of very old people. If community care is to be made a reality and if the present inadequate levels of service are to be maintained, let alone improved, then additional resources, greater cooperation among agencies, and a more imaginative approach to the development and delivery of services are urgently needed. PMID:3103837
Jusela, Cheryl; Struble, Laura; Gallagher, Nancy Ambrose; Redman, Richard W; Ziemba, Rosemary A
HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE INSTRUCTIONS 1.3 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded once you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. To obtain contact hours you must: 1. Read the article, "Communication Between Acute Care Hospitals and Skilled Nursing Facilities During Care Transitions: A Retrospective Chart Review" found on pages 19-28, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website listed above to register for contact hour credit. You will be asked to provide your name; contact information; and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until February 29, 2020. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. ACTIVITY OBJECTIVES 1. Discuss problematic barriers during care transitions
Trusz, Sarah Geiss; Wagner, Amy W; Russo, Joan; Love, Jeff; Zatzick, Douglas F
Cognitive Behavioral Therapy (CBT) interventions are efficacious in reducing posttraumatic stress disorder (PTSD) but are challenging to implement in acute care and other non-specialty mental health settings. This investigation identified barriers impacting CBT delivery through a content analysis of interventionist chart notes from an acute care PTSD prevention trial. Only 8.5% of all intervention patients were able to complete CBT. Lack of engagement, clinical and logistical barriers had the greatest impact on CBT entry. Treatment preferences and stigma only prevented entry when more primary barriers resolved. Patients with prior diagnosis of alcohol abuse or dependence were able to enter CBT after six months of sobriety. Based on the first trial, we developed a CBT readiness assessment tool. We implemented and evaluated the tool in a second early intervention trial. Lack of engagement emerged again as the primary impediment to CBT entry. Patients who were willing to enter CBT treatment but demonstrated high rates of past trauma or diagnosis of PTSD were also the least likely to engage in any PTSD treatment one month post-discharge. Findings support the need for additional investigations into engagement and alternative delivery strategies, including those which dismantle traditional office-based, multi-session CBT into stepped, deliverable components.
Danzl, Megan M; Hunter, Elizabeth G
Connecting the continuum of post-acute care stroke services may be important for easing patients' transition between settings and facilitating recovery and community reintegration. The use of outcome measures is suggested as one means of connecting the continuum. The purpose of this qualitative case study is to describe administrators' and physiotherapists' perceived value of an outcomes program across the post-acute care stroke continuum at a rehabilitation hospital. Data were collected through individual interviews and focus groups with 18 participants. Three themes emerged on the value of the outcomes program: 1) enhanced communication; 2) supports clinical decision-making; and 3) value of objective data. These findings lend support for the use of standardized outcome measures by physiotherapists in stroke rehabilitation. Findings from this study may be useful for organizations and physiotherapists who wish to integrate outcome measures into practice.
Beer, Martin D.
Community care is a complex operation that requires the interaction of large numbers of dedicated individuals, managed by an equally wide range of organisations. They are also by their nature highly mobile and flexible, moving between clients in whatever order person receiving care is that they receive what they expect regularly, reliably and when they expect to receive it. Current systems are heavily provider focused on providing the scheduled care with as high apparent cost effectiveness as possible. Unfortunately, the lack of focus on the client often leads to inflexibility with expensive services being provided when they are not needed, large scale duplication of effort or inadequate flexibility to change the care regime to meet changing circumstances. Add to this the problems associated with the lack of integration of emergency and routing care and the extensive support given by friends and family and many opportunities exist to improve both the levels of support and the efficiency of care. The move towards Individual Care Plans requires much closer monitoring to ensure that the care specified for each individual is actually delivered and when linked with smart home technology in conjunction with appropriate sensors allows a much richer range of services to be offered which can be customised to meet the needs of each individual, giving them the assurance to continue to live independently.
Buntin, Melinda Beeuwkes; Colla, Carrie Hoverman; Escarce, José J
Objective To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies. Data Sources Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data. Study Design We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems. Data Extraction Methods A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement. Principal Findings Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill. Conclusions Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites. PMID:19490159
...We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems and to implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010......
Mandrioli, Matteo; Inaba, Kenji; Piccinini, Alice; Biscardi, Andrea; Sartelli, Massimo; Agresta, Ferdinando; Catena, Fausto; Cirocchi, Roberto; Jovine, Elio; Tugnoli, Gregorio; Di Saverio, Salomone
The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers, for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a
Mandrioli, Matteo; Inaba, Kenji; Piccinini, Alice; Biscardi, Andrea; Sartelli, Massimo; Agresta, Ferdinando; Catena, Fausto; Cirocchi, Roberto; Jovine, Elio; Tugnoli, Gregorio; Di Saverio, Salomone
The greatest advantages of laparoscopy when compared to open surgery include the faster recovery times, shorter hospital stays, decreased postoperative pain, earlier return to work and resumption of normal daily activity as well as cosmetic benefits. Laparoscopy today is considered the gold standard of care in the treatment of cholecystitis and appendicitis worldwide. Laparoscopy has even been adopted in colorectal surgery with good results. The technological improvements in this surgical field along with the development of modern techniques and the acquisition of specific laparoscopic skills have allowed for its utilization in operations with fully intracorporeal anastomoses. Further progress in laparoscopy has included single-incision laparoscopic surgery and natural orifice trans-luminal endoscopic surgery. Nevertheless, laparoscopy for emergency surgery is still considered challenging and is usually not recommended due to the lack of adequate experience in this area. The technical difficulties of operating in the presence of diffuse peritonitis or large purulent collections and diffuse adhesions are also given as reasons. However, the potential advantages of laparoscopy, both in terms of diagnosis and therapy, are clear. Major advantages may be observed in cases with diffuse peritonitis secondary to perforated peptic ulcers, for example, where laparoscopy allows the confirmation of the diagnosis, the identification of the position of the ulcer and a laparoscopic repair with effective peritoneal washout. Laparoscopy has also revolutionized the approach to complicated diverticulitis even when intestinal perforation is present. Many other emergency conditions can be effectively managed laparoscopically, including trauma in select hemodynamically-stable patients. We have therefore reviewed the most recent scientific literature on advances in laparoscopy for acute care surgery and trauma in order to demonstrate the current indications and outcomes associated with a
Roffe, D.; Roffe, C.
Care in the community for insane people today is more a matter of expert provision than communal support. In consequence, although they are no longer confined to hospital, mentally ill people largely remain marginalised in a society that does not have the resources, nor often the inclination, to take responsibility for their care. The experience of insane people in medieval England seems to have been of a different order, as shown by a particularly well documented case dating from 1383. From the late 13th century congenital idiots were protected by law. Care of lunatics, by contrast, was primarily the responsibility of the family. However, where the family could not or was unwilling to provide, provision was made by the crown. Through the instrument of the inquisition, the diagnosis and social circumstances of each case were determined by commissioners in consultation with a local jury and all interested parties, including the subject himself or herself. The best interests of the subject remained a prime concern, and the settlement that was ordained was tried and enforced in law. The process was confined to those with real or personal estate, but it encompassed poor as well as rich and proved, through the close identity of the local community with the process, to be a sophisticated and effective mechanism for maintaining and sustaining insane people. Unlike today, care in the community was a communal activity that ensured a truly public provision for those who could not look after themselves. Images p1711-a Fig 1 PMID:8541770
Roffe, D; Roffe, C
Care in the community for insane people today is more a matter of expert provision than communal support. In consequence, although they are no longer confined to hospital, mentally ill people largely remain marginalised in a society that does not have the resources, nor often the inclination, to take responsibility for their care. The experience of insane people in medieval England seems to have been of a different order, as shown by a particularly well documented case dating from 1383. From the late 13th century congenital idiots were protected by law. Care of lunatics, by contrast, was primarily the responsibility of the family. However, where the family could not or was unwilling to provide, provision was made by the crown. Through the instrument of the inquisition, the diagnosis and social circumstances of each case were determined by commissioners in consultation with a local jury and all interested parties, including the subject himself or herself. The best interests of the subject remained a prime concern, and the settlement that was ordained was tried and enforced in law. The process was confined to those with real or personal estate, but it encompassed poor as well as rich and proved, through the close identity of the local community with the process, to be a sophisticated and effective mechanism for maintaining and sustaining insane people. Unlike today, care in the community was a communal activity that ensured a truly public provision for those who could not look after themselves.
Scahill, Shane; Harrison, Jeff; Carswell, Peter; Shaw, John
The aim of our paper is to expose the challenges primary health care reform is exerting on community pharmacy and other groups. Our paper is underpinned by the notion that a broad understanding of the issues facing pharmacy will help facilitate engagement by pharmacy and stakeholders in primary care. New models of remuneration are required to deliver policy expectations. Equally important is redefining the place of community pharmacy, outlining the roles that are mooted and contributions that can be made by community pharmacy. Consistent with international policy shifts, New Zealand primary health care policy outlines broad directives which community pharmacy must respond to. Policymakers are calling for greater integration and collaboration, a shift from product to patient-centred care; a greater population health focus and the provision of enhanced cognitive services. To successfully implement policy, community pharmacists must change the way they think and act. Community pharmacy must improve relationships with other primary care providers, District Health Boards (DHBs) and Primary Health Organisations (PHOs). There is a requirement for DHBs to realign funding models which increase integration and remove the requirement to sell products in pharmacy in order to deliver services. There needs to be a willingness for pharmacy to adopt a user pays policy. General practitioners (GPs) and practice nurses (PNs) need to be aware of the training and skills that pharmacists have, and to understand what pharmacists can offer that benefits their patients and ultimately general practice. There is also a need for GPs and PNs to realise the fiscal and professional challenges community pharmacy is facing in its attempt to improve pharmacy services and in working more collaboratively within primary care. Meanwhile, community pharmacists need to embrace new approaches to practice and drive a clearly defined agenda of renewal in order to meet the needs of health funders, patients
Finch, S J; Burgess, P M; Herrman, H E
This article describes three recently established community-based crisis services for people with acute psychiatric illness. Data were obtained from local information systems developed in the early phase of service operation. Patterns of service were found to vary among the teams in terms of the frequency of contact with the client, the period of contact with the client and the overall numbers of contacts. Such diversification of services reflects, at least in part, the differences in the service networks within which the new services were Such diversification of services is inevitable and creative, and the evaluation of these services must consider not only the short-term impact of crisis services, but also the impact of the network of care services on longer term outcomes for the client.
Redding, Sarah; Conrey, Elizabeth; Porter, Kyle; Paulson, John; Hughes, Karen; Redding, Mark
The evidence is limited on the effectiveness of home visiting care coordination in addressing poor birth outcome, including low birth weight (LBW). The Community Health Access Project (CHAP) utilizes community health workers (CHWs) to identify women at risk of having poor birth outcomes, connect them to health and social services, and track each identified health or social issue to a measurable completion. CHWs are trained individuals from the same highest risk communities. The CHAP Pathways Model is used to track each maternal health and social service need to resolution and CHWs are paid based upon outcomes. We evaluated the impact of the CHAP Pathways program on LBW in an urban Ohio community. Women participating in CHAP and having a live birth in 2001 through 2004 constituted the intervention group. Using birth certificate records, each CHAP birth was matched through propensity score to a control birth from the same census tract and year. Logistic regression was used to examine the association of CHAP participation with LBW while controlling for risk factors for LBW. We identified 115 CHAP clients and 115 control births. Among the intervention group there were seven LBW births (6.1 %) compared with 15 (13.0 %) among non-CHAP clients. The adjusted odds ratio for LBW was 0.35 (95 % confidence interval, 0.12-0.96) among CHAP clients. This study provides evidence that structured community care coordination coupled with tracking and payment for outcomes may reduce LBW birth among high-risk women.
Nivet, Marc A; Berlin, Anne
While the levers for the social determinants of health reside largely outside institutional walls, this does not absolve health professional schools from exercising their influence to improve the communities in which they are located. Fulfilling this charge will require a departure from conventional thinking, particularly when it comes to educating future health professionals. We describe efforts within medical education to transform recruitment, admissions, and classroom environments to emphasize diversity and inclusion. The aim is to cultivate a workforce with the perspectives, aptitudes, and skills needed to fuel community-responsive health-care institutions.
Chela, C M; Campbell, I D; Siankanga, Z
Inpatient and community-based care can be complementary in relation to the management of HIV disease. Some special features and advantages of community-based care are described, drawing on experience from Zambia.
Strickland, Pamela A. Ohman; Hudson, Shawna V.; Piasecki, Alicja; Hahn, Karissa; Cohen, Deborah; Orzano, A. John; Parchman, Michael L.; Crabtree, Benjamin F.
Background The Chronic Care Model (CCM) was developed to improve chronic disease care, but may also inform other types of preventive care delivery. Using hierarchical analyses of service delivery to patients, we explore associations of CCM implementation with diabetes care and counseling for diet or weight loss and physical activity in community-based primary care offices. Methods Secondary analysis focused on baseline data from 25 practices (with an average of four physicians per practice) participating in an intervention trial targeting improved colorectal cancer screening rates. This intervention made no reference to the CCM. CCM implementation (measured through staff and clinical management surveys) and was associated with patient care indicators (chart audits and patient questionnaires). Results Overall, practices had low levels of CCM implementation. However, higher levels of CCM implementation were associated with better diabetes assessment and treatment of patients (p=0.009, 0.015), particularly in practices open to “innovation”. Physical activity counseling for obese and particularly overweight patients was strongly associated with CCM implementation (p=0.0017), particularly among practices open to “innovation”; however, this association did not hold for overweight and obese patients with diabetes. Conclusions Very modest levels of CCM implementation in unsupported primary care practices are associated with improved care for patients with diabetes and higher rates of behavioral counseling. Incremental incorporation of CCM components is an option, especially for resource stretched community practices with cultures of “innovativeness.” PMID:20453175
Acute care nurse practitioner roles have been introduced in many countries. The acute care nurse practitioner provides nursing and medical care to meet the complex needs of patients and their families using a holistic, health-centred approach. There are many pressures to adopt a performance framework and execute activities and tasks. Little time may be left to explore domains of advanced practice nursing and develop other forms of knowledge. The primary objective of praxis is to integrate theory, practice and art, and facilitate the recognition and valuing of different types of knowledge through reflection. With this framework, the acute care nurse practitioner assumes the role of clinician and researcher. Praxis can be used to develop the acute care nurse practitioner role as an advanced practice nursing role. A praxis framework permeates all aspects of the acute care nurse practitioner's practice. Praxis influences how relationships are structured with patients, families and colleagues in the work setting. Decision-makers at different levels need to recognize the contribution of praxis in the full development of the acute care nurse practitioner role. Different strategies can be used by educators to assist students and practitioners to develop a praxis framework.
Esandi, Nuria; Canga, Ana
Along with ageing population, there has been an increase in the prevalence and incidence of chronic and debilitating conditions, such as dementia which, in turn, has increased the demands for long term care in the community. This is challenging current health care systems that wish to provide an appropriate response whilst intensify its efforts to contain costs. This paper, through a critical reflection, argues for an integrative, positive, and systemic care approach, focused not only on the person with dementia but also on the entire family unit. For this purpose, it approaches the impact that dementia has for the family, and therefore for Primary Health Care professional. In addition care strategies aimed at strengthening the whole family system are suggested.
Bridgeman, Mary Barna; Abazia, Daniel T
The authors review the historical use of medicinal cannabis and discuss the agent's pharmacology and pharmacokinetics, select evidence on medicinal uses, and the implications of evolving regulations on the acute care hospital setting.
Johnston, David; Tough, Suzanne; Siever, Jodi
This article describes The Community Perinatal Care Study, a community-based study of pregnancy support that was conducted in Calgary, Alberta, Canada, between 2001 and 2004. The study was conducted to learn how to improve community-based pregnancy care and to improve prenatal care and healthy births, particularly for women with increased…
Amy, Chen; Zagorski, Brandon; Chan, Vincy; Parsons, Daria; Vander Laan, Rika; Colantonio, Angela
Alternate-level-of-care (ALC) days represent hospital beds that are taken up by patients who would more appropriately be cared for in other settings. ALC days have been found to be costly and may result in worse functional outcomes, reduced motor skills and longer lengths of stay in rehabilitation. This study examines the factors that are associated with acute care ALC days among patients with acquired brain injury (ABI). We used the Discharge Abstract Database to identify patients with ABI using International Classification of Disease-10 codes. From fiscal years 2007/08 to 2009/10, 17.5% of patients with traumatic and 14% of patients with non-traumatic brain injury had at least one ALC day. Significant predictors include having a psychiatric co-morbidity, increasing age and length of stay in acute care. These findings can inform planning for care of people with ABI in a publicly funded healthcare system.
Bika, O H; Edozien, L C
Emergency obstetric care in the UK has been systematically developed over the years to high quality standards. More recently, advances have been made in the organisation and delivery of care for women presenting with acute gynaecological problems, but a lot remains to be done, and emergency gynaecology has a lot to learn from the evolution of its sister special interest area: acute obstetric care. This paper highlights areas such as consultant presence, risk management, patient flow pathways, out-of-hours care, clinical guidelines and protocols, education and training and facilities, where lessons from obstetrics are transferrable to emergency gynaecology.
Wells, Chris L
This article provides an overview of the utilization of ventricular assist devices (VADs), reviews the common features of VADs and management of VAD recipients, discusses clinical considerations in the rehabilitation process, and describes the role of the acute care physical therapist in the care of VAD recipients. With more than 5 million people in the United States with heart failure, and with a limited ability to manage the progressive and debilitating nature of heart failure, VADs are becoming more commonplace. In order to prescribe a comprehensive and effective plan of care, the physical therapist needs to understand the type and function of the VADs and the goals of the VAD program. The goals for the physical therapist are: (1) to deliver comprehensive rehabilitation services to patients on VAD support, (2) to develop an understanding of the role of functional mobility in recovery, and (3) to understand how preoperative physical function may contribute to the VAD selection process. The acute care physical therapist has an increasing role in providing a complex range of rehabilitation services, as well as serving as a well-educated resource to physical therapists across the health care spectrum, as more VAD recipients are living in the community.
Lemieux-Charles, Louis; Chambers, Larry W.; Cockerill, Rhonda; Jaglal, Susan; Brazil, Kevin; Cohen, Carole; LeClair, Ken; Dalziel, Bill; Schulman, Barbara
Purpose: The Dementia Care Networks' Study examined the effectiveness of four community-based, not-for-profit dementia networks. The study involved assessing the relationship between the types of administrative and service-delivery exchanges that occurred among the networked agencies and the network members' perception of the effectiveness of…
Warren, Jared S.; Nelson, Philip L.; Mondragon, Sasha A.; Baldwin, Scott A.; Burlingame, Gary M.
Objective: The authors compared symptom change trajectories and treatment outcome categories in children and adolescents receiving routine outpatient mental health services in a public community mental health system and a private managed care organization. Method: Archival longitudinal outcome data from parents completing the Youth Outcome…
Hartwig, M S; Landis, B J
This article explicates the Arkansas Area Health Education Center (AHEC) model of community-oriented primary care (COPC) and the role of the family nurse practitioner (FNP) in its implementation. The AHECs collaborate with local agencies to provide comprehensive, accessible, quality health care to specific patient populations, and offer learning opportunities to a wide variety of health professions students. The FNP demonstrates organizational and role competencies that include directing patient care, providing professional leadership, and developing the advanced practice nursing role. Two case studies are used to illustrate the FNPs' approach to COPC: (1) selection of interdisciplinary, multidisciplinary, and transdisciplinary approaches to management of a patient with chronic illnesses, and (2) the Sexual Assault Nurse Examiners Training Project.
Thornicroft, Graham; Deb, Tanya; Henderson, Claire
This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low- and middle-income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long-term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.
Thornicroft, Graham; Deb, Tanya; Henderson, Claire
This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low‐ and middle‐income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long‐term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness. PMID:27717265
Peek, Monica E.
Designing and implementing effective lifestyle modification strategies remains one of the great challenges in diabetes care. Historically, programs have focused on individual behavior change with little or no attempt to integrate change within the broader social framework or community context. However, these contextual factors have been shown to be associated with poor diabetes outcomes, particularly in low-income minority populations. Recent evidence suggests that one way to address these disparities is to match patient needs to existing community resources. Not only does this position patients to more quickly adapt behavior in a practical way, but this also refers patients back to their local communities where a support mechanism is in place to sustain healthy behavior. Technology offers a new and promising platform for connecting patients to meaningful resources (also referred to as “assets”). This paper summarizes several noteworthy innovations that use technology as a practical bridge between healthcare and community-based resources that promote diabetes self-care. PMID:25994856
... nursing home care beyond six months. 17.60 Section 17.60 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Use of Community Nursing Home Care Facilities § 17.60 Extensions of community nursing home care beyond six months. Directors of health care facilities may authorize, for...
... nursing home care beyond six months. 17.60 Section 17.60 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Use of Community Nursing Home Care Facilities § 17.60 Extensions of community nursing home care beyond six months. Directors of health care facilities may authorize, for...
... nursing home care beyond six months. 17.60 Section 17.60 Pensions, Bonuses, and Veterans' Relief DEPARTMENT OF VETERANS AFFAIRS MEDICAL Use of Community Nursing Home Care Facilities § 17.60 Extensions of community nursing home care beyond six months. Directors of health care facilities may authorize, for...
Jia, Huanguang; Pei, Qinglin; Sullivan, Charles T; Cowper Ripley, Diane C; Wu, Samuel S; Vogel, W Bruce; Wang, Xinping; Bidelspach, Douglas E; Hale-Gallardo, Jennifer L; Bates, Barbara E
Introduction Effective post-acute multidisciplinary rehabilitation therapy improves stroke survivors’ functional recovery and daily living activities. The US Department of Veterans Affairs (VA) places veterans needing post-acute institutional care in private community nursing homes (CNHs). These placements are made under the same rules and regulations across the VA health care system and through individual per diem contracts between local VA facilities and CNHs. However, there is limited information about utilization of these veterans’ health services as well as the geographic variation of the service utilization. Aim The aims of this study were to determine rehabilitation therapy and restorative nursing care utilization by veterans with stroke in VA-contracted CNHs and to assess risk-adjusted regional variations in the utilization of rehabilitation therapy and restorative nursing care. Methods This retrospective study included all veterans diagnosed with stroke residing in VA-contracted CNHs between 2006 and 2009. Minimum Dataset (a health status assessment tool for CNH residents) for the study CNHs was linked with veterans’ inpatient and outpatient data within the VA health care system. CNHs were grouped into five VA-defined geographic regions: the North Atlantic, Southeast, Midwest, Continental, and Pacific regions. A two-part model was applied estimating risk-adjusted utilization probability and average weekly utilization days. Two dependent variables were rehabilitation therapy and restorative nursing care utilization by veterans during their CNH stays. Results The study comprised 6,206 veterans at 2,511 CNHs. Rates for utilization of rehabilitation therapy and restorative nursing care were 75.7% and 30.1%, respectively. Veterans in North Atlantic and Southeast CNHs were significantly (p<0.001) more likely to receive rehabilitation therapies than veterans from other regions. However, veterans in Southeast CNHs were significantly (p<0.001) less likely to
Dinardi, Graciela; Canevari, Cecilia; Torabi, Nahal
Chagas disease (CD) is a tropical parasitic disease largely underdiagnosed and mostly asymptomatic affecting marginalized rural populations. Argentina regularly reports acute cases of CD, mostly young individuals under 14 years old. There is a void of knowledge of health care seeking behavior in subjects experiencing a CD acute condition. Early treatment of the acute case is crucial to limit subsequent development of disease. The article explores how the health outcome of persons with acute CD may be conditioned by their health care seeking behavior. The study, with a qualitative approach, was carried out in rural areas of Santiago del Estero Province, a high risk endemic region for vector transmission of CD. Narratives of 25 in-depth interviews carried out in 2005 and 2006 are analyzed identifying patterns of health care seeking behavior followed by acute cases. Through the retrospective recall of paths for diagnoses, weaknesses of disease information, knowledge at the household level, and underperformance at the provincial health care system level are detected. The misdiagnoses were a major factor in delaying a health care response. The study results expose lost opportunities for the health care system to effectively record CD acute cases. PMID:27829843
Mumford, Virginia; Greenfield, David; Hinchcliff, Reece; Moldovan, Max; Forde, Kevin; Westbrook, Johanna I; Braithwaite, Jeffrey
Introduction The Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork—Cost–Benefit Analysis (ACCREDIT-CBA (Acute)) study is designed to determine and make explicit the costs and benefits of Australian acute care accreditation and to determine the effectiveness of acute care accreditation in improving patient safety and quality of care. The cost–benefit analysis framework will be provided in the form of an interactive model for industry partners, health regulators and policy makers, accreditation agencies and acute care service providers. Methods and design The study will use a mixed-method approach to identify, quantify and monetise the costs and benefits of accreditation. Surveys, expert panels, focus groups, interviews and primary and secondary data analysis will be used in cross-sectional and case study designs. Ethics and dissemination The University of New South Wales Human Research Ethics Committee has approved this project (approval number HREC 10274). The results of the study will be reported via peer-reviewed publications, conferences and seminar resentations and will form part of a doctoral thesis. PMID:23396564
Gausvik, Christian; Lautar, Ashley; Miller, Lisa; Pallerla, Harini; Schlaudecker, Jeffrey
Efficient, accurate, and timely communication is required for quality health care and is strongly linked to health care staff job satisfaction. Developing ways to improve communication is key to increasing quality of care, and interdisciplinary care teams allow for improved communication among health care professionals. This study examines the patient- and family-centered use of structured interdisciplinary bedside rounds (SIBR) on an acute care for the elderly (ACE) unit in a 555-bed metropolitan community hospital. This mixed methods study surveyed 24 nurses, therapists, patient care assistants, and social workers to measure perceptions of teamwork, communication, understanding of the plan for the day, safety, efficiency, and job satisfaction. A similar survey was administered to a control group of 38 of the same staff categories on different units in the same hospital. The control group units utilized traditional physician-centric rounding. Significant differences were found in each category between the SIBR staff on the ACE unit and the control staff. Nurse job satisfaction is an important marker of retention and recruitment, and improved communication may be an important aspect of increasing this satisfaction. Furthermore, improved communication is key to maintaining a safe hospital environment with quality patient care. Interdisciplinary team rounds that take place at the bedside improve both nursing satisfaction and related communication markers of quality and safety, and may help to achieve higher nurse retention and safer patient care. These results point to the interconnectedness and dual benefit to both job satisfaction and patient quality of care that can come from enhancements to team communication.
Soares, Luiz Guilherme L; Japiassu, André M; Gomes, Lucia C; Pereira, Rogéria
Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P < .001) and mechanical ventilation (2% vs 40%, P < .001), when compared to noncancer patients. Approximately one-third of discharges from hospitals to a PACF involved a heterogeneous group of patients in need of palliative care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.
Wald, Heidi L.; Leykum, Luci K.; Mattison, Melissa L. P.; Vasilevskis, Eduard E.; Meltzer, David O.
Hospitalists and others acute care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine (SHM) sponsored the Acute Care of Older Patients (ACOP) Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute (PCORI) framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through four steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a Partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of ten research questions in the following areas: advanced care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision-making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training. PMID:25877486
Wald, Heidi L; Leykum, Luci K; Mattison, Melissa L P; Vasilevskis, Eduard E; Meltzer, David O
Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training.
Lagman, Ruth; Walsh, Declan; Heintz, Jessica; Legrand, Susan B; Davis, Mellar P
Palliative care in advanced disease is complex. Knowledge and experience of symptom control and management of multiple complications are essential. An interdisciplinary team is also required to meet the medical and psychosocial needs in life-limiting illness. Acute care palliative medicine is a new concept in the spectrum of palliative care services. Acute care palliative medicine, integrated into a tertiary academic medical center, provides expert medical management and specialized care as part of the spectrum of acute medical care services to this challenging patient population. The authors describe a case series to provide a snapshot of a typical day in an acute care inpatient palliative medicine unit. The cases illustrate the sophisticated medical care involved for each individual and the important skill sets of the palliative medicine specialist required to provide high-quality acute medical care for the very ill.
Mejía-Trujillo, Juliana; Pérez-Gómez, Augusto; Reyes-Rodríguez, María Fernanda
For more than two years, Corporación Nuevos Rumbos (Colombia) has been carrying out, in eight Colombian communities, a preventive system called Comunidades Que se Cuidan (CQC), an adaptation of Communities That Care (CTC), created at the University of Washington (Seattle), developed for more than 25 years in the United States of America and implemented in eight countries of America, Oceania, and Europe. The system is based on the public health approach, and the social development strategy for community empowerment. The core idea is to teach communities how to make decisions based on data regarding drugs and alcohol consumption and the identification of protective and risk factors, on the basis of the original survey validated in Colombia: these will allow communities to choose the best preventive interventions, tailored for each of them according to their needs. This paper describes the process of implementation of CQC in Colombia, its differences with CTC, the creation of Colombian cut-points, the main difficulties and how these were solved. CQC seems to be a preventive system with a wide potential applicability in other Latin American countries.
Wyder, Marianne; Ehrlich, Carolyn; Crompton, David; McArthur, Leianne; Delaforce, Caroline; Dziopa, Fiona; Ramon, Shulamit; Powell, Elizabeth
Inpatient psychiatric care requires a balance between working with consumers' priorities and goals, managing expectations of the community, legal, professional and service responsibilities. In order to improve service delivery within acute mental health units, it is important to understand the constraints and facilitating factors for good care. We conducted a systematic narrative synthesis, where findings of qualitative studies are synthesised to generate new insights. 21 articles were identified. Our results show that personal qualities, professional skills as well as environmental factors all influence the ability to provide recovery focused care. Three overarching themes which either facilitated or hindered were identified. These included: (i) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); (ii) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); and (iii) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self-care). We suggest that the therapeutic use of self is central to the provision of recovery oriented care. However person-centred practice can be fragile and fluid and a compassionate system of support is needed to enable an understanding of context and self. It is critical to have a work environment which fosters hope and optimism and is supportive of autonomy, ensures workload balance, and is safe.
Lappegard, Øystein; Hjortdahl, Per
There is growing international interest in the geography of health care provision, with health care providers searching for alternatives to acute hospitalization. In Norway, the government has recently legislated for municipal authorities to develop local health services for a selected group of patients, with a quality equal to or better than that provided by hospitals for emergency admissions. General practitioners in Hallingdal, a rural district in southern Norway, have for several years referred acutely somatically ill patients to a community hospital, Hallingdal sjukestugu (HSS). This article analyzes patients' perceived quality of HSS to demonstrate factors applicable nationally and internationally to aid in the development of local alternatives to general hospitals. We used a mixed-methods approach with questionnaires, individual interviews and a focus group interview. Sixty patients who were taking part in a randomized, controlled study of acute admissions at HSS answered the questionnaire. Selected patients were interviewed about their experiences and a focus group interview was conducted with representatives of local authorities, administrative personnel and health professionals. Patients admitted to HSS reported statistically significant greater satisfaction with several care aspects than those admitted to the general hospital. Factors highlighted by the patients were the quiet and homelike atmosphere; a small facility which allowed them a good overall view of the unit; close ties to the local community and continuity in the patient-staff relationship. The focus group members identified some overarching factors: an interdisciplinary and holistic approach, local ownership, proximity to local general practices and close cooperation with the specialist health services at the hospital. Most of these factors can be viewed as general elements relevant to the development of local alternatives to acute hospitalization both nationally and internationally. This
Zhu, Thein Hlaing; Hollister, Lisa; Scheumann, Christopher; Konger, Jennifer; Opoku, Dazar
The study evaluates (1) health care provider perception of the Rural Trauma Team Development Course (RTTDC); (2) improvement in acute trauma emergency care knowledge; and (3) early transfer of trauma patients from rural emergency departments (EDs) to a verified trauma center. A 1-day, 8-hour RTTDC was given to 101 nurses and other health care providers from nine rural community hospitals from 2011 to 2013. RTTDC participants completed questionnaires to address objectives (1) and (2). ED and trauma registry data were queried to achieve objective (3) for assessing reduction in ED time (EDT), from patient arrival to decision to transfer and ED length of stay (LOS). The RTTDC was positively perceived by health care providers (96.3% of them completed the program). Significant improvement in 13 of the 19 knowledge items was observed in nurses. Education intervention was an independent predictor in reducing EDT by 28 minutes and 95% confidence interval (CI) [-57, -0.1] at 6 months post-RTTDC, and 29 minutes and 95% CI [-53, -6] at 12 months post-RTTDC. Similar results were observed with ED LOS. The RTTDC is well-perceived as an education program. It improves acute trauma emergency care knowledge in rural health care providers. It promotes early transfer of severely injured patients to a higher level of care.
National Academies Press, 2010
The Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the IOM, seeks to transform nursing as part of larger efforts to reform the health care system. The first of the Initiative's three forums was held on October 19, 2009, and focused on safety, technology, and interdisciplinary collaboration in acute care. Appended are: (1)…
Piquette, Dominique; Moulton, Carol-Anne; LeBlanc, Vicki R.
Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand…
Baldwin, Laura-Mae; MacLehose, Richard F.; Hart, L. Gary; Beaver, Shelli K.; Every,Nathan; Chan,Leighton
Context: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. Purpose: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers.…
...We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems and to implement certain provisions of the Affordable Care Act and other legislation. In addition, we describe the changes to the amounts and factors used to determine......
...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...
...-AR12 Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific...
...; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory...
Zakus, J D
Great hope is accorded to community participation in health. A large number of potential benefits are attributed to participatory processes, including better addressing community needs through more locally adapted organizational processes and improvement in health outcomes. To this end, many governments around the world have adopted policies and programmes of community participation as part of their strategy to implement primary health care services. In Mexico this is, in great part, realized through the module programme of the Ministry of Health. A module is characterized by various village based health posts (casas de salud), each operated by a community volunteer and associated with a health committee, all of which are supervised by a nurse from a nearby health centre. The southern Mexican state of Oaxaca was chosen for a study of the module programme (during the period 1987-1992) to gain a better understanding of how organizational processes impact on the implementation and outcomes of community participation programmes in large institutions (i.e. the Ministry of Health). The resource dependency perspective formed the basis for the theoretical framework used. Some 75 towns and villages were visited and about 170 health related personnel from all over the state were interviewed to obtain data on the operation and impact of the module programme. As predicted by resource dependency theory, which postulates that organizations will react to pressures in their external environment to secure the resources needed for survival, the findings of this research led to the conclusion that the Ministry of Health had co-opted the resources of the communities it was involving in the module programme in order to meet its policy objectives, especially those related to expanding service coverage. Community participation in the module programme was found to have been implemented entirely for its utility in supplying resources and not for democratic or intrinsic values. This
Johansson, Barbara; Harkey, Jane
This article examines the role of care coordination, when fulfilled by a professional board-certified case manager, in successful long-term home- and community-based care (HCBC). A facet of care coordination, as also discussed, is a robust assessment of the individual by the professional case manager, who devises and implements a comprehensive care plan to address the clinical, psychosocial, and environmental needs of the individual as part of a person-centered, evidenced-based approach. To be successful, long-term HCBC starts with a robust assessment of the individual by a professional board-certified case manager. The case manager uses specific tools that incorporate qualitative measurements to address factors such as medical/clinical needs, (e.g., diagnoses, chronic conditions, and/or health risks); mental/behavioral health (e.g., geriatric depression screening); medication/pharmacology (e.g., review and reconciliation of prescribed and over the counter medications and supplements) and the individual's ability to self-administer; home safety; and presence of a family/support system and their ability and willingness to provide care. Based on these findings, the case manager puts in place a comprehensive care plan, working with a well-coordinated multidisciplinary team, including informal supports, physicians, registered nurses, occupational therapists, pharmacists, social workers, nutritionists, and other allied health professionals. From the beginning, the rigor of care coordination is essential to the how successfully individuals and their families/support systems realize their goal of long-term HCBC.
Thorsell, Kajsa BE; Nordström, Berit M; Nyberg, Per; Sivberg, Bengt V
Background Almost every country in the Western world has great difficulties allocating enough financial resources to meet the needs in the care of the increasing elderly population. The main problem is common to all countries and concerns the efforts to meet elderly persons' needs on an individual level while still maintaining society's responsibility for distributing justice. The aim of this study is to elaborate an instrument for measuring the quality of individual care and staff's working time in order to allocate public resources fairly. The present study gives an account of a new classification system named TiC (Time in Care), indicating how it can be used most effectively and also investigating the validity and reliability of the system. Methods All recipients in 13 sheltered homes for elderly care (n = 505) in a Swedish municipality were surveyed regarding the care they needed, in dimensions of General Care, Medical Care, Cognitive Dysfunction and Rehabilitation, and the time required. Construct validity was assessed by means of factor analysis. The inter-rater agreement of two raters concerning 79 recipients was measured using weighted Kappa. The stability of the instrument and its sensitivity to change were investigated through test-retest reliability measurements, conducted once a month during a six-month period. The content validity of the instrument was also assessed. Results Factor analysis resulted in a reduction of the number of items from 25 to 16 in three dimensions: General Care, Medical Care and Cognitive Dysfunction. The Kappa analysis showed satisfactory to excellent inter-rater agreement. The care need scores were basically stable but showed sensitivity to change in health status. Conclusion The instrument was found to be useful and reliable for assessing individual needs in community health care. PMID:16984634
Lenze, Shannon; Brown, Teresa; Lawrence, Lisa; Nickel, Mike; Morrow-Howell, Nancy; Proctor, Enola K.
Description This manuscript details potential benefits for using a research-practice partnership to adapt collaborative depression care for public community long-term care agencies serving older adults. We used sequential, multi-phase, and mixed methods approaches for documenting the process of adaptation within a case study. Systematic adaptation strategies are described, such as leveraging long-term research-practice collaborations, consulting with multiple stakeholders across all levels and disciplines, and balancing demands to monitor treatment fidelity, clinical outcomes, and implementation results. These examples demonstrate that researchers interested in implementation science need skills to negotiate the competing demands that arise from both the research and practice settings. PMID:24072560
Hasche, Leslie K; Lenze, Shannon; Brown, Teresa; Lawrence, Lisa; Nickel, Mike; Morrow-Howell, Nancy; Proctor, Enola K
This manuscript details potential benefits for using a research-practice partnership to adapt collaborative depression care for public community long-term care agencies serving older adults. We used sequential, multi-phase, and mixed methods approaches for documenting the process of adaptation within a case study. Systematic adaptation strategies are described, such as leveraging long-term research-practice collaborations, consulting with multiple stakeholders across all levels and disciplines, and balancing demands to monitor treatment fidelity, clinical outcomes, and implementation results. These examples demonstrate that researchers interested in implementation science need skills to negotiate the competing demands that arise from both the research and practice settings.
Shoulders, Bridget; Follett, Corrinne; Eason, Joyce
The complexity of patients in the critical and acute care settings requires that nurses be skilled in early recognition and management of rapid changes in patient condition. The interpretation and response to these events can greatly impact patient outcomes. Nurses caring for these complex patients are expected to use astute critical thinking in their decision making. The purposes of this article were to explore the concept of critical thinking and provide practical strategies to enhance critical thinking in the critical and acute care environment.
Cashen, Margaret S; Bradley, Victoria; Farrell, Ann; Murphy, Judy; Schleyer, Ruth; Sensmeier, Joyce; Dykes, Patricia C
A focus group using nursing informatics experts as informants was conducted to guide development of a survey to explore the impact of health information technology on the role of nurses and interdisciplinary communication in acute care settings. Through analysis of focus group transcripts, five key themes emerged: information, communication, care coordination, interdisciplinary relationships, workflow, and practice effectiveness and efficiency. This served as the basis for development of a survey that will investigate perceptions of acute care providers across the United States regarding the impact of health information technology on the role of nurses and interdisciplinar communication in acute care settings. The purpose of this paper is to describe the process of survey development including analysis of transcripts, emergence of key themes, and the processes by which the themes will be employed to inform survey development.
Manito Lorite, N; Manzano Espinosa, L; Llorens Soriano, P; Masip Utset, J; Comín Colet, J; Formiga Pérez, F; Herrero Puente, P; Delgado Jiménez, J; Montero-Pérez-Barquero, M; Jacob Rodríguez, J; López de Sá Areses, E; Pérez Calvo, J I; Martín-Sánchez, F J; Miró Andreu, Ò
The purpose of this consensus document was to reach an agreement among experts on the multidisciplinary care of patients with acute heart failure. Starting with a narrative review of the care provided to these patients and a critical analysis of the healthcare procedures, we identified potential shortcomings and improvements and formalised a document on recommendations for optimising the clinical and therapeutic approach for acute heart failure. This document was validated through an in-person group session guided using participatory techniques. The process resulted in a set of 36 recommendations formulated by experts of the Spanish Society of Cardiology, the Spanish Society of Internal Medicine and the Spanish Society of Urgent and Emergency Care. The recommendations are designed to optimise the healthcare challenge presented by the care of patients with acute heart failure in the context of Spain's current National Health System.
Kano, Miria; Willging, Cathleen E.; Rylko-Bauer, Barbara
In 2005, New Mexico implemented a unique reform in managed behavioral health services that seeks to ensure delivery of consumer-driven, recovery-oriented care to low-income individuals. Distinguishing features of the reform are the Local Collaboratives (LCs), regionally based community organizations designed by state government to represent behavioral health concerns of New Mexico's diverse cultural populations. We examine community response to the LCs, focusing on two broad sets of themes derived from 18 months of ethnographic fieldwork. The first set—structure and function—encompasses several issues: predominance of provider versus consumer voice; insufficient resources to support internal operations; imposition of state administrative demands; and perceived lack of state response to LC efforts. The second set—participation and collaboration—reveals how problems of information flow and other logistical factors impact involvement in LCs and how the construction of “community” introduced under this initiative exacerbates tensions across localities with varied histories and populations. PMID:19764315
Background Evidence-based care should improve acute stroke outcomes with the same magnitude of effect for stroke patients of all ages. However, there is evidence to suggest that, in some instances, older stroke patients may receive poorer quality care than younger patients. Our aim was to systematically review evidence of the quality of care provided to patients with acute stroke related to their age. Quality of care was determined by compliance with recommended care processes. Methods We systematically searched MEDLINE, CINAHL, ISI Web of Knowledge, Ageline and the Cochrane Library databases to identify publications (1995-2009) that reported data on acute stroke care process indicators by patient age. Data extracted included patient demographics and process indicator compliance. Included publications were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool, and a comparison was made of the risk of bias according to studies' findings. The evidence base for reported process indicators was determined, and meta-analysis was undertaken for studies with sufficient similarity. Results Nine from 163 potential studies met the inclusion criteria. Of the 56 process indicators reported, eleven indicators were evidence-based. Seven of these indicators (64%) showed significantly poorer care for older patients compared to younger ones, while younger patients received comparatively inferior care for only antihypertensive therapy at discharge. Our findings are limited by the variable methodological quality of included studies. Conclusion Patients' age may be a factor in the care they receive after an acute stroke. However, the possible influence of patients' age on clinicians' decision-making must be considered in terms of the many complex issues that surround the provision of optimal care for older patients with acute stroke. PMID:21729329
Hoffmann, P; Tiggemann, H G
Psychiatric care has gradually been shifting in Germany from its original inpatient basis to outpatient and complementary treatment. This shift of emphasis resulted in a transfer of psychiatry-political responsibility to communal bodies and hence also to communal public health services. Sociopsychiatric service ranks high in communal psychiatric care setups, since it promotes cooperation and helps to coordinate efforts in individual cases in respect of focal points on which such care is centered. For the future, an expert commission has suggested that the various institutions actively engaged in community psychiatric care should team up in each region. This applies in particular to mobile services visiting the patients in their homes, and to the offices providing contracts to sociopsychiatric services of public health offices. Despite positive outlooks there are also quite a few negative aspects of present-day practice. One of them is poor definition of tasks and functions of communal sociopsychiatric services, whereas another one are the unsatisfactory quantitative and qualitative means at their disposal. It is also too often overlooked that psychiatric patients and disabled persons are entitled to compensation insurance payments to promote their rehabilitation, as provided for by individual legislation in the various German laender. To tap these sources sufficiently well, sociopsychiatric services must be better equipped in every respect. The professional competence of social workers and physicians, as well as of the relevant staff, must be safeguarded by continuing education and specialist training measures.
Neogi, S B; Sharma, J; Chauhan, M; Khanna, R; Chokshi, M; Srivastava, R; Prabhakar, P K; Khera, A; Kumar, R; Zodpey, S; Paul, V K
India has contributed immensely toward generating evidence on two key domains of newborn care: Home Based Newborn Care (HBNC) and community mobilization. In a model developed in Gadchiroli (Maharashtra) in the 1990s, a package of Interventions delivered by community health workers during home visits led to a marked decline in neonatal deaths. On the basis of this experience, the national HBNC program centered around Accredited Social Health Activists (ASHAs) was introduced in 2011, and is now the main community-level program in newborn health. Earlier in 2004, the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program was rolled out with inclusion of home visits by Anganwadi Worker as an integral component. IMNCI has been implemented in 505 districts in 27 states and 4 union territories. A mix of Anganwadi Workers, ASHAs, auxiliary nursing midwives (ANMs) was trained. The rapid roll out of IMNCI program resulted in improving quality of newborn care at the ground field. However, since 2012 the Ministry of Health and Family Welfare decided to limit the IMNCI program to ANMs only and leaving the Anganwadi component to the stewardship of the Integrated Child Development Services. ASHAs, the frontline workers for HBNC, receive four rounds of training using two modules. There are a total of over 900 000 ASHAs per link workers in the country, out of which, only 14% have completed the fourth round of training. The pace of uptake of the HBNC program has been slow. Of the annual rural birth cohort of over 17 million, about 4 million newborns have been visited by ASHA during the financial year 2013–2014 and out of this 120 000 neonates have been identified as sick and referred to health facilities for higher level of neonatal care. Supportive supervision remains a challenge, the role of ANMs in supervision needs more clarity and there are issues surrounding quality of training and the supply of HBNC kits. The program has low visibility in many states
Nam, Hyun Joo
Since the introduction of long-term nursing care insurance in 2008, the Korean elderly in need of care are entitled to residential care or home based care services, as in the other welfare states. This article initially introduces the Korean nursing care insurance (PfV) for the elderly to give an overview of the healthcare system. Subsequently, the latest model project "Community based comprehensive care system" is introduced. The confusing care and social services should be networked and provided in a manner customized to the needs of the elderly, so that home based care before residential care can be realized.
Sakti, G M; Boldy, D P
This study assessed the usefulness and relevance of the information, which had been provided by the Ministry of Health for use in community health centers. Furthermore, this identified the needs of health professionals in terms of relevant information for providing health care to the elderly in the community health centers. A total of 105 questionnaires were administered to 35 doctors and 70 health care workers. The overall response rate of the 105 questionnaires sent out was 80%. Findings revealed that the overall opinion expressed by the health professionals was that the information leaflets, in general, were good. However, some gaps existed between the information provided by the Ministry of Health and the information needs perceived by health professionals working in community health centers for providing health care to the elderly. The majority commented that pertinent information on health problems related to hypertension, arthritis, and heart disease needed to be added. Furthermore, effective pre-testing of the prepared information materials with the target groups before their production and distribution may lessen such gaps or deficiencies. Recommendations to ensure appropriate information are also given and presented in this article.
Okihiro, May; Pillen, Michelle; Ancog, Cristeta; Inda, Christy; Sehgal, Vija
Obesity, the most common chronic disease of childhood, is prevalent among economically disadvantaged children. The Chronic Care and Obesity Care Models are comprehensive health care strategies to improve outcomes by linking primary care best practices and community-based programs. Pediatric providers and community health centers are well positioned to design and implement coordinated and synergistic programs to address childhood health disparities. This article describes a comprehensive project based on the Obesity Care Model initiated at a rural community health center in Hawaii to address childhood obesity including: (1) the health care delivery changes constituting the quality improvement project; (2) capacity and team-building activities; (3) use of the project community level data to strengthen community engagement and investment; and (4) the academic-community partnership providing the project framework. We anticipate that these efforts will contribute to the long-term goal of reducing the prevalence of obesity and obesity associated morbidity in the community.
van Zyl, Marjorie; Eygelaar, Johanna
Background Interventions by community care workers within the context of community-based integrated management of childhood illness (CIMCI) may have a positive effect on child health if the health workers have adequate knowledge about key family practices. Setting The study was conducted in rural areas of the West Coast district in the Western Cape, South Africa. Objectives The objective of this study was to determine the knowledge of community care workers about five of the 16 key family practices of CIMCI. Methods A descriptive survey collected a self-administered questionnaire from 257 community care workers out of a possible total of 270 (95.2% response rate). Descriptive and inferential statistical analysis was applied. Results Only 25 of the respondents (10%) obtained a score higher than 70% on the knowledge-based items of the questionnaire. Less than 25% of respondents answered questions in these key areas correctly (pneumonia [17%], tuberculosis [13%], HIV/AIDS [9%] immunisation [3%] and recommendations for a child with fever [21%]). Statistically significant correlations were found between the total score a respondent achieved and the highest level of education obtained (p < 0.01), the level of in-service training (p < 0.01), attendance of a CIMCI five-day training course (p < 0.01), and completing a subsequent refresher course (p < 0.01). Conclusion The knowledge of CCWs was inadequate to provide safe, quality CIMCI. CIMCI refresher courses should be offered annually to improve CCWs’ knowledge and the quality of care that they render. Regular update courses could contribute to building competence. PMID:26842523
Caplain, Roland; Yacoubou, Ismaïl; Adedemy, Didier; Sani, Alidou; Takam, Sandrine; Desplats, Dominique
Considerable effort has been made to provide rural African populations with basic health care, but the quality of this care remains unsatisfactory due to the absence of first-line GPs. This is a paradoxical situation in view of the large number of physicians trained in medical schools in French-speaking Africa and Madagascar. of the lack of GPs working in rural areas is a real concern, as many young doctors remain unemployed in cities. For more than 20 years, the NGO Santé Sud has proposed a Community General Medicine concept, which, combined with a support system, has allowed the installation of more than 200 community GPs in Mali and Madagascar. The advantage of this concept is that it provides family medicine and primary health care in the same practice. Since 2009, Santé Sud supports an installation project in rural areas of northern Benin, where community GPs work independently, as a complementary partner of the public sector. Since 2013, the installation process comprises a university degree created with the University of Parakou Faculty of Medicine. Based on this experience in Benin, the authors show that the presence of a first-line general practitioner is an original strategy that provides a major contribution to health promotion : reducing health inequalities between rural and urban populations, allowing women to receive medically assisted childbirth close to home, developing family planning activities, education and health care for chronic diseases, strengthening health coverage by participating in vaccination campaigns, etc. Due to their functions and proximity, community GPs represent an added value for health promotion.
The nursing discipline is vital throughout patients' hospital progression. One of the most critical moments in the hospital stay is the postoperative period. Neurosurgical patients require a high level of nursing care and vigilance and additional postoperative monitoring in intensive care units designed specifically for this demographic. In the postoperative setting, patient care must be transferred from anesthesia to nursing in a manner that is continuous and safe. This article focuses on neurosurgical patients in the postoperative period, the assessment of these patients, and critical care nursing, with emphasis on common issues and interventions for this dynamic patient population.
Bauman, Kay A.; Magill, Michael K.
Students at the University of Arizona College of Medicine participated in an exercise in community-oriented primary care. They learned basic principles of health risk analysis and community-oriented care and then designed hypothetical, comprehensive health care services for medical students by using knowledge of health risks specific to their…
... HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program: Community-Based Care... about the upcoming Community-based Care Transitions Program. The meeting is open to the public, but... will be posted on the CMS Care Transitions Web site at...
Johnson, Alice; And Others
This publication has been designed to help nurses, teachers, volunteers, health administrators, social workers, and other individuals in the community in improving dental care instruction for the children in a community dental care program. The publication is based on the premise that availability of dental care services does not necessarily…
Jackson, Mike; Heroux, Janet
Many members of the Hispanic community are separated from the larger community by language barriers and different cultures and belief systems. These factors can affect Hispanic Americans' ability to seek and gain access to the health care system. The Program To Address Sociocultural Barriers to Health Care in the Hispanic Community, known as…
Gewirtz, Abigail H.; August, Gerald J.
This article proposes a framework for embedding prevention services into community sectors-of-care. Community sectors-of-care include both formal and grassroot organizations distributed throughout a community that provide various resources and services to at-risk children and their families. Though the child population served by these…
In 2001, Arizona's Children's Action Alliance (CCA) developed a resource for community groups interested in exploring the need for care for school-age children. Titled "School-Age Care Tool Kit: A Guide for Measuring Needs in Your Community," the resource provided step-by-step advice to community organizations on how to identify the need…
William, J. Ferguson; Laurie, E. Kost
Goals This article a) defines point of care (POC) culture; b) presents seven underlying fundamental principles; c) describes the importance of needs assessment; d) introduces a new innovation, the spatial care path™; and e) illustrates how POC testing that properly fulfills needs and spatial care paths™ enable community and global resilience. Observations Often, POC testing supplants the conventional clinical laboratory, which may be too distant, prohibitively expensive, or simply not available in limited-resource settings. New POC technologies “fit” future medical problem solving. Screening and testing directly in the home or primary care facilitate rapid diagnosis, monitoring, and treatment. In contrast to the past where attention has been placed on emergency departments, hospitals, and referral centers, the spatial care path™ starts with the patient and guides him or her through an efficient strategy of care in small-world networks (SWNs) defined by local geography and topology, long-standing customs, public health jurisdictions, and geographic information systems (GIS). Conclusions POC testing needs in limited-resource settings are striking. Fulfillment is best guided by thorough understanding of POC culture. Quick feedback and fast decision-making by patients and physicians alike yield significant value that motivates changes in patient lifestyles and physician interactions. Culturally sensitive technology assimilation addresses leadership challenges in nations adapting to increasing populations of young and old, despite scarcity of resources. The spatial care path™ facilitates an essential balance of prevention and intervention in public health and shifts future focus to the patient, empowerment, and primary care within the context of POC culture. PMID:27683461
Rushton, Carole; Edvardsson, David
Relationships are central to enacting person-centred care of the older person with cognitive impairment. A fuller understanding of relationships and the role they play facilitating wellness and preserving personhood is critical if we are to unleash the productive potential of nursing research and person-centred care. In this article, we target the acute care setting because much of the work about relationships and older people with cognitive impairment has tended to focus on relationships in long-term care. The acute care setting is characterized by archetypal constraints which differentiate it from long-term care, in terms of acuity and haste, task-orientated work patterns and influence from "the rule of medicine," all of which can privilege particular types of relating. In this article, we drew on existing conceptualizations of relationships from theory and practice by tapping in to the intellectual resources provided by nurse researchers, the philosophy of Martin Buber and ANT scholars. This involved recounting two examples of dyadic and networked relationships which were re-interpreted using two complementary theoretical approaches to provide deeper and more comprehensive conceptualizations of these relationships. By re-presenting key tenets from the work of key scholars on the topic relationships, we hope to hasten socialization of these ideas into nursing into the acute care setting. First, by enabling nurses to reflect on how they might work toward cultivating relationships that are more salutogenic and consistent with the preservation of personhood. Second, by stimulating two distinct but related lines of research enquiry which focus on dyadic and networked relationships with the older person with cognitive impairment in the acute care setting. We also hope to reconcile the schism that has emerged in the literature between preferred approaches to care of the older person with cognitive impairment, that is person-centred care versus relationship-centred care
Green, Brandn; Lyerla, Rob; Stroup, Donna F; Azofeifa, Alejandro; High, Patrick M
Evidence-based programs for prevention and intervention in substance abuse are increasing. Community needs assessments and health rankings provide descriptions of local behavioral health needs but do not provide public health practitioners and policy makers with guidelines on the number of programs, health care practitioners, or interventions needed in the local substance abuse care system. This article presents a new framework for measuring and assessing the substance abuse care system in a community. The assessment can inform resource allocation across the continuum of care to more equitably and efficiently distribute interventions and care. We conducted 2 literature reviews and synthesized our findings to create a community assessment methodology and needs calculator, CAST (calculating for an adequate system tool). We reviewed 212 articles to produce an inventory of community and social correlates of behavioral health, components of a substance abuse care system, and numerical values for guidelines for estimating community needs. CAST produces community-specific assessments of the capacity of the components of a community substance abuse care system. CAST generates recommendations by the application of social and community determinants of health as risk coefficients to each estimate of component need. CAST can assist public health practitioners in evaluation and improvement of the capacity of community-based, substance abuse care systems. By using recommendations for component needs across the continuum of care, community leaders can use CAST to prioritize resource allocation more effectively and efficiently.
Randall, Carla E; Tate, Betty; Lougheed, Mary
Much has been written in the nursing literature about the intentions and desires of a transformatory movement in nursing education. However, dialogue and critique related to actual implementation of a curriculum revolution begun in the late 1980s are lacking. The acute care context of nursing practice holds particular challenges for faculty teaching in an emancipatory curriculum. How do faculty implement a philosophy of teaching-learning congruent with the curriculum revolution, in the context of an acute care setting that privileges empirical knowledge and values a behaviorist paradigm? In this article, we provide an example of one teaching approach grounded in an emancipatory ideology: critical questioning. We also discuss some of the tensions we associate with teaching-learning in an acute care context and our experiences of navigating these tensions.
Sidani, Souraya; Reeves, Scott; Hurlock-Chorostecki, Christina; van Soeren, Mary; Fox, Mary; Collins, Laura
There is limited evidence of the extent to which Healthcare professionals implement patient-centered care (PCC) and of the factors influencing their PCC practices in acute care organizations. This study aimed to (1) examine the practices reported by health professionals (physicians, nurses, social workers, other healthcare providers) in relation to three PCC components (holistic, collaborative, and responsive care), and (2) explore the association of professionals' characteristics (gender, work experience) and a contextual factor (caseload), with the professionals' PCC practices. Data were obtained from a large scale cross-sectional study, conducted in 18 hospitals in Ontario, Canada. Consenting professionals (n = 382) completed a self-report instrument assessing the three PCC components and responded to standard questions inquiring about their characteristics and workload. Small differences were found in the PCC practices across professional groups: (1) physicians reported higher levels of enacting the holistic care component; (2) physicians, other healthcare providers, and social workers reported implementing higher levels of the collaborative care component; and (3) physicians, nurses, and other healthcare providers reported higher levels of providing responsive care. Caseload influenced holistic care practices. Interprofessional education and training strategies are needed to clarify and address professional differences in valuing and practicing PCC components. Clinical guidelines can be revised to enable professionals to engage patients in care-related decisions, customize patient care, and promote interprofessional collaboration in planning and implementing PCC. Additional research is warranted to determine the influence of professional, patient, and other contextual factors on professionals' PCC practices in acute care hospitals.
Mohamed-Rambaran, Pheona; Wilson, Alexis; James, Colin; Indar, Lisa
Guyana is an English-speaking country in South America and, culturally, it is part of the Caribbean. Objective of this study was to determine the community prevalence and true burden and economic impact of acute gastroenteritis (AGE) and foodborne diseases (FBDs) in Guyana. A cross-sectional population-based survey was conducted in 7 of the 10 regions in Guyana during August and November 2009 to capture the high- and low-AGE season respectively. Overall, 1,254 individual surveys were administered at a response rate of 96.5%. The overall monthly prevalence of self-reported cases of AGE was 7.7% (97 cases) (95% CI 6.3-9.3), and the yearly incidence was 1.0 episodes per person-year. The highest monthly prevalence of AGE was observed in region 4 (8.9%) and in children aged 1-4 year(s) (12.7%). Of the 97 AGE cases, 23% sought medical care; 65% reported spending time at home due to their illness [range 1-20 day(s), mean 2.7 days], of whom 51% required other individuals to look after them while ill. The maximum number of stools per 24 hours ranged from 3 to 9 (mean 4.5), and number of days an individual suffered from AGE ranged from 1 to 21 day(s) (mean 2.7 days). The burden of syndromic AGE cases in the population for 2009 was estimated to be 131,012 cases compared to the reported 30,468 cases (76.7% underreporting), which implies that, for every syndromic case of AGE reported, there were additional 4.3 cases occurring in the community. For every laboratory-confirmed case of FBD/AGE pathogen reported, it was estimated that approximately 2,881 more cases were occurring in the population. Giardia was the most common foodborne pathogen isolated. The minimum estimated annual cost associated with the treatment for AGE was US$ 2,358,233.2, showing that AGE and FBD pose a huge economic burden on Guyana. Underreporting of AGE and foodborne pathogens, stool collection, and laboratory capacity were major gaps, affecting the surveillance of AGE in Guyana.
Anderson, Daren R; Zlateva, Ianita; Coman, Emil N; Khatri, Khushbu; Tian, Terrence; Kerns, Robert D
Purpose Treating pain in primary care is challenging. Primary care providers (PCPs) receive limited training in pain care and express low confidence in their knowledge and ability to manage pain effectively. Models to improve pain outcomes have been developed, but not formally implemented in safety net practices where pain is particularly common. This study evaluated the impact of implementing the Stepped Care Model for Pain Management (SCM-PM) at a large, multisite Federally Qualified Health Center. Methods The Promoting Action on Research Implementation in Health Services framework guided the implementation of the SCM-PM. The multicomponent intervention included: education on pain care, new protocols for pain assessment and management, implementation of an opioid management dashboard, telehealth consultations, and enhanced onsite specialty resources. Participants included 25 PCPs and their patients with chronic pain (3,357 preintervention and 4,385 postintervention) cared for at Community Health Center, Inc. Data were collected from the electronic health record and supplemented by chart reviews. Surveys were administered to PCPs to assess knowledge, attitudes, and confidence. Results Providers’ pain knowledge scores increased to an average of 11% from baseline; self-rated confidence in ability to manage pain also increased. Use of opioid treatment agreements and urine drug screens increased significantly by 27.3% and 22.6%, respectively. Significant improvements were also noted in documentation of pain, pain treatment, and pain follow-up. Referrals to behavioral health providers for patients with pain increased by 5.96% (P=0.009). There was no significant change in opioid prescribing. Conclusion Implementation of the SCM-PM resulted in clinically significant improvements in several quality of pain care outcomes. These findings, if sustained, may translate into improved patient outcomes. PMID:27881926
Objective We seek to address gaps in knowledge and agreement around optimal frailty assessment in the acute medical care setting. Frailty is a common term describing older persons who are at increased risk of developing multimorbidity, disability, institutionalisation and death. Consensus has not been reached on the practical implementation of this concept to assess clinically and manage older persons in the acute care setting. Design Modified Delphi, via electronic questionnaire. Questions included ranking items that best recognise frailty, optimal timing, location and contextual elements of a successful tool. Intraclass correlation coefficients for overall levels of agreement, with consensus and stability tested by 2-way ANOVA with absolute agreement and Fisher's exact test. Participants A panel of national experts (academics, front-line clinicians and specialist charities) were invited to electronic correspondence. Results Variables reflecting accumulated deficit and high resource usage were perceived by participants as the most useful indicators of frailty in the acute care setting. The Acute Medical Unit and Care of the older Persons Ward were perceived as optimum settings for frailty assessment. ‘Clinically meaningful and relevant’, ‘simple (easy to use)’ and ‘accessible by multidisciplinary team’ were perceived as characteristics of a successful frailty assessment tool in the acute care setting. No agreement was reached on optimal timing, number of variables and organisational structures. Conclusions This study is a first step in developing consensus for a clinically relevant frailty assessment model for the acute care setting, providing content validation and illuminating contextual requirements. Testing on clinical data sets is a research priority. PMID:27742633
Best, Allyson M.; Dixon, Cinnamon A.; Kelton, W. David; Lindsell, Christopher J.
Objectives Crowding and limited resources have increased the strain on acute care facilities and emergency departments (EDs) worldwide. These problems are particularly prevalent in developing countries. Discrete event simulation (DES) is a computer-based tool that can be used to estimate how changes to complex healthcare delivery systems, such as EDs, will affect operational performance. Using this modality, our objective was to identify operational interventions that could potentially improve patient throughput of one acute care setting in a developing country. Methods We developed a simulation model of acute care at a district level hospital in Ghana to test the effects of resource-neutral (e.g. modified staff start times and roles) and resource-additional (e.g. increased staff) operational interventions on patient throughput. Previously captured, de-identified time-and-motion data from 487 acute care patients were used to develop and test the model. The primary outcome was the modeled effect of interventions on patient length of stay (LOS). Results The base-case (no change) scenario had a mean LOS of 292 minutes (95% CI 291, 293). In isolation, neither adding staffing, changing staff roles, nor varying shift times affected overall patient LOS. Specifically, adding two registration workers, history takers, and physicians resulted in a 23.8 (95% CI 22.3, 25.3) minute LOS decrease. However, when shift start-times were coordinated with patient arrival patterns, potential mean LOS was decreased by 96 minutes (95% CI 94, 98); and with the simultaneous combination of staff roles (Registration and History-taking) there was an overall mean LOS reduction of 152 minutes (95% CI 150, 154). Conclusions Resource-neutral interventions identified through DES modeling have the potential to improve acute care throughput in this Ghanaian municipal hospital. DES offers another approach to identifying potentially effective interventions to improve patient flow in emergency and acute
Abbott, P A; Quirolgico, S; Candidate, D; Manchand, R; Canfield, K; Adya, M
This paper is intended to give an overview of Knowledge Discovery in Large Datasets (KDD) and data mining applications in healthcare particularly as related to the Minimum Data Set, a resident assessment tool which is used in US long-term care facilities. The US Health Care Finance Administration, which mandates the use of this tool, has accumulated massive warehouses of MDS data. The pressure in healthcare to increase efficiency and effectiveness while improving patient outcomes requires that we find new ways to harness these vast resources. The intent of this preliminary study design paper is to discuss the development of an approach which utilizes the MDS, in conjunction with KDD and classification algorithms, in an attempt to predict admission from a long-term care facility to an acute care facility. The use of acute care services by long term care residents is a negative outcome, potentially avoidable, and expensive. The value of the MDS warehouse can be realized by the use of the stored data in ways that can improve patient outcomes and avoid the use of expensive acute care services. This study, when completed, will test whether the MDS warehouse can be used to describe patient outcomes and possibly be of predictive value.
Conger, Cynthia O'Neill; Baldwin, Joan H.; Abegglen, JoAnn; Callister, Lynn C.
Brigham Young University's nursing curriculum was revised to reflect the community-driven nature of primary health care. Curricular threads of inquiry, practice, stewardship, spirituality, and service are the framework for integrating community health nursing practice. (SK)
Feldman, Kira; Berall, Anna; Karuza, Jurgis; Senderovich, Helen; Perri, Giulia-Anna; Grossman, Daphna
Management of pain in the frail elderly presents many challenges in both assessment and treatment, due to the presence of multiple co-morbidities, polypharmacy, and cognitive impairment. At Baycrest Health Sciences, a geriatric care centre, pain in its acute care unit had been managed through consultations with the pain team on a case-by-case basis. In an intervention informed by knowledge translation (KT), the pain specialists integrated within the social network of the acute care team for 6 months to disseminate their expertise. A survey was administered to staff on the unit before and after the intervention of the pain team to understand staff perceptions of pain management. Pre- and post-comparisons of the survey responses were analysed by using t-tests. This study provided some evidence for the success of this interprofessional education initiative through changes in staff confidence with respect to pain management. It also showed that embedding the pain team into the acute care team supported the KT process as an effective method of interprofessional team building. Incorporating the pain team into the acute care unit to provide training and ongoing decision support was a feasible strategy for KT and could be replicated in other clinical settings.
Marshall, Ernie; Krzyzanowska, Monika; Robinson, Bridget; Brown, Sean; Collinson, Fiona; Seligmann, Jennifer; Abbas, Afroze; Rees, Adrian; Swinson, Daniel; Neville-Webbe, Helen; Selby, Peter
Remarkable progress has been made over the past decade in cancer medicine. Personalized medicine, driven by biomarker predictive factors, novel biotherapy, novel imaging, and molecular targeted therapeutics, has improved outcomes. Cancer is becoming a chronic disease rather than a fatal disease for many patients. However, despite this progress, there is much work to do if patients are to receive continuous high-quality care in the appropriate place, at the appropriate time, and with the right specialized expert oversight. Unfortunately, the rapid expansion of therapeutic options has also generated an ever-increasing burden of emergency care and encroaches into end-of-life palliative care. Emergency presentation is a common consequence of cancer and of cancer treatment complications. It represents an important proportion of new presentations of previously undiagnosed malignancy. In the U.K. alone, 20%–25% of new cancer diagnoses are made following an initial presentation to the hospital emergency department, with a greater proportion in patients older than 70 years. This late presentation accounts for poor survival outcomes and is often associated with poor patient experience and poorly coordinated care. The recent development of acute oncology services in the U.K. aims to improve patient safety, quality of care, and the coordination of care for all patients with cancer who require emergency access to care, irrespective of the place of care and admission route. Furthermore, prompt management coordinated by expert teams and access to protocol-driven pathways have the potential to improve patient experience and drive efficiency when services are fully established. The challenge to leaders of acute oncology services is to develop bespoke models of care, appropriate to local services, but with an opportunity for acute oncology teams to engage cancer care strategies and influence cancer care and delivery in the future. This will aid the integration of highly
Holub, Karen; Camune, Barbara
Acute fatty liver of pregnancy, although rare, is usually a third trimester of pregnancy occurrence that may be life threatening for both the pregnant woman and the fetus. Often, the onset resembles gastroenteritis or cholecystitis and correct diagnosis is delayed. Because it can also present with preeclampsia and eclampsia, it may be mistakenly diagnosed as hemolysis, elevated liver enzymes, low platelet syndrome. This article presents diagnostic differences between liver conditions that can complicate pregnancy and management strategies for treating and maintaining the well-being of pregnant women, fetuses, and infants who are affected by acute fatty liver of pregnancy. Early recognition and rapid intervention from antepartum diagnosis through delivery and the postpartum period are required by the nursing team and medical providers to reduce maternal and neonatal morbidity and mortality.
Allen, Amy; Des Jardins, Terrisca R.; Heider, Arvela; Kanger, Chatrian R.; Lobach, David F.; McWilliams, Lee; Polello, Jennifer M.; Schachter, Abigail A.; Singh, Ranjit; Sorondo, Barbara; Tulikangas, Megan C.; Turske, Scott A.
Abstract Care management aims to provide cost-effective, coordinated, non-duplicative care to improve care quality, population health, and reduce costs. The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management. This article profiles 6 Beacon Communities' health IT-enabled care management programs, highlighting the influence of local context on program strategy and design, and describing challenges, lessons learned, and policy implications for care delivery and payment reform. The unique needs (eg, disease burden, demographics), community partnerships, and existing resources and infrastructure all exerted significant influence on the overall priorities and design of each community's care management program. Though each Beacon Community needed to engage in a similar set of care management tasks—including patient identification, stratification, and prioritization; intervention; patient engagement; and evaluation—the contextual factors helped shape the specific strategies and tools used to carry out these tasks and achieve their objectives. Although providers across the country are striving to deliver standardized, high-quality care, the diverse contexts in which this care is delivered significantly influence the priorities, strategies, and design of community-based care management interventions. Gaps and challenges in implementing effective community-based care management programs include: optimizing allocation of care management services; lack of available technology tailored to care management needs; lack of standards and interoperability; integrating care management into care settings; evaluating impact; and funding and sustainability. (Population Health Management 2014;17:149–158) PMID
Allen, Amy; Des Jardins, Terrisca R; Heider, Arvela; Kanger, Chatrian R; Lobach, David F; McWilliams, Lee; Polello, Jennifer M; Rein, Alison L; Schachter, Abigail A; Singh, Ranjit; Sorondo, Barbara; Tulikangas, Megan C; Turske, Scott A
Care management aims to provide cost-effective, coordinated, non-duplicative care to improve care quality, population health, and reduce costs. The 17 communities receiving funding from the Office of the National Coordinator for Health Information Technology through the Beacon Community Cooperative Agreement Program are leaders in building and strengthening their health information technology (health IT) infrastructure to provide more effective and efficient care management. This article profiles 6 Beacon Communities' health IT-enabled care management programs, highlighting the influence of local context on program strategy and design, and describing challenges, lessons learned, and policy implications for care delivery and payment reform. The unique needs (eg, disease burden, demographics), community partnerships, and existing resources and infrastructure all exerted significant influence on the overall priorities and design of each community's care management program. Though each Beacon Community needed to engage in a similar set of care management tasks--including patient identification, stratification, and prioritization; intervention; patient engagement; and evaluation--the contextual factors helped shape the specific strategies and tools used to carry out these tasks and achieve their objectives. Although providers across the country are striving to deliver standardized, high-quality care, the diverse contexts in which this care is delivered significantly influence the priorities, strategies, and design of community-based care management interventions. Gaps and challenges in implementing effective community-based care management programs include: optimizing allocation of care management services; lack of available technology tailored to care management needs; lack of standards and interoperability; integrating care management into care settings; evaluating impact; and funding and sustainability.
Andersson, Sten-Ove; Dahlgren, Lars Owe; Lundberg, Lars; Sjöström, Björn
Emergency medical care for seriously injured patients in war or warlike situations is highly important when it comes to soldiers' survival and morale. The Swedish Armed Forces sends nurses, who have limited experience of caring for injured personnel in the field, on a variety of international missions. The aim of this investigation was to identify the kind of criteria nurses rely on when assessing acute trauma and what factors are affecting the emergency care of injured soldiers. A phenomenographic research approach based on interviews was used. The database for the study consists of twelve nurses who served in Bosnia in 1994-1996. The criteria nurses rely on, when assessing acute trauma in emergency care, could be described in terms of domain-specific criteria such as a physiological, an anatomical, a causal and a holistic approach as well as contextual criteria such as being able to communicate, having a sense of belonging, the military environment, the conscript medical orderly and familiarity with health-caring activity. The present study shows that the specific contextual factors affecting emergency care in the field must also be practised before the nurse faces military emergency care situations. This calls for realistic exercises and training programs, where experience from civilian emergency care is interwoven with the knowledge specific to military medical care.
Goldstein, Judah; McVey, Jennifer; Ackroyd-Stolarz, Stacy
Caring for older adults is a major function of emergency medical services (EMS). Traditional EMS systems were designed to treat single acute conditions; this approach contrasts with best practices for the care of frail older adults. Care might be improved by the early identification of those who are frail and at highest risk for adverse outcomes. Paramedics are well positioned to play an important role via a more thorough evaluation of frailty (or vulnerability). These findings may inform both pre-hospital and subsequent emergency department (ED) based decisions. Innovative programs involving EMS, the ED, and primary care could reduce the workload on EDs while improving patient access to care, and ultimately patient outcomes. Some frail older adults will benefit from the resources and specialized knowledge provided by the ED, while others may be better helped in alternative ways, usually in coordination with primary care. Discerning between these groups is a challenge worthy of further inquiry. In either case, care should be timely, with a focus on identifying emergent or acute care needs, frailty evaluation, mobility assessments, identifying appropriate goals for treatment, promoting functional independence, and striving to have the patient return to their usual place of residence if this can be done safely. Paramedics are uniquely positioned to play a larger role in the care of our aging population. Improving paramedic education as it pertains to geriatrics is a critical next step.
Caffrey, Rosalie A
Few nurses have the experience of developing an independent practice. This ethnographic study explores the process and challenges of becoming an entrepreneur as described by nurses developing independent practices in community care gerontologic nursing. The process included developing a legal contract, marketing strategies, and reimbursement amounts and strategies. Major barriers to implementing this role identified by the nurses included ignorance and confusion by others about their role, financial issues related to an uncertain income, time management, and legal concerns especially around delegation. These were experienced and dedicated nurses who were also risk-takers and enjoyed the independence of practicing nursing because they believed it was meant to be practiced. Suggestions for research, education, and practice are included.
Sydnor, Emily R. M.; Perl, Trish M.
Summary: Health care-associated infections (HAIs) have become more common as medical care has grown more complex and patients have become more complicated. HAIs are associated with significant morbidity, mortality, and cost. Growing rates of HAIs alongside evidence suggesting that active surveillance and infection control practices can prevent HAIs led to the development of hospital epidemiology and infection control programs. The role for infection control programs has grown and continues to grow as rates of antimicrobial resistance rise and HAIs lead to increasing risks to patients and expanding health care costs. In this review, we summarize the history of the development of hospital epidemiology and infection control, common HAIs and the pathogens causing them, and the structure and role of a hospital epidemiology and infection control program. PMID:21233510
Farquhar, J W; Campbell, M L
Brief admission of the new diabetic child and of a parent to an enlightened hospital for stabilisation, preliminary education, and familiarisation with hospital and community staff is well worth while. The greater the demand for constant control of the highest quality, the greater the need for a close understanding of the psychosocial factors concerned and for clinical skill. The nature of the home and the family relationships should in theory be available from the child's general practitioner at the time of the first referral since he has so much information about the whole family. With the virtual disappearance, however, of mutual consultation in the patient's home in many places, the opportunity for oral communication has declined, and availability on the telephone is not always easy. The busy general practitioner (far less an unknown physician from a deputising service without access to the records) has little time to write a comprehensive letter. In practice a relatively small hospital-based mobile team of specially experienced sisters who are keen to communicate in the home, the GP's surgery, and the school makes a major contribution to the diabetic care of a young population vulnerable to major handicap in what should be the prime of life. Their cost effectiveness may be difficult to prove but it is not at all in doubt--especially when the sisters as in this area deal in the community with a wider range of chronic illnesses and handicaps in children. PMID:7437869
Kelly, Edward; Rogers, Selwyn O
The increasing need for skilled emergency surgical providers, coupled with decreasing experience in emergency surgery among trainees, has led to significant shortages in the availability of such surgeons. In response to this crisis, surgical leaders have developed a comprehensive curriculum and a set of professional standards to guide the training of a new specialist: the acute care surgeon. This article reviews the development and goals for Fellowship training of this new specialty.
Sicotte, Claude; D'Amour, Danielle; Moreault, Marie-Pierre
Central to the success of many recent health system reforms is the implementation of new primary health care delivery models. The central characteristic common to these new models usually emphasises interdisciplinary collaboration. Using empirical research, this paper studies interdisciplinary collaboration among various groups of professionals within an original Canadian primary health care delivery model, the Quebec Community Health Care Centres (CCHCs). The entire population of more than 150 CHCCs have been surveyed. The goals of this study are (1) to measure the achieved intensity of inter-professional collaboration among Quebec CHCCs, and (2) to identify the organisational and professional factors fostering or limiting interdisciplinary collaboration. The results show that Quebec CHCCs have reached modest results in achieving interdisciplinary collaboration especially since interdisciplinary collaboration is a central objective that has been pursued for more than 25 years. This study demonstrates that the main factors associated with interdisciplinary collaboration are closely linked to work group internal dynamics. Interdisciplinary collaboration is linked to the simultaneous and antagonistic effect of some central intragroup process factors. Conflicting values and beliefs are present that both enhance and limit interdisciplinary collaboration. The presence of conflicting stimuli seriously undermines the strength of the CHCC work group's shared beliefs and strongly limits interdisciplinary collaboration. The results also stress the importance of administrative formalisation initiatives to enhance collaboration among different professions. The efficacy of formalisation in this context is based on its capacity to offer an articulated and operative interdisciplinary framework that can generate a counteractive effect to the traditional professional framework. It offers concrete rules that help align the work group beliefs with interdisciplinary values. The
DeVore, Adam D; Allen, Larry A; Eapen, Zubin J
The management of acute heart failure is shifting toward treatment approaches outside of a traditional hospital setting. Many heart failure providers are now treating patients in less familiar health care settings, such as acute care clinics, emergency departments, and skilled nursing facilities. In this review we describe the current pressures driving change in the delivery of acute heart failure and summarize the evidence regarding treatments for acute heart failure outside of the inpatient setting. We also provide considerations for the design of future treatment strategies to be implemented in alternative care settings.
Ikenaka, Yoshinori; Sakamoto, Masaki; Nagata, Takamaru; Takahashi, Hirokazu; Miyabara, Yuichi; Hanazato, Takayuki; Ishizuka, Mayumi; Isobe, Tomohiko; Kim, Jun-Woo; Chang, Kwang-Hyeon
We estimated acute toxicity of benzo[a]pyrene (B[a]P) using two cladoceran species, Ceriodaphnia reticulata and Daphnia magna, and also analyzed its impact on zooplankton community throughout an exposure experiment using small-scale mesocosms. LC(50) of B[a]P for C. reticulata and D. magna was 4.3 and 4.7 µg/l, respectively. However, individuals fed with Chlorella showed higher LC(50), 6.1 µg/l for C. reticulata and 8.0 µg/l for D. magna. In the exposure experiment, we examined the impact of B[a]P on zooplankton community using conceivable concentrations in the environment (5 and 10 µg/l) using typical zooplankton community in eutrophicated systems. Despite the residence time of B[a]P in the water column was short as < 4 days, application of B[a]P induced decrease of zooplankton abundance. However, the recovery pattern was different among cladocerans and rotifers. Consequently, B[a]P showed insecticide-like impacts, suppressing cladoceran populations and inducing the dominance of rotifers particularly under high concentration (10 µg/l). Results have suggested that, even such short duration of B[a]P in the water body can have impact on zooplankton abundance and community structure. Since B[a]P easily precipitate to the bottom and rapidly disappears from the water body, careful monitoring and further assessment of the potential toxicity of polycyclic aromatic hydrocarbons are necessary.
Del Mar, Chris
Sore throat and acute sinusitis are not straightforward diagnoses. Trying to guess the responsible pathogen may not be the best approach. Being guided by empirical evidence may be more useful. It suggests some, but very few, benefits for antibiotics. This has to be balanced with some, but few, harms from antibiotics, including diarrhoea, rash and thrush. Prescribers should also be aware of the risk of antibiotic resistance for the individual, as well as for the population as a whole. GPs should explain the evidence for the benefits and the harms of antibiotics to patients within a shared decision-making framework.
DeCoster, Vaughn; Ehlman, Katie; Conners, Carolyn
Medicare spending is expected to increase by 79% between the years 2010 and 2020, caused, in-part, by hospital readmissions within 30 days of discharge. This study identified factors contributing to hospital readmissions in a midwest heath service area (HSA), using Coleman's Transition Care Model as the theoretical framework. The researchers…
Hagvall, Monica; Ehnfors, Margareta; Anderzén-Carlsson, Agneta
Parents of children with medical complexity have described being responsible for providing advanced care for the child. When the child is acutely ill, they must rely on the health-care services during short or long periods of hospitalization. The purpose of this study was to describe parental experiences of caring for their child with medical complexity during hospitalization for acute deterioration, specifically focussing on parental needs and their experiences of the attitudes of staff. Data were gathered through individual interviews and analyzed using qualitative content analysis. The care period can be interpreted as a balancing act between acting as a caregiver and being in need of care. The parents needed skilled staff who could relieve them of medical responsibility, but they wanted to be involved in the care and in the decisions taken. They needed support, including relief, in order to meet their own needs and to be able to take care of their children. It was important that the child was treated with respect in order for the parent to trust the staff. An approach where staff view parents and children as a single unit, as recipients of care, would probably make the situation easier for these parents and children.
Maguire, Michelle; Bennett, Marialice S.
Objective. To determine the impact of an elective course on students’ perception of opportunities and of their preparedness for patient care in community and ambulatory pharmacy settings. Design. Each course meeting included a lecture and discussion to introduce concepts and active-learning activities to apply concepts to patient care or practice development in a community or ambulatory pharmacy setting. Assessment. A survey was administered to students before and after the course. Descriptive statistics were used to assess student responses to survey questions, and Wilcoxon signed rank tests were used to analyze the improvement in student responses with an alpha level set at 0.05. Students felt more prepared to provide patient care, develop or improve a clinical service, and effectively communicate recommendations to other health care providers after course completion. Conclusion. This elective course equipped students with the skills necessary to increase their confidence in providing patient care services in community and ambulatory settings. PMID:27168617
O'Connell, Bev; Gardner, Anne; Takase, Miyuki; Hawkins, Mary T; Ostaszkiewicz, Joan; Ski, Chantal; Josipovic, Patricia
Reality Orientation (RO) was developed as a strategy to assist people with dementia to improve their orientation and everyday function. Although its efficacy has been extensively studied in long-term care facilities, its effectiveness has rarely been examined in acute care settings. The aim of this review was to examine the studies cited in systematic reviews of RO to determine the potential clinical usefulness and the feasibility of using RO in acute care settings. Based on this information, the authors make recommendations for future research in this area. The feasibility of implementing RO in acute care poses challenges because of the short time a patient is in hospital and their ability to participate given their acute medical condition. Although the efficacy and feasibility of using RO in acute care settings have not been sufficiently examined, its potential to improve care should not be ignored. A comprehensive and rigorous study is necessary to investigate the usefulness of RO in the acute care setting and to help establish clinical guidelines for dementia care in the context of acute care nursing.
Polo, Isabel; And Others
A clinical geriatric pharmacy clerkship containing three separate practice areas (long-term, acute, and ambulatory care) is described. The program follows the medical education clerkship protocol, with a clinical pharmacy specialist, pharmacy practice resident, and student. Participation in medical rounds, interdisciplinary conferences, and…
Toyoda, Kazunori; Koga, Masatoshi; Hayakawa, Mikito; Yamagami, Hiroshi
The current status of and prospects for acute stroke care in Asia in the situation where both intravenous thrombolysis and endovascular therapies have been recognized as established strategies for acute stroke are reviewed. Of 15 million people annually having stroke worldwide, ≈9 million are Asians. The burdens of both ischemic and hemorrhagic strokes are severe in Asia. The unique features of stroke in Asia include susceptibility to intracranial atherosclerosis, high prevalence of intracerebral hemorrhage, effects of dietary and lifestyle habits, and several disorders with genetic causes. These features affect acute stroke care, such as the dosage of alteplase for thrombolysis and consideration of bleeding complications during antithrombotic therapy. Acute endovascular thrombectomy, as well as intravenous thrombolysis, is relatively prevalent in East Asia, but most of the other Asian countries need to develop their human resources and fundamental medical infrastructure for stroke care. A limitation of endovascular therapy in East Asia is the high prevalence of intracranial atherosclerosis that can cause recanalization failure and require additional angioplasty or permanent stent insertion although intracranial stenting is not an established strategy. Multinational collaboration on stroke research among Asian countries is infrequent. Asians should collaborate to perform their own thrombolytic and endovascular trials and seek the optimal strategy for stroke care specific to Asia.
Oberengadin Hospital in Samedan is faced with particular challenges, as the highest-elevation acute-care hospital in Europe (1750 m = 5,740 ft above sea level). The factors responsible for this are elevation-related and meteorological/climatic influences, as well as seasonal variations in Südbünden's demographic structure due to tourism.
Ho, Samuel M. Y.; Kwong-Lo, Rosalie S. Y.; Mak, Christine W. Y.; Wong, Joe S.
In this study, the authors examined fear related to severe acute respiratory syndrome (SARS) among 2 samples of hospital staff in Hong Kong. Sample 1 included health care workers (n = 82) and was assessed during the peak of the SARS epidemic. Sample 2 included hospital staff who recovered from SARS (n = 97). The results show that participants in…
Garrison, Laurel E; Shaw, Kristin M S; McCollum, Jeffrey T; Dexter, Carol; Vagnone, Paula M Snippes; Thompson, Jamie H; Giambrone, Gregory; White, Benjamin; Thomas, Stepy; Carpenter, L Rand; Nichols, Megin; Parker, Erin; Petit, Susan; Hicks, Lauri A; Langley, Gayle E
We surveyed 399 US acute care hospitals regarding availability of on-site Legionella testing; 300 (75.2%) did not offer Legionella testing on site. Availability varied according to hospital size and geographic location. On-site access to testing may improve detection of Legionnaires disease and inform patient management and prevention efforts.
Lyerly, Michael J; Wu, Tzu-Ching; Mullen, Michael T; Albright, Karen C; Wolff, Catherine; Boehme, Amelia K; Branas, Charles C; Grotta, James C; Savitz, Sean I; Carr, Brendan G
Racial and ethnic disparities have been previously reported in acute stroke care. We sought to determine the effect of telemedicine (TM) on access to acute stroke care for racial and ethnic minorities in the state of Texas. Data were collected from the US Census Bureau, The Joint Commission and the American Hospital Association. Access for racial and ethnic minorities was determined by summing the population that could reach a primary stroke centre (PSC) or telemedicine spoke within specified time intervals using validated models. TM extended access to stroke expertise by 1.5 million residents. The odds of providing 60-minute access via TM were similar in Blacks and Whites (prevalence odds ratios (POR) 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.001). The odds of providing access via TM were also similar for Hispanics and non-Hispanics (POR 1.000, 95% CI 1.000-1.000), even after adjustment for urbanization (POR 1.000, 95% CI 1.000-1.000). We found that telemedicine increased access to acute stroke care for 1.5 million Texans. While racial and ethnic disparities exist in other components of stroke care, we did not find evidence of disparities in access to the acute stroke expertise afforded by telemedicine.
The development of infection control strategies at acute-care hospitals has contributed to an overall decline in the number of healthcare-associated infections (HAI’s) in the United States, especially those caused by contaminated equipment used in surgical procedures and co...
Yost, David A
The clinical assessment of an acutely intoxicated patient should be performed with meticulous care and include repetitive examinations to properly determine the patient's condition. Multiple factors, such as trauma and concomitant use of other drugs, can confuse the diagnostic picture and affect the choice of therapy. In this article, Dr Yost reviews the diagnostic considerations, appropriate treatment, and clinic discharge for the intoxicated patient.
Li, Hong; Morrow-Howell, Nancy; Proctor, Enola K.
After inpatient hospitalization, many elderly patients with congestive heart failure (CHF) are discharged home and receive post-acute home care from informal (family) caregivers and formal service providers. Hospital readmission rates are high among elderly patients with CHF, and it is thought that use of informal and formal services may reduce…
... Inpatient Prospective Payment Systems for Acute Care Hospitals and Fiscal Year 2011 Final Wage Indices...), HHS. ACTION: Notice. SUMMARY: This notice contains the final fiscal year (FY) 2011 wage indices and... the expiration date for certain geographic reclassifications and special exception wage...
Dalal, Anuj K; Schnipper, Jeffrey; Massaro, Anthony; Hanna, John; Mlaver, Eli; McNally, Kelly; Stade, Diana; Morrison, Constance; Bates, David W
Communication in acute care settings is fragmented and occurs asynchronously via a variety of electronic modalities. Providers are often not on the same page with regard to the plan of care. We designed and developed a secure, patient-centered "microblog" messaging platform that identifies care team members by synchronizing with the electronic health record, and directs providers to a single forum where they can communicate about the plan of care. The system was used for 35% of patients admitted to a medical intensive care unit over a 6-month period. Major themes in messages included care coordination (49%), clinical summarization (29%), and care team collaboration (27%). Message transparency and persistence were seen as useful features by 83% and 62% of respondents, respectively. Availability of alternative messaging tools and variable use by non-unit providers were seen as main barriers to adoption by 83% and 62% of respondents, respectively. This approach has much potential to improve communication across settings once barriers are addressed.
Rowe, Stevie; Siegel, David; Benjamin, Daniel K.
Purpose Approximately 1 out of 6 children in the United States is obese. This has important implications for drug dosing and safety, as pharmacokinetic (PK) changes are known to occur in obesity due to altered body composition and physiology. Inappropriate drug dosing can limit therapeutic efficacy and increase drug-related toxicity for obese children. Few systematic reviews examining PK and drug dosing in obese children have been performed. Methods We identified 25 acute care drugs from the Strategic National Stockpile and Acute Care Supportive Drugs List and performed a systematic review for each drug in 3 study populations: obese children (2–18 years of age), normal weight children, and obese adults. For each study population, we first reviewed a drug’s Food and Drug Administration (FDA) label, followed by a systematic literature review. From the literature, we extracted drug PK data, biochemical properties, and dosing information. We then reviewed data in 3 age subpopulations (2–7 years, 8–12 years, and 13–18 years) for obese and normal weight children and by route of drug administration (intramuscular, intravenous, by mouth, and inhaled). If sufficient PK data were not available by age/route of administration, a data gap was identified. Findings Only 2/25 acute care drugs (8%) contained dosing information on the FDA label for each obese children and adults compared with 22/25 (88%) for normal weight children. We found no sufficient PK data in the literature for any of the acute care drugs in obese children. Sufficient PK data were found for 7/25 acute care drugs (28%) in normal weight children and 3/25 (12%) in obese adults. Implications Insufficient information exists to guide dosing in obese children for any of the acute care drugs reviewed. This knowledge gap is alarming, given the known PK changes that occur in the setting of obesity. Future clinical trials examining the PK of acute care medications in obese children should be prioritized. PMID
Provisional NQF (n=13) ANA (n=10) Death in low mortality DRG X Decubitus /pressure ulcer X X X Failure to rescue X X X Infection due to medical care X...overlap in these measure sets, with the exception of decubitus /pressure ulcer and failure to rescue. Caution should be taken since the measure intent...patient falls, pressure ulcers , and mortality, with increasing detail in measure specification.11 For example, nosocomial infections are broken down into
Payne, Sarah; Cole, Elaine
Many patients with minor burns present at emergency departments and urgent care centres, where their management is often undertaken by experienced nurses rather than experts in treating burns. This article describes a small study of the clinical decision making that underpins nurses' management of minor burns in these non-specialist settings. The results suggest that, due to a lack of relevant research, nurses base their decisions on previous experience or expert colleagues' opinions and advice rather than on the evidence.
Stevens, Kathleen R; Engh, Eileen P; Tubbs-Cooley, Heather; Conley, Deborah Marks; Cupit, Tammy; D'Errico, Ellen; DiNapoli, Pam; Fischer, Joleen Lynn; Freed, Ruth; Kotzer, Anne Marie; Lindgren, Carolyn L; Marino, Marie Ann; Mestas, Lisa; Perdue, Jessica; Powers, Rebekah; Radovich, Patricia; Rice, Karen; Riley, Linda P; Rosenfeld, Peri; Roussel, Linda; Ryan-Wenger, Nancy A; Searle-Leach, Linda; Shonka, Nicole M; Smith, Vicki L; Sweatt, Laura; Townsend-Gervis, Mary; Wathen, Ellen; Withycombe, Janice S
Frontline nurses encounter operational failures (OFs), or breakdowns in system processes, that hinder care, erode quality, and threaten patient safety. Previous research has relied on external observers to identify OFs; nurses have been passive participants in the identification of system failures that impede their ability to deliver safe and effective care. To better understand frontline nurses' direct experiences with OFs in hospitals, we conducted a multi-site study within a national research network to describe the rate and categories of OFs detected by nurses as they provided direct patient care. Data were collected by 774 nurses working in 67 adult and pediatric medical-surgical units in 23 hospitals. Nurses systematically recorded data about OFs encountered during 10 work shifts over a 20-day period. In total, nurses reported 27,298 OFs over 4,497 shifts, a rate of 6.07 OFs per shift. The highest rate of failures occurred in the category of Equipment/Supplies, and the lowest rate occurred in the category of Physical Unit/Layout. No differences in OF rate were detected based on hospital size, teaching status, or unit type. Given the scale of this study, we conclude that OFs are frequent and varied across system processes, and that organizations may readily obtain crucial information about OFs from frontline nurses. Nurses' detection of OFs could provide organizations with rich, real-time information about system operations to improve organizational reliability. © 2017 Wiley Periodicals, Inc.
Çinkir, Sakir; Nayir, K. Funda; Çetin, Saadet Kuru
Schools are social organizations where children came together from different cultures. Creating sense of community is important for schools for the formation of social culture. In schools where sense of community is formed, it is observed that students treat each other with respect, are caring and sharing and have high academic success, and rates…
Casper, Virginia; Lamb-Parker, Faith
The Developing Families Project-South Africa (DFP-SA) is a community-based model of education and training for the care, support and education of vulnerable children birth-to-three and their caregivers, guardians and families in rural and peri-urban townships. The approach fosters interactive learning among community members about early care and…
Allen, David; Mix, Janet
In 1989, the Community Partnership: Child Care and Early Education was formed to examine policies and make recommendations with respect to early childhood care and education (ECCE) in Ramsey County, Minnesota. The Partnership established a Task Force to develop a long-term vision for ECCE consistent with community values and to create a blueprint…
Hawkins, J. David; Catalano, Richard F; Arthur, Michael W.; Egan, Elizabeth; Brown, Eric C.; Abbott, Robert D.; Murray, David M.
Recent advances in prevention science provide evidence that adolescent health and behavior problems can be prevented by high-quality prevention services. However, many communities continue to use prevention strategies that have not been shown to be effective. Studying processes for promoting the dissemination and high-quality implementation of prevention strategies found to be effective in controlled research trials has become an important focus for prevention science. The Communities That Care prevention operating system provides manuals, tools, training, and technical assistance to activate communities to use advances in prevention science to plan and implement community prevention services to reduce adolescent substance use, delinquency, and related health and behavior problems. This paper describes the rationale, aims, intervention, and design of the Community Youth Development Study, a randomized controlled community trial of the Communities That Care system, and investigates the baseline comparability of the 12 intervention and 12 control communities in the study. Results indicate baseline similarity of the intervention and control communities in levels of adolescent drug use and antisocial behavior prior to the Communities That Care intervention. Strengths and limitations of the study’s design are discussed. PMID:18516681
Deacon, M; Warne, T; McAndrew, S
This paper makes a case for the attractiveness of acute mental health inpatient nursing (acute nursing) and argues that an altered perception of this work is essential if we are to provide the most acutely mentally ill and vulnerable people with a stable and expert nursing workforce. The discussion draws on an ethnographic study conducted in an inner-city psychiatric unit in England and the advantages of this method for understanding nursing work are described. Within our findings, we set out two overarching themes: the contextual realities of the contemporary acute ward and features of attraction that encourage nurses to work in the acute care setting. The former includes nurses' responsibility for the total ward environment and the latter the 'comfort of closeness' and 'surviving and thriving in chaos and crisis'. In conclusion, we argue that despite the unpopularity of the acute inpatient mental health environment, the highly sophisticated skills employed by acute nurses actually ensure the promotion of health for the majority of service users.
Donaldson, Nancy; Shapiro, Susan
California is the first state to enact legislation mandating minimum nurse-to-patient ratios at all times in acute care hospitals. This synthesis examines 12 studies of the impact of California's ratios on patient care cost, quality, and outcomes in acute care hospitals. A key finding from this synthesis is that the implementation of minimum nurse-to-patient ratios reduced the number of patients per licensed nurse and increased the number of worked nursing hours per patient day in hospitals. Another finding is that there were no significant impacts of these improved staffing measures on measures of nursing quality and patient safety indicators across hospitals. A critical observation may be that adverse outcomes did not increase despite the increasing patient severity reflected in case mix index. We cautiously posit that this finding may actually suggest an impact of ratios in preventing adverse events in the presence of increased patient risk.
Urban, Ann-Marie; Wagner, Joan I
Hospitals are situated within historical and socio-political contexts; these influence the provision of patient care and the work of registered nurses (RNs). Since the early 1990s, restructuring and the increasing pressure to save money and improve efficiency have plagued acute care hospitals. These changes have affected both the work environment and the work of nurses. After recognizing this impact, healthcare leaders have dedicated many efforts to improving the work environment in hospitals. Admirable in their intent, these initiatives have made little change for RNs and their work environment, and thus, an opportunity exists for other efforts. Research indicates that spirit at work (SAW) not only improves the work environment but also strengthens the nurse's power to improve patient outcomes and contribute to a high-quality workplace. In this paper, we present findings from our research that suggest SAW be considered an important component in improving the work environment in acute care hospitals.
Langhan, Melissa L; Riera, Antonio; Kurtz, Jordan C; Schaeffer, Paula; Asnes, Andrea G
Technologies are not always successfully implemented into practice. This study elicited experiences of acute care providers with the introduction of technology and identified barriers and facilitators in the implementation process. A qualitative study using one-on-one interviews among a purposeful sample of 19 physicians and nurses within 10 emergency departments and intensive care units was performed. Grounded theory, iterative data analysis and the constant comparative method were used to inductively generate ideas and build theories. Five major categories emerged: decision-making factors, the impact on practice, technology's perceived value, facilitators and barriers to implementation. Barriers included negative experiences, age, infrequent use and access difficulties. A positive outlook, sufficient training, support staff and user friendliness were facilitators. This study describes strategies implicated in the successful implementation of newly adopted technology in acute care settings. Improved implementation methods and evaluation of implementation processes are necessary for successful adoption of new technology.
The biggest asset of the NHS is its staff. Health professionals working in the community are faced with a number of challenges to maintain and develop their knowledge and skills in their clinical practice. NHS England's Five Year Forward View describes the need for change, identifying the necessity to reshape care delivery, harnessing technology, and driving down variations in quality and safety of care. This article explores some of the challenges faced by community health-care providers and reviews possible solutions to meet community health-care needs for now as well as the future.
Westfall, John M
By providing enhanced primary care and social services to patients with high utilization of expensive emergency and hospital care, there is evidence that their health can improve and their costs can be lowered. This type of "hot-spotting" improves the care of individual patients. It may be that these patients live in communities with disintegrated social determinants of health, little community support, and poor access to primary care. These "cold spots" in the community may be amenable to interventions targeted at linking primary care and public health at broader community and population levels. Building local communities of solution that address the individual and population may help decrease these cold spots, thereby eliminating the hot spots as well.
Albright, Karen C; Schott, Todd C; Boland, Debbie F; George, Leslie; Boland, Kevin P; Wohlford-Wessels, Mary Pat; Finnerty, Edward P; Jacoby, Michael R K
Prior studies have suggested that stroke care is more fragmented in rural or neurologically underserved areas. The purpose of this study was to determine the availability of diagnostic and treatment services for acute stroke care in Iowa and to identify factors influencing care. Each of the 118 facilities in Iowa with emergency departments was surveyed by telephone. This survey consisted of 10 questions, focusing on the existence of pre-hospital and emergency room acute stroke protocols and the availability of essential personnel and diagnostic and treatment modalities essential for acute stroke care. Of the 118 hospitals with emergency departments, 109 (92.4%) had CT available. Within the subset having CT capabilities, 89.9% (98/109) had intravenous tissue plasminogen activator (IV t-PA) available. Of those facilities with both CT and IV t-PA, 46% (45/98) had around-the-clock in-house physician coverage. Further, 31% (14/45) of sites with CT, t-PA, and an in-house physician had a radiology technician on site. Only 12% (14/118) of centers could offer all essential components. Despite 88% of Iowa hospitals not providing all of these components, only 31% of these hospitals reported protocols for stabilization and immediate transfer of acute stroke patients. These findings indicate that the development of a stroke system is still in its infancy in Iowa. Collaborative efforts are needed to address barriers in rural Iowa and to assist facilities in providing the best possible care. Creativity will be paramount in establishing a functional statewide system to ensure optimum care for all Iowans.
Nicolasora, Nelson P; Zacharek, Mark A; Malani, Anurag N
Staphylococcus aureus has long been recognized as a cause of acute bacterial parotitis. A case of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) parotitis is presented, highlighting the emergence of this increasingly important pathogen to cause a wide variety of infections. Also reviewed are the salient clinical and microbiologic features of this novel infection.
Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim
Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician–patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients’ experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships. PMID:27789958
Stein, G L; Bonuck, K A
Gay men and lesbians have special interests in documenting their preferences regarding advance care planning and end-of-life care. A 64-item survey instrument was developed to ascertain the preferences of this community regarding approaches to end-of-life care, viewpoints on physician-assisted suicide (PAS) and euthanasia, and practices regarding advance care planning. The survey was completed by 575 participants recruited through community-based health care and social service organizations serving the lesbian and gay community, primarily in the New York metropolitan area. Respondents represent a diverse group of women (36%) and men (63%) from various age, racial/ethnic, and religious/spiritual backgrounds; 10% were human immunodeficiency virus (HIV)-positive. Respondents' perspectives on end-of-life care are generally consistent with findings from other attitudinal studies of U.S. adults: a majority supported legalization of PAS and preferred a palliative approach to end-of-life care. However, the gay community sample revealed even stronger support for assisted suicide and palliative care. Although respondents completed advance directives at a higher rate than adults generally, the legal importance for gay men and lesbians to execute directives should encourage health care providers and community organizations to assume a larger educational role on advance care planning. Results confirm other reports on the need to address provider communication skills. It is speculated that the HIV epidemic was a major influence behind these results because of the overwhelming personal impact of the epidemic on most gay men and lesbians during the past two decades.
Christianson, Jon B; Ginsburg, Paul B; Draper, Debra A
This paper assesses the evolving "facilitated consumerism" model of health care at the community level using data from the Community Tracking Study (CTS). We find that in a relatively short time, large employers and health plans have made notable progress in putting the building blocks in place to support their vision of consumerism. However, developments in the CTS communities suggest that the consumerism strategy evolving in local markets is more nuanced than implied by some descriptions of health care consumerism.
Gopalan, Saji S; Durairaj, Varatharajan
Given the increasing need for mainstreaming household financing for women's nonmaternal health care and evidences on community-based financing's contribution to women's health care in general, this study explored their scope for nonmaternal health care in Orissa. A qualitative assessment conducted focus group discussions with rural women who met the eligibility criteria. Community-based financing provided financial access and risk protection for women's nonmaternal health care during the previous 1 year, though not adequately. Schemes covering outpatient care (or mild illnesses) provided relatively more financial access. The major determinants of their restricted financial access were limited sum assured, noncomprehensive coverage of services, exclusion of elderly women, and the lower priority households gave to nonmaternal health care. Community-based financing requires relevant structural changes along with demand-side behavioral modifications to ensure optimal attention to women's nonmaternal health care.
Carcillo, Joseph A.; And Others
Describes an underserved rural community in which health care initiatives increased access to comprehensive care. Over a 3-year period, increased accessibility to maternal and child health care also increased use of preventive services, thus decreasing emergency room visits and hospitalizations as well as low birth weight, risk of congenital…
Rowe, Jennifer L.; Bruce, Martha L.; Conwell, Yeates
Home health care patients often have several late-life risk factors for suicide and constitute a high risk group for suicidal behaviors. In this study, we examined the characteristics of 14 older adult home health care utilizers who died by suicide and four community controls who used similar services. Both groups of home health care utilizers had…
Quinby, Rose K.; Hanson, Koren; Brooke-Weiss, Blair; Arthur, Michael W.; Hawkins, J. David; Fagan, Abigail A.
This article describes the degree to which high fidelity implementation of the Communities That Care (CTC) prevention operating system was reached during the first 18 months of intervention in 12 communities in the Community Youth Development Study, a 5-year group randomized controlled trial designed to test the efficacy of the CTC system. CTC…
Evenson, Kelly R.; Foraker, Randi; Morris, Dexter L.; Rosamond, Wayne D.
The purpose of this study was to systematically review and summarize prehospital and in-hospital stroke evaluation and treatment delay times. We identified 123 unique peer-reviewed studies published from 1981 to 2007 of prehospital and in-hospital delay time for evaluation and treatment of patients with stroke, transient ischemic attack, or stroke-like symptoms. Based on studies of 65 different population groups, the weighted Poisson regression indicated a 6.0% annual decline (p<0.001) in hours/year for prehospital delay, defined from symptom onset to emergency department (ED) arrival. For in-hospital delay, the weighted Poisson regression models indicated no meaningful changes in delay time from ED arrival to ED evaluation (3.1%, p=0.49 based on 12 population groups). There was a 10.2% annual decline in hours/year from ED arrival to neurology evaluation or notification (p=0.23 based on 16 population groups) and a 10.7% annual decline in hours/year for delay time from ED arrival to initiation of computed tomography (p=0.11 based on 23 population groups). Only one study reported on times from arrival to computed tomography scan interpretation, two studies on arrival to drug administration, and no studies on arrival to transfer to an in-patient setting, precluding generalizations. Prehospital delay continues to contribute the largest proportion of delay time. The next decade provides opportunities to establish more effective community based interventions worldwide. It will be crucial to have effective stroke surveillance systems in place to better understand and improve both prehospital and in-hospital delays for acute stroke care. PMID:19659821
McCabe, Margaret; Patricia, Branowicki
Nurses commonly assess their patients for symptoms and intervene to ease any patient distress, yet children are seldom asked about feeling fatigued. The existing pediatric literature suggests that fatigue goes unrecognized and therefore untreated in children, particularly children experiencing stressful events, such as illness and/or hospitalization. In an effort to better understand the presence of the symptom in our environment we conducted a program specific point prevalence survey. Data were collected on nine inpatient and 11 outpatient units of a university affiliated tertiary care children's hospital. Overall, this sample reported higher levels of fatigue than published data from their healthy and chronically ill peers by total fatigue score and sub scores. This brief description of the symptom in our inpatient and ambulatory settings has provided information that will inform our nursing practice and drive future research.
Bittner, Edward A.; Shank, Erik; Woodson, Lee; Martyn, J.A. Jeevendra
Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury are characterized by a reduction in cardiac output, increased systemic and pulmonary vascular resistance. Approximately 2–5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic end points. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia and altered pharmacology. PMID:25485468
Sintonen, Sanna; Pehkonen, Aini
The effect of social surroundings has been noted as an important component of the well-being of elderly people. A strong social network and strong and steady relationships are necessary for coping when illness or functional limitations occur in later life. Vulnerability can affect well-being and functioning particularly when sudden life changes occur. The objective of this study was to analyse how the determinants of social well-being affect individual acute care needs when sudden life changes occur. Empirical evidence was collected using a cross-sectional mail survey in Finland in January 2011 among individuals aged 55-79 years. The age-stratified random sample covered 3000 individuals, and the eventual response rate was 56% (1680). Complete responses were received from 1282 respondents (42.7%). The study focuses on the compactness of social networks, social disability, the stability of social relationships and the fear of loneliness as well as how these factors influence acute care needs. The measurement was based on a latent factor structure, and the key concepts were measured using two ordinal items. The results of the structural model suggest that the need for care is directly affected by social disability and the fear of loneliness. In addition, social disability is a determinant of the fear of loneliness and therefore plays an important role if sudden life changes occur. The compactness of social networks decreases social disability and partly diminishes the fear of loneliness and therefore has an indirect effect on the need for care. The stability of social relationships was influenced by the social networks and disability, but was an insignificant predictor of care needs. To conclude, social networks and well-being can decrease care needs, and supportive actions should be targeted to avoid loneliness and social isolation so that the informal network could be applied as an aspect of care-giving when acute life changes occur.
Ngako, Kgalabi J; Van Rensburg, Elsie S J; Mataboge, Sanah M L
Psychiatric nurse practitioners (PNPs) working with mental health care users presenting with acute symptoms work in a complex environment. This environment is characterised by mental health care users who may present with a history of violence, sexual assault and substance misuse. The objectives of this study were twofold: firstly, to explore and describe the experiences of PNPs working with mental health care users (MHCUs) presenting with acute symptoms; and secondly, to make recommendations for the advanced PNPs to facilitate promotion of the mental health of PNPs with reference to nursing practice, research and education. A qualitative, explorative, descriptive and contextual design was used. The target population was PNPs working with MHCUs presenting with acute symptoms in a public mental health care institution in Gauteng. Data were collected by means of four focus group interviews involving 21 PNPs. The researcher made use of drawings, naïve sketches and field notes for the purpose of data triangulation. Data were analysed in accordance with Tesch's method of open coding. The three themes that emerged were: PNPs experienced working with these MHCUs as entering an unsafe world where care became a burden; they experienced negative emotional reactions and attitudes towards these MHCUs that compromised quality nursing care; and they made a plea for a nurturing environment that would enhance quality nursing care. The PNPs suggest skills and competency development, organisational support, and a need for external resources. Creation of a positive environment and mobilisation of resources as well as the identification and bridging of obstacles are essential in the promotion of the overall wellbeing and mental health of PNPs.
Hirshon, Jon Mark; Hansoti, Bhakti; Hauswald, Mark; Sethuraman, Kinjal; Kerr, Nancy Louise; Scordino, David; Biros, Michelle H
The 2013 Academic Emergency Medicine consensus conference focused on global health and emergency care research. One conference breakout session discussed research ethics and developed a research agenda concerning global acute care research ethics. This article represents the proceedings from that session, particularly focusing on ethical issues related to protecting human subjects while conducting acute care research. Protecting human research subjects from unnecessary risk is an important component of conducting ethical research, regardless of the research site. There are widely accepted ethical principles related to human subjects research; however, the interpretation of these principles requires specific local knowledge and expertise to ensure that research is conducted ethically within the societal and cultural norms. There is an obligation to conduct research ethically while recognizing the roles and responsibilities of all participants. This article discusses the complexities of determining and applying socially and culturally appropriate ethical principles during the conduct of global acute care research. Using case studies, it focuses both on the procedural components of ethical research conducted outside of "Western" culture and on basic ethical principles that are applicable to all human subjects research. This article also proposes specific research topics to stimulate future thought and the study of ethics in these complex circumstances.
Teichman, Sam L; Maisel, Alan S; Storrow, Alan B
Acute heart failure is a common condition associated with considerable morbidity, mortality, and cost. However, evidence-based data on treating heart failure in the acute setting are limited, and current individual treatment options have variable efficacy. The healthcare team must often individualize patient care in ways that may extend beyond available clinical guidelines. In this review, we address the question, "How do you do the best you can clinically with incomplete evidence and imperfect drugs?" Expert opinion is provided to supplement guideline-based recommendations and help address the typical challenges that are involved in the management of patients with acute heart failure. Specifically, we discuss 4 key areas that are important in the continuum of patient care: differential diagnosis and risk stratification; choice and implementation of initial therapy; assessment of the adequacy of therapy during hospitalization or observation; and considerations for discharge/transition of care. A case study is presented to highlight the decision-making process throughout each of these areas. Evidence is accumulating that should help guide patients and healthcare providers on a path to better quality of care.
Maisel, Alan S.; Storrow, Alan B.
Acute heart failure is a common condition associated with considerable morbidity, mortality, and cost. However, evidence-based data on treating heart failure in the acute setting are limited, and current individual treatment options have variable efficacy. The healthcare team must often individualize patient care in ways that may extend beyond available clinical guidelines. In this review, we address the question, “How do you do the best you can clinically with incomplete evidence and imperfect drugs?” Expert opinion is provided to supplement guideline-based recommendations and help address the typical challenges that are involved in the management of patients with acute heart failure. Specifically, we discuss 4 key areas that are important in the continuum of patient care: differential diagnosis and risk stratification; choice and implementation of initial therapy; assessment of the adequacy of therapy during hospitalization or observation; and considerations for discharge/transition of care. A case study is presented to highlight the decision-making process throughout each of these areas. Evidence is accumulating that should help guide patients and healthcare providers on a path to better quality of care. PMID:25679083
Kumar, Chandrika; Bensadon, Benjamin A.; Van Ness, Peter H.; Cooney, Leo M.
Most geriatric care is provided in non-hospital settings. Internal Medicine and Family Medicine residents should therefore learn about these different clinical sites and acuity levels of care. To help facilitate this learning, a geriatrics training curriculum for internal medicine residents was developed that focused on cognition, function, goals…
Carpenter, Joan G
Although palliative care consultation teams are common in U.S. hospitals, follow up and outcomes of consultations for frail older adults discharged to nursing facilities are unclear. To summarize and critique research on the care of patients discharged to nursing facilities following a hospital-based palliative care consult, a systematic search of PubMed, CINAHL, Ageline, and PsycINFO was conducted in February 2016. Data from the articles (N = 12) were abstracted and analyzed. The results of 12 articles reflecting research conducted in five countries are presented in narrative form. Two studies focused on nurse perceptions only, three described patient/family/caregiver experiences and needs, and seven described patient-focused outcomes. Collectively, these articles demonstrate that disruption in palliative care service on hospital discharge and nursing facility admission may result in high symptom burden, poor communication, and inadequate coordination of care. High mortality was also noted. [Res Gerontol Nurs. 2017; 10(1):25-34.].
Griffies, W Scott
One of the greatest challenges of restoring the New Orleans health care infrastructure since the post-Katrina disaster has been shortages of health care providers. Many providers had prolonged displacements or did not return to their practices, depleting the city of valuable resources. This Open Forum chronicles the displacement of Louisiana State University's Department of Psychiatry and discusses barriers to returning health care providers to their communities expeditiously. Predisaster planning and policy changes are proposed to facilitate a quicker return and decrease the attrition of health care providers after future disasters. A community's predisaster plans should include a mechanism to allow funds to follow patients instead of hospitals, to provide bridge funding that pays local health care providers to work as first responders and serve uninsured patients while these providers rebuild their practices, and to provide funds to quickly expand services and usable space in undamaged clinics and hospitals and to shore up reparable structures.
Spath, M; Buttlar, L
The majority of nurses surveyed used the library on a regular but limited basis to obtain information needed in caring for or making decisions about their patients. A minority indicated that the libraries in their own institutions totally met their information needs. In fact, only 4% depended on the library to stay abreast of new information and developments in the field. Many of the nurses had their own journal subscriptions, which could account in part for the limited use of libraries and the popularity of the professional journal as the key information source. This finding correlates with the research of Binger and Huntsman, who found that 95% of staff development educators relied on professional journal literature to keep up with current information in the field, and only 45% regularly monitored indexing-and-abstracting services. The present study also revealed that nurses seek information from colleagues more than from any other source, supporting the findings of Corcoran-Perry and Graves. Further research is necessary to clarify why nurses use libraries on a limited basis. It appears, as Bunyan and Lutz contend, that a more aggressive approach to marketing the library to nurses is needed. Further research should include an assessment of how the library can meet the information needs of nurses for both research and patient care. Options to be considered include offering library orientation sessions for new staff nurses, providing current-awareness services by circulating photocopied table-of-contents pages, sending out reviews of new monographs, inviting nurses to submit search requests on a topic, scheduling seminars and workshops that teach CD-ROM and online search strategies, and providing information about electronic databases covering topics related to nursing. Information on databases may be particularly important in light of the present study's finding that databases available in CD-ROM format are consulted very little. Nursing education programs should
Kamal, Arif H; Currow, David C; Ritchie, Christine S; Bull, Janet; Abernethy, Amy P
Palliative care in the U.S. has evolved from a system primarily reliant on community-based hospices to a combined model that includes inpatient services at most large hospitals. However, these two dominant approaches leave most patients needing palliative care-those at home (including nursing homes) but not yet ready for hospice-unable to access the positive impacts of the palliative care approach. We propose a community-based palliative care (CPC) model that spans the array of inpatient and outpatient settings in which palliative care is provided and links seamlessly to inpatient care; likewise, it would span the full trajectory of advanced illness rather than focusing on the period just before death. Examples of CPC programs are developing organically across the U.S. As our understanding of CPC expands, standardization is needed to ensure replicability, consistency, and the ability to relate intervention models to outcomes. A growing body of literature examining outpatient palliative care supports the role of CPC in improving outcomes, including reduction in symptom burden, improved quality of life, increased survival, better satisfaction with care, and reduced health care resource utilization. Furthermore the examination of how to operationalize CPC is needed before widespread implementation can be realized. This article describes the key characteristics of CPC, highlighting its role in longitudinal care across patient transitions. Distinguishing features include consistent care across the disease trajectory independent of diagnosis and prognosis; inclusion of inpatient, outpatient, long-term care, and at-home care delivery; collaboration with other medical disciplines, nursing, and allied health; and full integration into the health care system (rather than parallel delivery).
Wolfe, C D; Taub, N A; Woodrow, J; Richardson, E; Warburton, F G; Burney, P G
OBJECTIVE--To quantify the use of health care services by acutely ill stroke patients in three district health authorities. DESIGN--A follow up study of all patients recorded in population based registers who had a first ever stroke in three district health authorities, with assessment following the onset and three months after the stroke. SETTING--West Lambeth, Lewisham and North Southwark, and Tunbridge Wells District Health Authorities in south east England. SUBJECTS--All first time stroke patients under the age of 75 years who presented between 15 August 1989 and 14 August 1990. MEASUREMENTS AND MAIN RESULTS--Hospital admission rates, rates of use of rehabilitation services, and contact with medical practitioners together with assessment of disability and handicap were determined. A total of 386 strokes were registered. Seventy eight per cent were treated in hospital and younger and incontinent patients were significantly more likely to be admitted. The median stay was 21 days. Patients in West Lambeth, those paralysed, and those who stayed longer in hospital were more likely to receive physiotherapy. Altogether 265 patients were followed up, 117 having died within three months of the stroke. During the three months, 150 (57%) had seen a hospital physician and 181 (69%) their general practitioner, but 18 (7%) had seen neither. Sixty seven (26%) patients were moderately or severely disabled. Twenty seven per cent of inpatients had received no inpatient physiotherapy and 67% of all patients no outpatient physiotherapy during the three months. CONCLUSIONS--The hospital admission rates were high, with long lengths of stay. There were significant differences in the amount of rehabilitation received in each district. This was low overall, especially for those not admitted to hospital. As expected, patients admitted for long periods were the most likely to receive therapy. Before district policies for admission and management of stroke patients can be drawn up
Praptiningsih, Catharina Y; Lafond, Kathryn E; Wahyuningrum, Yunita; Storms, Aaron D; Mangiri, Amalya; Iuliano, Angela D; Samaan, Gina; Titaley, Christiana R; Yelda, Fitra; Kreslake, Jennifer; Storey, Douglas; Uyeki, Timothy M
Understanding healthcare-seeking patterns for respiratory illness can help improve estimations of disease burden and inform public health interventions to control acute respiratory disease in Indonesia. The objectives of this study were to describe healthcare-seeking behaviors for respiratory illnesses in one rural and one urban community in Western Java, and to explore the factors that affect care seeking. From February 8, 2012 to March 1, 2012, a survey was conducted in 2520 households in the East Jakarta and Bogor districts to identify reported recent respiratory illnesses, as well as all hospitalizations from the previous 12-month period. We found that 4% (10% of those less than 5years) of people had respiratory disease resulting in a visit to a healthcare provider in the past 2weeks; these episodes were most commonly treated at government (33%) or private (44%) clinics. Forty-five people (0.4% of those surveyed) had respiratory hospitalizations in the past year, and just over half of these (24/45, 53%) occurred at a public hospital. Public health programs targeting respiratory disease in this region should account for care at private hospitals and clinics, as well as illnesses that are treated at home, in order to capture the true burden of illness in these communities.
Ferrer, Robert L; Gonzalez Schlenker, Carolina; Lozano Romero, Raquel; Poursani, Ramin; Bazaldua, Oralia; Davidson, DeWayne; Ann Gonzales, Melissa; Dehoyos, Janie; Castilla, Martha; Corona, Betty A; Tysinger, James; Alsip, Bryan; Trejo, Jonathan; Jaén, Carlos Roberto
Improving health among people living in poverty often transcends narrowly focused illness care. Meaningful success is unlikely without confronting the complex social origins of illness. We describe an emerging community of solution to improve health outcomes for a population of 6000 San Antonio, Texas, residents enrolled in a county health care program. The community of solution comprises a county health system, a family medicine residency program, a metropolitan public health department, and local nonprofit organizations and businesses. Community-based activities responding to the needs of individuals and their neighborhoods are driven by a cohort of promotores (community health workers) whose mission encompasses change at both the individual and community levels. Centered on patients' functional goals, promotores mobilize family and community resources and consider what community-level action will address the social determinants of health. On the clinical side, care teams implement population-based risk assessment and nurse care management with a focus on care transitions as well as other measures to meet the needs of patients with high morbidity and high use of health care. Population-based outcome metrics include reductions in hospitalizations, emergency department and urgent care visits, and the associated charges. Promotores also assess patients' progress along the trajectory of their selected functional goals.
Schultz, Carl H; Koenig, Kristi L; Whiteside, Mary; Murray, Rick
The training of medical personnel to provide care for disaster victims is a priority for the physician community, the federal government, and society as a whole. Course development for such training guided by well-accepted standardized core competencies is lacking, however. This project identified a set of core competencies and performance objectives based on the knowledge, skills, and attitudes required by the specific target audience (emergency department nurses, emergency physicians, and out-of-hospital emergency medical services personnel) to ensure they can treat the injuries and illnesses experienced by victims of disasters regardless of cause. The core competencies provide a blueprint for the development or refinement of disaster training courses. This expert consensus project, supported by a grant from the Robert Wood Johnson Foundation, incorporated an all-hazard, comprehensive emergency management approach addressing every type of disaster to minimize the effect on the public's health. An instructional systems design process was used to guide the development of audience-appropriate competencies and performance objectives. Participants, representing multiple academic and provider organizations, used a modified Delphi approach to achieve consensus on recommendations. A framework of 19 content categories (domains), 19 core competencies, and more than 90 performance objectives was developed for acute medical care personnel to address the requirements of effective all-hazards disaster response. Creating disaster curricula and training based on the core competencies and performance objectives identified in this article will ensure that acute medical care personnel are prepared to treat patients and address associated ramifications/consequences during any catastrophic event.
Hubble, Rosemary; Trowbridge, Kelly; Hubbard, Claudia; Ahsens, Leslie; Ward-Smith, Peggy
The capability of effectively communicating is crucial when providing palliative care, especially when the patient is a child. Communication among healthcare professionals with the child and family members must be clear, concise, and consistent. Use of a communication tool provides documentation for conversations, treatment plans, and specific desires related to care. This paper describes communication theory, portrays the use of this theory to develop a communication tool, and illustrates the use of this tool by multidisciplinary members of a healthcare team to provide pediatric palliative care.
hospitalized due to chemical hazard release of hydrogen fluoride had acute respiratory, gastrointestinal, and neurologic health problems. Non-hospitalized patients have acute symptoms mainly related to upper respiratory irritation. PMID:24472561
Anders, Robert L; Olson, Tom; Bader, Julia
The relationship between quality of care and patient satisfaction has been documented. The specific research aim related to this study is to determine if differences exist among Caucasians, Asians, and Pacific Islanders who are hospitalized for an acute mental illness with regard to their perceived satisfaction with the care. The results of the overall study have been reported elsewhere. The sample was composed of 138 patients, of whom 34.7% were Caucasian, 31.2% Pacific Islanders, and 34.8% Asians. Within 24 hours of discharge, patients completed the Perceptions of Care instrument. Caucasians were over-represented in our sample in comparison to their percentage in the general population of Hawaii. These patients were significantly more satisfied (p = .04) with their care than the other ethnic groups. No single variable was found to specifically indicate why they were more satisfied than Pacific Islanders and Asians.
Zechner, P M; Seibel, A; Aichinger, G; Steigerwald, M; Dorr, K; Scheiermann, P; Schellhaas, S; Cuca, C; Breitkreutz, R
The development of modern critical care lung ultrasound is based on the classical representation of anatomical structures and the need for the assessment of specific sonography artefacts and phenomena. The air and fluid content of the lungs is interpreted using few typical artefacts and phenomena, with which the most important differential diagnoses can be made. According to a recent international consensus conference these include lung sliding, lung pulse, B-lines, lung point, reverberation artefacts, subpleural consolidations and intrapleural fluid collections. An increased number of B-lines is an unspecific sign for an increased quantity of fluid in the lungs resembling interstitial syndromes, for example in the case of cardiogenic pulmonary edema or lung contusion. In the diagnosis of interstitial syndromes lung ultrasound provides higher diagnostic accuracy (95%) than auscultation (55%) and chest radiography (72%). Diagnosis of pneumonia and pulmonary embolism can be achieved at the bedside by evaluating subpleural lung consolidations. Detection of lung sliding can help to detect asymmetrical ventilation and allows the exclusion of a pneumothorax. Ultrasound-based diagnosis of pneumothorax is superior to supine anterior chest radiography: for ultrasound the sensitivity is 92-100% and the specificity 91-100%. For the diagnosis of pneumothorax a simple algorithm was therefore designed: in the presence of lung sliding, lung pulse or B-lines, pneumothorax can be ruled out, in contrast a positive lung point is a highly specific sign of the presence of pneumothorax. Furthermore, lung ultrasound allows not only diagnosis of pleural effusion with significantly higher sensitivity than chest x-ray but also visual control in ultrasound-guided thoracocentesis.
Pruitt, Rosanne H.; Campbell, Becky F.
Proposes that nursing education should focus on less expensive prevention instead of care after the disease has become full blown, involve customers in decision making, and better use the health care delivery system. (JOW)
Schick, Michael; Grether-Jones, Kendra
We describe a case where a patient presented with acute angiotensin-converting enzyme inhibitor (ACE-I) induced angioedema without signs or symptoms of upper airway edema beyond lip swelling. Point-of-care ultrasound (POCUS) was used as an initial diagnostic test and identified left-sided subglottic upper airway edema that was immediately confirmed with indirect fiberoptic laryngoscopy. ACE-I induced angioedema and the historical use of ultrasound in evaluation of the upper airway is briefly discussed. To our knowledge, POCUS has not been used to identify acute upper airway edema in the emergency setting. Further investigation is needed to determine if POCUS is a sensitive and specific-enough tool for the identification and evaluation of acute upper airway edema. PMID:27833699
Li, Hong; Morrow-Howell, Nancy; Proctor, Enola K
After inpatient hospitalization, many elderly patients with congestive heart failure (CHF) are discharged home and receive post-acute home care from informal (family) caregivers and formal service providers. Hospital readmission rates are high among elderly patients with CHF, and it is thought that use of informal and formal services may reduce hospital readmission during the post-acute period. Using proportional Cox regression analysis, the authors examined the independent and joint effects of post-acute informal and formal services on hospital readmission. No evidence of service impact was found. Rather, hospital readmission was associated with a longer length of CHF history and noncompliance with medication regimes. Research, policy, and practice implications are discussed.
Boschek, H J
A key element in the demographic transition process is the increase in the number of very old people (80+) leading to a rising need for long-term care. For the municipalities the efficient organisation of the local support for senior citizens is an important task for legal, political and financial reasons. The local planning process must be based on systematic reporting about long-term care in the community. This report must contain fundamental facts about the demographic situation, the health care system, including the quality of care in nursing homes, by ambulatory services and families as well as the resulting costs in the local welfare budget. Comparing the problem to the methods in local health promotion it is favourable to establish an office to manage the planning process and a committee for matters of care. Committee members should be all relevant stakeholders of the local health, the care and the social sector. The first priority is to achieve the participation of patients, their relatives and the local politicians to agree on targets and measures in the planning process. Key targets are the prevention of risks for long-term care, to secure the quality of care and the preference for ambulatory services, optimisation of local cooperation and minimising the costs for the community. The whole process should be guided by these targets for the provision of care.
van de Goor, Ien AM; Voogt, Margot CM; van Assen, Marcel ALM; Garretsen, Henk FL
Background and aims: Interferential care differs from the current community-based care programs in that it targets a larger, heterogeneous group and combines brokerage and full service elements in a multi-organizational care team. The team provides all the services itself, but with the aim to prepare clients within a few months for referral to regular (ambulant) healthcare services. The aim of this study was to assess the effectiveness of interferential care. Methods: In a multisite, pretest–posttest design, 523 patients of three interferential care teams were followed. Quality of life, problem severity, problems with referral and engagement were assessed at baseline, at referral and again after 6 months. Analyses were performed using linear mixed modeling. Results: Interferential care showed moderate to strong effects on quality of life and problem severity. These effects persisted (quality of life) or further improved (problem severity) until follow-up 6 months after referral to regular services. There were also small effects on both engagement and problems with referral. Conclusion: Interferential care offers significant improvements in quality of life and problem severity in persons who have severe problems on several life areas and who are currently not reached by healthcare services. It is a promising community-based care program for healthcare systems in which regular care already contains many elements of home-based practice. PMID:24221098
Sanger, Patrick; Hartzler, Andrea; Lober, William B; Evans, Heather L; Pratt, Wanda
Many current mobile health applications ("apps") and most previous research have been directed at management of chronic illnesses. However, little is known about patient preferences and design considerations for apps intended to help in a post-acute setting. Our team is developing an mHealth platform to engage patients in wound tracking to identify and manage surgical site infections (SSI) after hospital discharge. Post-discharge SSIs are a major source of morbidity and expense, and occur at a critical care transition when patients are physically and emotionally stressed. Through interviews with surgical patients who experienced SSI, we derived design considerations for such a post-acute care app. Key design qualities include: meeting basic accessibility, usability and security needs; encouraging patient-centeredness; facilitating better, more predictable communication; and supporting personalized management by providers. We illustrate our application of these guiding design considerations and propose a new framework for mHealth design based on illness duration and intensity.
Chuang, Alice; Munz, Stephanie M.; Dabiri, Darya
Prenatal oral health extends beyond the oral cavity, impacting the general well-being of the pregnant patient and her fetus. This case report follows a 19-year-old pregnant female presenting with acute liver failure secondary to acetaminophen overdose for management of dental pain following extensive dental procedures. Through the course of her illness, the patient suffered adverse outcomes including fetal demise, acute kidney injury, spontaneous bacterial peritonitis, and septic shock before eventual death from multiple organ failure. In managing the pregnant patient, healthcare providers, including physicians and dentists, must recognize and optimize the interconnected relationships shared by the health disciplines. An interdisciplinary approach of collaborative and coordinated care, the timing, sequence, and treatment for the pregnant patient can be improved and thereby maximize overall quality of health. Continued efforts toward integrating oral health into general healthcare education through interprofessional education and practice are necessary to enhance the quality of care that will benefit all patients. PMID:27847654
Anderson, Deverick J.; Podgorny, Kelly; Berríos-Torres, Sandra I.; Bratzler, Dale W.; Dellinger, E. Patchen; Greene, Linda; Nyquist, Ann-Christine; Saiman, Lisa; Yokoe, Deborah S.; Maragakis, Lisa L.; Kaye, Keith S.
PURPOSE Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their surgical site infection (SSI) prevention efforts. This document updates “Strategies to Prevent Surgical Site Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2 PMID:24799638
This paper provides the results of the survey-2000 measuring technology transfer and, specifically, Internet usage. The purpose of the survey was to measure the levels of Internet and Intranet existence and usage in acute care hospitals. The depth of the survey includes e-commerce for both business-to-business and customers. These results are compared with responses to the same questions in survey-1997. Changes in response are noted and discussed. This information will provide benchmarks for hospitals to plan their network technology position and to set goals. This is the third of three articles based upon the results of the survey-2000. Readers are referred to prior articles by the author, which discuss the survey design and provide a tutorial on technology transfer in acute care hospitals. (1) Thefirst article based upon the survey results discusses technology transfer, system design approaches, user involvement, and decision-making purposes. (2)
Lee, Sarah K Y; Quinonez, Rocio B; Chuang, Alice; Munz, Stephanie M; Dabiri, Darya
Prenatal oral health extends beyond the oral cavity, impacting the general well-being of the pregnant patient and her fetus. This case report follows a 19-year-old pregnant female presenting with acute liver failure secondary to acetaminophen overdose for management of dental pain following extensive dental procedures. Through the course of her illness, the patient suffered adverse outcomes including fetal demise, acute kidney injury, spontaneous bacterial peritonitis, and septic shock before eventual death from multiple organ failure. In managing the pregnant patient, healthcare providers, including physicians and dentists, must recognize and optimize the interconnected relationships shared by the health disciplines. An interdisciplinary approach of collaborative and coordinated care, the timing, sequence, and treatment for the pregnant patient can be improved and thereby maximize overall quality of health. Continued efforts toward integrating oral health into general healthcare education through interprofessional education and practice are necessary to enhance the quality of care that will benefit all patients.
Enhancing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidities after acute trauma
Zatzick, Douglas; Rivara, Frederick; Jurkovich, Gregory; Russo, Joan; Trusz, Sarah Geiss; Wang, Jin; Wagner, Amy; Stephens, Kari; Dunn, Chris; Uehara, Edwina; Petrie, Megan; Engel, Charles; Davydow, Dimitri; Katon, Wayne
Objective To develop and implement a stepped collaborative care intervention targeting PTSD and related co-morbidities to enhance the population impact of early trauma-focused interventions. Method We describe the design and implementation of the Trauma Survivors Outcomes & Support Study (TSOS II). An interdisciplinary treatment development team was comprised of trauma surgical, clinical psychiatric and mental health services “change agents” who spanned the boundaries between front-line trauma center clinical care and acute care policy. Mixed method clinical epidemiologic and clinical ethnographic studies informed the development of PTSD screening and intervention procedures. Results Two-hundred and seven acutely injured trauma survivors with high early PTSD symptom levels were randomized into the study. The stepped collaborative care model integrated care management (i.e., posttraumatic concern elicitation and amelioration, motivational interviewing, and behavioral activation) with cognitive behavioral therapy and pharmacotherapy targeting PTSD. The model was feasibly implemented by front-line acute care MSW and ARNP providers. Conclusions Stepped care protocols targeting PTSD may enhance the population impact of early interventions developed for survivors of individual and mass trauma by extending the reach of collaborative care interventions to acute care medical settings and other non-specialty posttraumatic contexts. PMID:21596205
Single-session groups are an effective method for providing mutual aid to patients and families experiencing crisis in acute care/emergency settings. This toolkit provides health care professionals with practical guidance in establishing, recruiting for, and facilitating single-session groups in hospital settings. A two-step literature search was conducted to identify all relevant articles. The literature was retrieved and reviewed for inclusion. The results of this review form the basis of the toolkit. A framework for establishing this type of group is explored. Challenges and strategies concerning recruitment are discussed. The practice skills relevant to facilitating time-limited groups are outlined.
Nieboer, Anna P.; Pijpers, Vanessa; Strating, Mathilde M. H.
Background: Community care is the support of people with intellectual disability in everyday life aimed at enhancing their integration into society. This article investigates influences of organizational characteristics on the implementation of community care in the Netherlands. In addition, we explored whether the attributes of community care as…
Adams, Mary; Robert, Glenn; Maben, Jill
This article examines the importance of some informal work practices among community nurses during a period of significant organizational change. Ethnographic fieldwork in two purposively selected adult community nursing services in England comprised 79 hours of observation of routine practice, 21 interviews with staff and 23 interviews with patients. We identified the informal work practice of 'catching up', informal work conversations between immediate colleagues, as an important but often invisible aspect of satisfying work relationships and of the relational care of patients. Drawing on anthropological literatures on 'communities of practice' the article examines two central issues concerning the practices of 'catching up': (1) how informal learning processes shape community nursing work; (2) how this informal learning is shaped both in relation to the ideals of community nursing work and the wider political and organizational contexts of community nursing practice. Our findings highlight the distinctive value of informal workplace 'catch ups' for nurses to manage the inherent challenges of good home care for patients and to develop a shared ethic of care and professional identity. Our findings also indicate the decline of 'catching up' between nurses along with diminishing time and opportunity for staff to care holistically for patients in present service climates.
Roscigno, Cecelia I.
Objective A child’s severe traumatic brain injury (TBI) creates a family crisis requiring extensive cultural, informational, psychological, and environmental support. Nurses need to understand parents’ expectations of caring in early acute care so they can tailor their attitudes, beliefs, and behaviors appropriately to accommodate the family’s needs. Methods In a previous qualitative study of 42 parents or caregivers from 37 families of children with moderate to severe TBI, parents of children with severe TBI (n = 25) described their appraisals of nurse caring and uncaring behaviors in early acute care. Swanson’s theory of caring was used to categorize parents’ descriptions in order to inform nursing early acute care practices and family-centered care. Results Caring nurse encounters included: (a) involving parents in the care of their child and reflecting on all socio-cultural factors shaping family resources and responses (knowing); (b) respecting that family grief can be co-mingled with resilience, and that parents are typically competent to be involved in decision-making (maintaining belief); (d) actively listening and engaging parents in order to fully understand family values and needs (being with); (e) decreasing parents’ workload to get information, emotional support, and providing a safe cultural, psychological, and physical environment for the family (doing for), and; (f) providing anticipatory guidance to navigate the early acute care system and giving assistance to learn and adjust to their situation (enabling). Conclusion Application of Swanson’s caring theory is prescriptive in helping individual nurses and early acute care systems to meet important family needs following children’s severe TBI. PMID:26871242
Hammond, Flora M.; Horn, Susan D.; Smout, Randall J.; Beaulieu, Cynthia L.; Barrett, Ryan S.; Ryser, David K.; Sommerfeld, Teri
Objective To investigate frequency, reasons, and factors associated with readmission to acute care (RTAC) during inpatient rehabilitation for traumatic brain injury (TBI). Design Prospective observational cohort. Setting Inpatient rehabilitation. Participants 2,130 consecutive admissions for TBI rehabilitation. Interventions Not applicable. Main Outcome Measure(s) RTAC incidence, RTAC causes, rehabilitation length of stay (RLOS), and rehabilitation discharge location. Results 183 participants (9%) experienced RTAC for a total 210 episodes. 161 patients experienced 1 RTAC episode, 17 had 2, and 5 had 3. Mean days from rehabilitation admission to first RTAC was 22 days (SD 22). Mean duration in acute care during RTAC was 7 days (SD 8). 84 participants (46%) had >1 RTAC episode for medical reasons, 102 (56%) had >1 RTAC for surgical reasons, and RTAC reason was unknown for 6 (3%) participants. Most common surgical RTAC reasons were: neurosurgical (65%), pulmonary (9%), infection (5%), and orthopedic (5%); most common medical reasons were infection (26%), neurologic (23%), and cardiac (12%). Older age, history of coronary artery disease, history of congestive heart failure, acute care diagnosis of depression, craniotomy or craniectomy during acute care, and presence of dysphagia at rehabilitation admission predicted patients with RTAC. RTAC was less likely for patients with higher admission Functional Independence Measure Motor scores and education less than high school diploma. RTAC occurrence during rehabilitation was significantly associated with longer RLOS and smaller likelihood of discharge home. Conclusion(s) Approximately 9% of patients with TBI experience RTAC during inpatient rehabilitation for various medical and surgical reasons. This information may help inform interventions aimed at reducing interruptions in rehabilitation due to RTAC. RTACs were associated with longer RLOS and discharge to an institutional setting. PMID:26212405
Atlas, Steven J; Deyo, Richard A
Acute low back pain is a common reason for patient calls or visits to a primary care clinician. Despite a large differential diagnosis, the precise etiology is rarely identified, although musculoligamentous processes are usually suspected. For most patients, back symptoms are nonspecific, meaning that there is no evidence for radicular symptoms or underlying systemic disease. Because episodes of acute, nonspecific low back pain are usually self-limited, many patients treat themselves without contacting their primary care clinician. When patients do call or schedule a visit, evaluation and management by primary care clinicians is appropriate. The history and physical examination usually provide clues to the rare but potentially serious causes of low back pain, as well as to identify patients at risk for prolonged recovery. Diagnostic testing, including plain x-rays, is often unnecessary during the initial evaluation. For patients with acute, nonspecific low back pain, the primary emphasis of treatment should be conservative care, time, reassurance, and education. Current recommendations focus on activity as tolerated (though not active exercise while pain is severe) and minimal if any bed rest. Referral for physical treatments is most appropriate for patients whose symptoms are not improving over 2 to 4 weeks. Specialty referral should be considered for patients with a progressive neurologic deficit, failure of conservative therapy, or an uncertain or serious diagnosis. The prognosis for most patients is good, although recurrence is common. Thus, educating patients about the natural history of acute low back pain and how to prevent future episodes can help ensure reasonable expectations. PMID:11251764
Mehling, Wolf E.; Gopisetty, Viranjini; Acree, Michael; Pressman, Alice; Carey, Tim; Goldberg, Harley; Hecht, Frederick; Avins, Andrew L
Study Design Prospective cohort study Objective to establish outcome measures for recovery and chronic pain for studies with patients that present with recent-onset acute low back pain in primary care Summary of Background Data Among back pain researchers, no consensus exists about outcome definitions or how to identify primary-care patients as not-recovered from an episode of low back pain. Cut points for outcome scales have mostly been arbitrarily chosen. Theoretical models for establishing minimal important change (MIC) values in studies of patients with low back pain have been proposed and need to be applied to real data. Methods In a sample of 521 patients which presented with acute low back pain (<4 weeks) in primary care clinics and were followed for 6 months, scores for pain and disability were compared with ratings on a global perceived effect scale. Using multiple potential “gold standards” as anchors (reference standards), the receiver operating characteristics method was used to determine optimal cut points for different ways of defining non-recovery from acute low back pain. Results MIC values and upper limits for pain and disability scores as well as minimal important percent changes are presented for five different definitions of recovery. A previously suggested 30% change from baseline scores does not accurately discriminate between recovered and not recovered patients in patients presenting with acute low back pain in primary care. Conclusions Outcome definitions that combine ratings from perceived recovery scales with pain and disability measures provide the highest accuracy in discriminating recovered from non-recovered patients. PMID:21311400
Ueng, Ruey-Shiuan; Hsu, Su-Hsuan; Shih, Chih-Yuan; Huang, Sheng-Jean
In Taiwan, the Department of Health (DOH) has implemented regulations and policies related to hospice and palliative care since 1995. Taiwan is the first country in Asia to have a Natural Death Act, promulgated in 2000. Although recognition of the need for palliative care in non-cancer terminally ill patients is increasing, at present, the needs of these patients are often not met. Moreover, while a majority of the population prefers to die at home, the percentage of patients who die in the home setting remains small. The palliative care system should be adjusted to improve the accessibility and continuity of care based on the needs of patients. Therefore, the Jin-Shan Branch of the National Taiwan University Hospital has run a pilot community palliative care service model since 2012. National Health Insurance reimbursement was introduced in 2014 for community-based palliative care services. Establishing a formal system of community-based palliative care should be encouraged in order to improve the quality of care at the end of life and to allow more patients to receive end-of-life care and die in their own communities. This system will require that skilled nurses provide discharge planning, symptoms control, end-of-life communications, social-resources integration, and social-support networks in order to achieve a high quality of end-of-life care.
Tsurukiri, Junya; Ohta, Shoichi; Mishima, Shiro; Homma, Hiroshi; Okumura, Eitaro; Akamine, Itsuro; Ueno, Masahito; Oda, Jun; Yukioka, Tetsuo
INTRODUCTION Comprehensive treatment of a patient in acute medicine and surgery requires the use of both surgical techniques and other treatment methods. Recently, acute vascular interventional radiology techniques (AVIRTs) have become increasingly popular, enabling adequately trained in-house experts to improve the quality of on-site care. METHODS After obtaining approval from our institutional ethics committee, we conducted a retrospective study of AVIRT procedures performed by acute care specialists trained in acute medicine and surgery over a 1-year period, including those conducted out of hours. Trained acute care specialists were required to be certified by the Japanese Association of Acute Medicine and to have completed at least 1 year of training as a member of the endovascular team in the radiology department of another university hospital. The study was designed to ensure that at least one of the physicians was available to perform AVIRT within 1 h of a request at any time. Femoral sheath insertion was usually performed by the resident physicians under the guidance of trained acute care specialists. RESULTS The study sample comprised 77 endovascular procedures for therapeutic AVIRT (trauma, n = 29, and nontrauma, n = 48) among 62 patients (mean age, 64 years; range, 9–88 years), of which 55% were male. Of the procedures, 47% were performed out of hours (trauma, 52%; and nontrauma, 44%). Three patients underwent resuscitative endovascular balloon occlusion of the aorta in the emergency room. No major device-related complications were encountered, and the overall mortality rate within 60 days was 8%. The recorded causes of death included exsanguination (n = 2), pneumonia (n = 2), sepsis (n = 1), and brain death (n = 1). CONCLUSION When performed by trained acute care specialists, AVIRT seems to be advantageous for acute on-site care and provides good technical success. Therefore, a standard training program should be established for acute care specialists
Heslop, Brett; Wynaden, Dianne; Tohotoa, Jenny; Heslop, Karen
Australian mental health policy is focused on providing mental health care in the community setting and community mental health teams provide services to clients in a shared model with primary care. The historical literature reports that community mental health nurses' experience high levels of stress and are often allocated the most complex and challenging clients managed by the team. Yet information on their specific roles remains limited. This paper reports on research conducted at one Australian public mental health service to identify the components of the community mental health nursing role and to quantify the time nurses spent in each component during the study period. Six focus groups were conducted with community mental health nurses to identify their perceived role within the team. Data analysis identified 18 components of which 10 were related to direct clinical contact with clients and eight covered administrative and care coordination activities. A data collection tool based on the findings of the focus groups was designed and nurses recorded workload data on the tool in 15-min intervals over a 4-week period. Seventeen nurses collected 1528 hours of data. Internal coordination of care was identified as the top workload item followed by clinical documentation and national data collection responsibilities supporting the complexity of the community mental health nursing role. The high rating attached to the internal coordination of care role demonstrates an important contribution that community mental health nurses make to the functioning of the team and the delivery of quality mental health care.
Pelzl, Steffen; Szecsenyi, Joachim; Laux, Gunter
Objectives Antibiotic overprescribing in primary care has major impacts on the development of antibiotic resistance. The objective of this study is to provide insight in antibiotics prescriptions for patients suffering from cough, acute bronchitis or community acquired pneumonia in primary care. Methods Data from 2009 to 2013 of electronic health records of 12,880 patients in Germany were obtained from a research database. The prescription of antibiotics for acute lower respiratory tract infections was compared to the national S3 guideline cough from the German Society of General Practitioners and Family Medicine. Results Antibiotics were prescribed in 41% of consultations. General practitioners’ decision of whether or not to prescribe an antibiotic was congruent with the guideline in 52% of consultations and the antibiotic choice congruence was 51% of antibiotic prescriptions. Hence, a congruent prescribing decision and a prescription of recommendation was found in only 25% of antibiotic prescriptions. Split by diagnosis we found that around three quarters of antibiotics prescribed for cough (73%) and acute bronchitis (78%) were not congruent to the guidelines. In contrast to that around one quarter of antibiotics prescribed for community acquired pneumonia (28%) were not congruent to the guidelines. Conclusions Our results show that there is a big gap between guideline recommendation and actual prescribing, in the decision to prescribe and the choice of antibiotic agent. This gap could be closed by periodic quality circles on antibiotic prescribing for GPs. PMID:28350820
Venkat, Arvind; Migyanka, Joann M.; Cramer, Ryan; McGonigle, John J.
We present an instrument to allow individuals with autism spectrum disorder, their families and/or their caregivers to prepare emergency department staff for the care needs of this patient population ahead of acute presentation.
Ewing, Gail; Farquhar, Morag; Booth, Sara
There has been a steady expansion of hospital-based palliative care in the United Kingdom but limited published research on health professionals' views of hospital multidisciplinary specialist palliative care services (SPCS). The aim of the study was to describe referrer (SPCS user) and provider (SPCS staff) perspectives on delivery of specialist palliative care in hospital. Interviews were conducted with referrers, including five junior doctors, 13 consultants, and six clinical nurse specialists, to investigate the reasons for referral, beneficial aspects, and barriers to use. Focus groups were conducted with providers, six medical and five nursing, to identify their perspective on delivering the specialist service in hospital. Discussions were tape recorded and transcribed verbatim. Data were analyzed thematically using a framework analysis approach. The study found large areas of agreement between referrers and providers on what hospital palliative care teams should be providing for patients, that is, expertise in managing difficult symptoms and complex psychosocial problems, and this was being achieved locally. Access to the specialist team was also important: visibility on the wards, informal routes of access to advice and a timely response by specialists. However, discordance in views of providing palliative care was also identified; in particular, whether specialists should be providing generalist palliative care (such as basic psychological support) neglected by ward teams and implementation of specialist advice by referrers. Such perspectives on the interface of generalist and specialist provision provide insights into improving care for palliative patients in the acute hospital setting.
OBJECTIVE: To assess the role of management practices for acute respiratory infections (ARIs) in improving the competency of community health volunteers in diagnosing and treating acute respiratory infections among children. METHODS: Data were collected by a group of research physicians who observed the performance of a sample of 120 health volunteers in 10 sub-districts in Bangladesh in which Bangladesh Rural Advancement Committee (BRAC) had run a community-based ARI control programme since mid-1992. Standardized tests were conducted until the 95% interphysician reliability on the observation of clinical examination was achieved. FINDINGS:The sensitivity, specificity, and overall agreement rates in diagnosing and treating ARIs were significantly higher among the health volunteers who had basic training and were supervised routinely than among those who had not. CONCLUSION: Diagnosis and treatment of ARIs at the household level in developing countries are possible if intensive basic training and the close supervision of service providers are ensured. PMID:12764514
Gardinassi, Luiz Gustavo Araujo; Simas, Paulo Vitor Marques; Gomes, Deriane Elias; do Bonfim, Caroline Measso; Nogueira, Felipe Cavassan; Garcia, Gustavo Rocha; Carareto, Claudia Márcia Aparecida; Rahal, Paula; de Souza, Fátima Pereira
HRSV is one of the most important pathogens causing acute respiratory tract diseases as bronchiolitis and pneumonia among infants. HRSV was isolated from two distinct communities, a public day care center and a public hospital in São José do Rio Preto – SP, Brazil. We obtained partial sequences from G gene that were used on phylogenetic and selection pressure analysis. HRSV accounted for 29% of respiratory infections in hospitalized children and 7.7% in day care center children. On phylogenetic analysis of 60 HRSV strains, 48 (80%) clustered within or adjacent to the GA1 genotype; GA5, NA1, NA2, BA-IV and SAB1 were also observed. SJRP GA1 strains presented variations among deduced amino acids composition and lost the potential O-glycosilation site at amino acid position 295, nevertheless this resulted in an insertion of two potential O-glycosilation sites at positions 296 and 297. Furthermore, a potential O-glycosilation site insertion, at position 293, was only observed for hospital strains. Using SLAC and MEME methods, only amino acid 274 was identified to be under positive selection. This is the first report on HRSV circulation and genotypes classification derived from a day care center community in Brazil. PMID:23202489
Kilbourne, Amy M; Schulberg, Herbert C; Post, Edward P; Rollman, Bruce L; Belnap, Bea Herbeck; Pincus, Harold Alan
Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care. PMID:15595945
The Environmental Health Coalition (EHC) is a recipient of a CARE Level II cooperative agreement grant. The Clean Ports, Healthy Communities in San Diego targets the Barrio Logan and Old Town National City areas located along San Diego Bay.
The burden of acute respiratory failure (ARF) has become one of the greatest epidemiological challenges for the modern health systems. Consistently, the imbalance between the increasing prevalence of acutely de-compensated respiratory diseases and the shortage of high-daily cost ICU beds has stimulated new health cost-effective solutions. Respiratory High-Dependency Care Units (RHDCU) provide a specialised environment for patients who require an "intermediate" level of care between the ICU and the ward, where non-invasive monitoring and assisted ventilation techniques are preferentially applied. Since they are dedicated to the management of "mono-organ" decompensations, treatment of ARF patients in RHDCU avoids the dangerous "under-assistance" in the ward and unnecessary "over-assistance" in ICU. RHDCUs provide a specialised quality of care for ARF with health resources optimisation and their spread throughout health systems has been driven by their high-level of expertise in non-invasive ventilation (NIV), weaning from invasive ventilation, tracheostomy care, and discharging planning for ventilator-dependent patients.
Atwal, Anita; Caldwell, Kay
Multidisciplinary teamwork is viewed as one of the key processes through which care is managed in the British National Health Service, and yet is often viewed as one of the most problematic. Working in a multidisciplinary team requires many skills, which involves understanding not only one's own role but also the role of other professionals. The aim of this study was to explore nurses' perceptions of multidisciplinary teamwork in acute health-care. Nineteen nurses were interviewed using the critical incident approach to obtain their perceptions of multidisciplinary teamwork. Direct observation was conducted to record interactions between nurses and health-care professionals in multidisciplinary teams. In total, 14 meetings were attended in elder care and orthopaedics and seven in acute medicine. The findings of this study identified three barriers that hindered teamwork: (i) differing perceptions of teamwork; (ii) different levels of skills acquisitions to function as a team member; and (iii) the dominance of medical power that influenced interaction in teams. Thus, education establishments and nursing managers need to ensure that the acquisition of team-playing skills is an integral part of continued professional development.
Sikka, Neal; Carlin, Katrina N; Pines, Jesse; Pirri, Michael; Strauss, Ryan; Rahimi, Faisil
There are a significant number of emergency department (ED) visits for lacerations each year. When individuals experience skin, soft tissue, or laceration symptoms, the decision to go to the ED is not always easy on the basis of the level of severity. For such cases, it may be feasible to use a mobile phone camera to submit images of their wound to a remote medical provider who can review and help guide their care choice decisions. The authors aimed to assess patient attitudes toward the use of mobile phone technology for laceration management. Patients presenting to an urban ED for initial care and follow-up visits for lacerations were prospectively enrolled. A total of 194 patients were enrolled over 8 months. Enrolled patients answered a series of questions about their injury and a survey on attitudes about the acceptability of making management decisions using mobile phone images only. A majority of those surveyed agreed that it was acceptable to send a mobile phone picture to a physician for a recommendation and diagnosis. Patients also reported few concerns regarding privacy and security and believe that this technology could be cost effective and convenient. In this study, the majority of patients had favorable opinions of using mobile phones for laceration care. Mobile phone camera images (a) may provide a useful modality for assessment of some acute wound care needs and (b) may decrease ED visits for a high-volume complaint such as acute wounds.
Vogel, Wendy H
Oncology care is becoming increasingly complex. The interprofessional team concept of care is necessary to meet projected oncology professional shortages, as well as to provide superior oncology care. The oncology advanced practitioner (AP) is a licensed health care professional who has completed advanced training in nursing or pharmacy or has completed training as a physician assistant. Oncology APs increase practice productivity and efficiency. Proven to be cost effective, APs may perform varied roles in an oncology practice. Integrating an AP into an oncology practice requires forethought given to the type of collaborative model desired, role expectations, scheduling, training, and mentoring.
Wang, Emily A; Hong, Clemens S; Samuels, Liz; Shavit, Shira; Sanders, Ronald; Kushel, Margot
Most California prisoners experience discontinuity of health care upon return to the community. In January 2006, physicians working with community organizations and representatives of the San Francisco Department of Public Health's safety-net health system opened the Transitions Clinic (TC) to provide transitional and primary care as well as case management for prisoners returning to San Francisco. This article provides a complete description of TC, including an illustrative case, and reports information about the recently released individuals who participated in the program. From January 2006 to October 2007, TC saw 185 patients with chronic medical conditions. TC patients are socially and economically disenfranchised; 86% belong to ethnic minority groups and 38% are homeless. Eighty-nine percent of patients did not have a primary care provider prior to their incarceration. Preliminary findings demonstrate that a community-based model of care tailored to this disenfranchised population successfully engages them in seeking health care.
Hurley, R E; Brewer, K P
The continuing care retirement community industry is a growing source of residential and health care services for the elderly population. It is also a relatively new and expanding career path for both health care and hospitality managers. Using in-depth interviews with executives in a sample of 26 communities, this study provides one of the most complete portraits to date of the nature of managing these communities. The findings indicate that these organizations are complex and multifaceted, demanding versatile skills and abilities. Most critical are those skills that enable a manager to interact effectively with residents and staff to build and maintain a hospitable, accommodating community environment. As competition in the industry intensifies, community viability may become synonymous with customer satisfaction. Management training and development will need to be highly attentive to the distinctive features of these intriguing organizations.
RAZZOUK, DENISE; GREGÓRIO, GUILHERME; ANTUNES, RENATO; MARI, JAIR DE JESUS
This paper summarizes the findings for the Latin American and Caribbean countries of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. It presents an overview of the provision of mental health services in the region; describes key experiences in Argentina, Belize, Brazil, Chile, Cuba, Jamaica and Mexico; and discusses the lessons learned in developing community mental health care. PMID:23024680
Dorsch, M; Lawrance, R; Sapsford, R; Oldham, J; Greenwood, D; Jackson, B; Morrell, C; Ball, S; Robinson, M; Hall, A
OBJECTIVE—To develop a simple risk model as a basis for evaluating care of patients admitted with acute myocardial infarction. METHODS—From coronary care registers, biochemistry records and hospital management systems, 2153 consecutive patients with confirmed acute myocardial infarction were identified. With 30 day all cause mortality as the end point, a multivariable logistic regression model of risk was constructed and validated in independent patient cohorts. The areas under receiver operating characteristic curves were calculated as an assessment of sensitivity and specificity. The model was reapplied to a number of commonly studied subgroups for further assessment of robustness. RESULTS—A three variable model was developed based on age, heart rate, and systolic blood pressure on admission. This produced an individual probability of death by 30 days (P30) where P30 = 1/(1 + exp(−L30)) and L30 = −5.624 + (0.085 × age) + (0.014 × heart rate) − (0.022 × systolic blood pressure). The areas under the receiver operating characteristic curves for the reference and test cohorts were 0.79 (95% CI 0.76 to 0.82) and 0.76 (95% CI 0.72 to 0.79), respectively. To aid application of the model to routine clinical audit, a normogram relating observed mortality and sample size to the likelihood of a significant deviation from the expected 30 day mortality rate was constructed. CONCLUSIONS—This risk model is simple, reproducible, and permits quality of care of acute myocardial infarction patients to be reliably evaluated both within and between centres. Keywords: acute myocardial infarction; risk model PMID:11454829
Saposnik, Gustavo; Goyal, Mayank; Majoie, Charles; Dippel, Diederik; Roos, Yvo; Demchuk, Andrew; Menon, Bijoy; Mitchell, Peter; Campbell, Bruce; Dávalos, Antoni; Jovin, Tudor; Hill, Michael D
Background Acute stroke care represents a challenge for decision makers. Recent randomized trials showed the benefits of endovascular therapy. Our goal was to provide a visual aid tool to guide clinicians in the decision process of endovascular intervention in patients with acute ischemic stroke. Methods We created visual plots (Cates' plots; www.nntonline.net ) representing benefits of standard of care vs. endovascular thrombectomy from the pooled analysis of five RCTs using stent retrievers. These plots represent the following clinically relevant outcomes (1) functionally independent state (modified Rankin scale (mRS) 0 to 2 at 90 days) (2) excellent recovery (mRS 0-1) at 90 days, (3) NIHSS 0-2 (4) early neurological recovery, and (5) revascularization at 24 h. Subgroups visually represented include time to treatment and baseline stroke severity strata. Results Overall, 1287 patients (634 assigned to endovascular thrombectomy, 653 assigned to control were included to create the visual plots. Cates' visual plots revealed that for every 100 patients with acute ischemic stroke and large vessel occlusion, 27 would achieve independence at 90 days (mRS 0-2) in the control group compared to 49 (95% CI 43-56) in the intervention group. Similarly, 21 patients would achieve early neurological recovery at 24 h compared to 54 (95% CI 45-63) out of 100 for the intervention group. Conclusion Cates' plots may assist clinicians and patients to visualize and compare potential outcomes after an acute ischemic stroke. Our results suggest that for every 100 treated individuals with an acute ischemic stroke and a large vessel occlusion, endovascular thrombectomy would provide 22 additional patients reaching independency at three months and 33 more patients achieving ENR compared to controls.
Cioffi, R N Jane
Communication with culturally and linguistically diverse (CLD) patients has been shown to be difficult. This study describes nurses' experiences of communicating with CLD patients in an acute care setting. A purposive sample of registered nurses and certified midwives (n=23) were interviewed. Main findings were: interpreters, bilingual health workers and combinations of different strategies were used to communicate with CLD patients; some nurses showed empathy, respect and a willingness to make an effort in the communication process with others showing an ethnocentric orientation. Main recommendations were: prioritising access to appropriate linguistic services, providing nurses with support from health care workers, e.g., bilingual health care workers who are able to provide more in-depth information, increasing nurses' understanding of legal issues within patient encounters, supporting nurses to translate their awareness of cultural diversity into acceptance of, appreciation for and commitment to CLD patients and their families.
Cofano, Gregory P.; Anderson, Benjamin C.; Stumpff, Eric R.
Objective The purpose of this case report is to describe chiropractic care of an adolescent with acute low back pain and incidental finding of spina bifida occulta managed with high-velocity low-amplitude manipulation. Clinical Features A 10-year-old boy was referred for chiropractic care by his pediatrician for the management of low back pain after a fall 3 days prior. Examination and medical records revealed the patient also had spina bifida occulta at the level of L5. Intervention and Outcome High-velocity low-amplitude treatment for lower back pain showed resolution of patient's pain after 6 visits. No adverse effects were reported. Conclusion An adolescent patient with lower back pain and incidental finding of spina bifida occulta improved with a course of care that included with high-velocity low-amplitude manipulation therapy. PMID:25435841
Background The integration of mental health and social services for people diagnosed with severe mental illness (SMI) has been a key aspect of attempts to reform mental health services in the UK and aims to minimise user and carer distress and confusion arising from service discontinuities. Community mental health teams (CMHTs) are a key component of UK policy for integrated service delivery, but implementing this policy has raised considerable organisational challenges. The aim of this study was to identify and explore facilitators and barriers perceived to influence continuity of care by health and social care professionals working in and closely associated with CMHTs. Methods This study employed a survey design utilising in-depth, semi-structured interviews with a proportionate, random sample of 113 health and social care professionals and representatives of voluntary organisations. Participants worked in two NHS Mental Health Trusts in greater London within eight adult CMHTs and their associated acute in-patient wards, six local general practices, and two voluntary organisations. Results Team leadership, decision making, and experiences of teamwork support were facilitators for cross boundary and team continuity; face-to-face communication between teams, managers, general practitioners, and the voluntary sector were facilitators for information continuity. Relational, personal, and longitudinal continuity were facilitated in some local areas by workforce stability. Barriers for cross boundary and team continuity were specific leadership styles and models of decision making, blurred professional role boundaries, generic working, and lack of training for role development. Barriers for relational, personal, and longitudinal continuity were created by inadequate staffing levels, high caseloads, and administrative duties that could limit time spent with users. Incompatibility of information technology systems hindered information continuity. Flexible continuity was
Tariq, Amina; Douglas, Heather E; Smith, Cheryl; Georgiou, Andrew; Osmond, Tracey; Armour, Pauline; Westbrook, Johanna I
Little is known about the types of incidents that occur to aged care clients in the community. This limits the development of effective strategies to improve client safety. The objective of the study was to present a profile of incidents reported in Australian community aged care settings. All incident reports made by community care workers employed by one of the largest community aged care provider organizations in Australia during the period November 1, 2012, to August 8, 2013, were analyzed. A total of 356 reports were analyzed, corresponding to a 7.5% incidence rate per client year. Falls and medication incidents were the most prevalent incident types. Clients receiving high-level care and those who attended day therapy centers had the highest rate of incidents with 14% to 20% of these clients having a reported incident. The incident profile indicates that clients on higher levels of care had higher incident rates. Incident data represent an opportunity to improve client safety in community aged care.
The article develops a hypothesis for improving primary care services through health care solutions that can exceed the models in use (essentially hierarchical and based on tasks) in favor of new relational, multi-sectoral and network approaches that could privilege the integration of social and health services at the regional and district level (Community care). A qualitative methodological approach which analyzes the role of social networks in Community care, some national and international experiences of primary care models and the evaluation of the different role given to primary care both in the hierarchical-pyramidal approach and in the horizontal one (network approach). Some Italian regions are experimenting effective organizational models of care such as Primary Care Teams, Primary Care Units, Regional teams, Departments of Primary Care, Houses of Health ... At international level, it should be mentioned the Chronic Care Model (CCM), recently identified by WHO as a reference model, and adopted by the Tuscany Region (Italy). People-centered health care projects need shared interventions by competent and functional multiprofessional teams: the best outcome for the patient depends on the good interaction between individuals. It's necessary that relationships between members of the group are based on interdependence, integration and consistency to avoid risks of group illusion.
Haas, Curtis E; Eckel, Stephen; Arif, Sally; Beringer, Paul M; Blake, Elizabeth W; Lardieri, Allison B; Lobo, Bob L; Mercer, Jessica M; Moye, Pamela; Orlando, Patricia L; Wargo, Kurt
This commentary from the 2010 Task Force on Acute Care Practice Model of the American College of Clinical Pharmacy was developed to compare and contrast the "unit-based" and "service-based" orientation of the clinical pharmacist within an acute care pharmacy practice model and to offer an informed opinion concerning which should be preferred. The clinical pharmacy practice model must facilitate patient-centered care and therefore must position the pharmacist to be an active member of the interprofessional team focused on providing high-quality pharmaceutical care to the patient. Although both models may have advantages and disadvantages, the most important distinction pertains to the patient care role of the clinical pharmacist. The unit-based pharmacist is often in a position of reacting to an established order or decision and frequently is focused on task-oriented clinical services. By definition, the service-based clinical pharmacist functions as a member of the interprofessional team. As a team member, the pharmacist proactively contributes to the decision-making process and the development of patient-centered care plans. The service-based orientation of the pharmacist is consistent with both the practice vision embraced by ACCP and its definition of clinical pharmacy. The task force strongly recommends that institutions pursue a service-based pharmacy practice model to optimally deploy their clinical pharmacists. Those who elect to adopt this recommendation will face challenges in overcoming several resource, technologic, regulatory, and accreditation barriers. However, such challenges must be confronted if clinical pharmacists are to contribute fully to achieving optimal patient outcomes.
Honda, Miwako; Ito, Mio; Ishikawa, Shogo; Takebayashi, Yoichi; Tierney, Lawrence
Management of Behavioral and Psychological Symptoms of Dementia (BPSD) is a key challenge in geriatric dementia care. A multimodal comprehensive care methodology, Humanitude, with eye contact, verbal communication, and touch as its elements, was provided to three geriatric dementia patients for whom conventional nursing care failed in an acute care hospital. Each episode was evaluated by video analysis. All patients had advanced dementia with BPSD. Failure of care was identified by patient's shouting, screaming, or abrupt movements of limbs. In this case series, conventional care failed for all three patients. Each element of care communication was much shorter than in Humanitude care, which was accepted by the patients. The average of the elements performed during the care was eye contact 0.6%, verbal communication 15.7%, and touch 0.1% in conventional care and 12.5%, 54.8%, and 44.5% in Humanitude care, respectively. The duration of aggressive behavior of each patient during care was 25.0%, 25.4%, and 66.3% in conventional care and 0%, 0%, and 0.3% in Humanitude, respectively. In our case series, conventional care was provided by less eye contact, verbal communication, and touch. The multimodal comprehensive care approach, Humanitude, decreased BPSD and showed success by patients' acceptance of care. PMID:27069478
Nate, Kent C.; Griffin, Kristen H.; Christianson, Jon B.; Dusek, Jeffery A.
Background. We describe the process and challenges of delivering integrative medicine (IM) at a large, acute care hospital, from the perspectives of IM practitioners. To date, minimal literature that addresses the delivery of IM care in an inpatient setting from this perspective exists. Methods. Fifteen IM practitioners were interviewed about their experience delivering IM services at Abbott Northwestern Hospital (ANW), a 630-bed tertiary care hospital. Themes were drawn from codes developed through analysis of the data. Results. Analysis of interview transcripts highlighted challenges of ensuring efficient use of IM practitioner resources across a large hospital, the IM practitioner role in affecting patient experiences, and the ways practitioners navigated differences in IM and conventional medicine cultures in an inpatient setting. Conclusions. IM practitioners favorably viewed their role in patient care, but this work existed within the context of challenges related to balancing supply and demand for services and to integrating an IM program into the established culture of a large hospital. Hospitals planning IM programs should carefully assess the supply and demand dynamics of offering IM in a hospital, advocate for the unique IM practitioner role in patient care, and actively support integration of conventional and complementary approaches. PMID:26693242
Slotkin, Jonathan R; Casale, Alfred S; Steele, Glenn D; Toms, Steven A
Comparative effectiveness research (CER) represents an evolution in clinical decision-making research that allows for the study of heterogeneous groups of patients with complex diseases processes. It has foundations in decision science, reliability science, and health care policy research. Health care finance will increasingly rely on CER for guidance in the coming years. There is increasing awareness of the importance of decreasing unwarranted variation in health care delivery. In the past 7 years, Geisinger Health System has performed broad reengineering of its acute episodic and chronic care delivery models utilizing macrosystem-level application of CER principles. These provider-driven process initiatives have resulted in significant improvement across all segments of care delivery, improved patient outcomes, and notable cost containment. These programs have led to the creation of novel pricing models, and when "hardwired" throughout a care delivery system, they can lead to correct medical decision making by 100% of providers in all patient encounters. Neurosurgery as a specialty faces unique challenges and opportunities with respect to broad adoption and application of CER techniques.
Longo, Bernadette M; Yang, Wei
Eruption at Kilauea Volcano, Hawai'i, has continued since 1983, emitting sulfurous air pollution into nearby communities. The purpose of this cohort study was to estimate the relative risk (RR) of acute bronchitis over a period from January 2004 to December 2006 in communities exposed to the volcanic air pollution. A community-based case review was conducted using medical records from clinics and emergency rooms in exposed and unexposed study areas. Initial visits by local residents for diagnosed acute bronchitis were clinically reviewed. The cumulative incidence rate for the 3-yr period was 117.74 per 1000 in unexposed communities and 184.63 per 1000 in exposed communities. RR estimates were standardized for age and gender, revealing an elevated cumulative incidence ratio (CIR) of 1.57 (95% CI = 1.36-1.81) for acute bronchitis in the exposed communities. Highest risk [CIR: 6.56 (95% CI = 3.16-13.6)] was observed in children aged 0-14 yr who resided in the exposed communities. Exposed middle-aged females aged 45-64 yr had double the risk for acute bronchitis than their unexposed counterparts. These findings suggest that communities continuously exposed to sulfurous volcanic air pollution may have a higher risk of acute bronchitis across the life span.
Parent, Vivien; Ludwig-Béal, Stéphanie; Sordet-Guépet, Hélène; Popitéan, Laura; Camus, Agnès; Da Silva, Sofia; Lubrano, Anne; Laissus, Frederick; Vaillard, Laurence; Manckoundia, Patrick
In France, the population of very old frail patients, who require appropriate high-quality care, is increasing. Given the current economic climate, the mean duration of hospitalization (MDH) needs to be optimized. This prospective study analyzed the causes of prolonged hospitalization in an acute geriatric care unit. Over 6 months, all patients admitted to the target acute geriatric care unit were included and distributed into two groups according to a threshold stay of 14 days: long MDH group (LMDHG) and short MDH group (SMDHG). These two groups were compared. 757 patients were included. The LMDHG comprised 442 with a mean age of 86.7 years, of whom 67.65% were women and the SMDHG comprised 315 with a mean age of 86.6 years, of whom 63.2% were women. The two groups were statistically similar for age, sex, living conditions at home (alone or not, help), medical history and number of drugs. Patients in the LMDHG were more dependent (p=0.005), and were more likely to be hospitalized for social reasons (p=0.024) and to have come from their homes (p=0.011) than those in the SMDHG. The reasons for the prolonged stay, more frequent in the LMDHG than the SMDHG (p<0.05), were principally: waiting for imaging examinations, medical complications, and waiting for discharge solutions, assistance from social workers and/or specialist consultations. In order to reduce the MDH in acute geriatric care unit, it is necessary to consider the particularities of the patients who are admitted, their medico-socio-psychological management, access to technical facilities/consultations and post-discharge accommodation.
Chuang, Tzu-Yi; Lin, Chou-Jui; Lee, Shih-Wei; Chuang, Chun-Pin; Jong, Yuh-Shiun; Chen, Wen-Jone; Hsueh, Po-Ren
We describe a previously healthy 52-year-old man with rapidly fatal community-acquired pneumonia caused by Klebsiella pneumoniae. The patient developed acute renal dysfunction, accelerated idioventricular rhythm (acute myocarditis), lactic acidosis and septic shock. He died within 15 hours after admission despite intravenous levofloxacin (750 mg daily) and aggressive medical treatment.
Sciegaj, Mark; Capitman, John A.; Kyriacou, Corrine Kay
Purpose. Even though consumer-directed care models are being advocated for use among elder populations, there are few data on the extent of elder interest in participating in the management of community long-term-care services, who they want involved in making these decisions, or their perceptions regarding the relative importance of different…
Mercier, Samuel; Desauty, Fabrice; Lamache, Christophe; Lefort, Hugues
In community-based care, the teams must adapt to the environment and perform a number of technical procedures. Foldable medical equipment has been developed and patented, enabling the care provision to approach hospital standards and improving working conditions in this context.
Cañada Dorado, A; Drake Canela, M; Olivera Cañadas, G; Mateos Rodilla, J; Mediavilla Herrera, I; Miquel Gómez, A
This paper describes the implementation of a patient safety strategy in primary care within the new organizational and functional structure that was created in October 2010 to cover the single primary health care area of the Community of Madrid. The results obtained in Patient Safety after the implementation of this new model over the first two years of its development are also presented.
Biswas, Radha Roy
The nation's 1,200 community colleges are well positioned to strengthen the workforce of one of America's most critical sectors--health care. They can provide training and credentialing for incumbent workers in health care and to prepare new workers to succeed in and meet the workforce demands for this sector--expanding individual opportunity and…
Gilbert, Jaesook Lee; Harte, Helene Arbouet
This paper describes efforts to increase the quality in early care and education through targeted coaching. A collaborative including several community agencies and a university developed a framework of support for early care and education providers, using coaching as its foundational basis, called Coaching to Quality (CTQ). This paper provides a…
What Works Clearinghouse, 2006
"Caring School Community[TM]" ("CSC") is a modified version of a program formerly known as the "Child Development Project." The program aims to promote core values, prosocial behavior, and a schoolwide feeling of community. The program consists of four elements originally developed for the "Child Development…
Magarian, Edward O.; And Others
An interdisciplinary project provided ambulatory care clinical training for pharmacy and nursing students in community-based pharmacies, promoting early detection and medical follow-up of common health problems within the community. Students learned new clinical skills in patient health assessment, new diagnostic technologies, patient education…
Slocum, Chloe; Gerrard, Paul; Black-Schaffer, Randie; Goldstein, Richard; Singhal, Aneesh; DiVita, Margaret A.; Ryan, Colleen M.; Mix, Jacqueline; Purohit, Maulik; Niewczyk, Paulette; Kazis, Lewis; Zafonte, Ross; Schneider, Jeffrey C.
Objective Acute care readmission risk is an increasingly recognized problem that has garnered significant attention, yet the reasons for acute care readmission in the inpatient rehabilitation population are complex and likely multifactorial. Information on both medical comorbidities and functional status is routinely collected for stroke patients participating in inpatient rehabilitation. We sought to determine whether functional status is a more robust predictor of acute care readmissions in the inpatient rehabilitation stroke population compared with medical comorbidities using a large, administrative data set. Methods A retrospective analysis of data from the Uniform Data System for Medical Rehabilitation from the years 2002 to 2011 was performed examining stroke patients admitted to inpatient rehabilitation facilities. A Basic Model for predicting acute care readmission risk based on age and functional status was compared with models incorporating functional status and medical comorbidities (Basic-Plus) or models including age and medical comorbidities alone (Age-Comorbidity). C-statistics were compared to evaluate model performance. Findings There were a total of 803,124 patients: 88,187 (11%) patients were transferred back to an acute hospital: 22,247 (2.8%) within 3 days, 43,481 (5.4%) within 7 days, and 85,431 (10.6%) within 30 days. The C-statistics for the Basic Model were 0.701, 0.672, and 0.682 at days 3, 7, and 30 respectively. As compared to the Basic Model, the best-performing Basic-Plus model was the Basic+Elixhauser model with C-statistics differences of +0.011, +0.011, and + 0.012, and the best-performing Age-Comorbidity model was the Age+Elixhauser model with C-statistic differences of -0.124, -0.098, and -0.098 at days 3, 7, and 30 respectively. Conclusions Readmission models for the inpatient rehabilitation stroke population based on functional status and age showed better predictive ability than models based on medical comorbidities. PMID
Socié, Gérard; Vigouroux, Stéphane; Yakoub-Agha, Ibrahim; Bay, Jacques-Olivier; Fürst, Sabine; Bilger, Karin; Suarez, Felipe; Michallet, Mauricette; Bron, Dominique; Gard, Philippe; Medeghri, Zakaria; Lehert, Philippe; Lai, Chinglin; Corn, Tim; Vernant, Jean-Paul
Treatment of steroid-resistant acute graft-versus-host disease (GVHD) remains an unmet clinical need. Inolimomab, a monoclonal antibody to CD25, has shown encouraging results in phase 2 trials. This phase 3 randomized, open-label, multicenter trial compared inolimomab vs usual care in adult patients with steroid-refractory acute GVHD. Patients were randomly selected to receive treatment with inolimomab or usual care (the control group was treated with antithymocyte globulin [ATG]). The primary objective was to evaluate overall survival at 1 year without changing baseline allocated therapy. A total of 100 patients were randomly placed: 49 patients in the inolimomab arm and 51 patients in the ATG arm. The primary criteria were reached by 14 patients (28.5%) in the inolimomab and 11 patients (21.5%) in the ATG arms, with a hazard ratio of 0.874 (P = .28). With a minimum follow-up of 1 year, 26 (53%) and 31 (60%) patients died in the inolimomab and ATG arms, respectively. Adverse events were similar in the 2 arms, with fewer viral infections in the inolimomab arm compared with the ATG arm. The primary end point of this randomized phase 3 trial was not achieved. The lack of a statistically significant effect confirms the need for development of more effective treatments for acute GVHD. This trial is registered to https://www.clinicaltrialsregister.eu/ctr-search/search as EUDRACT 2007-005009-24.
Schiele, Francois; Puymirat, Etienne; Bonello, Laurent; Meneveau, Nicolas; Collet, Jean-Philippe; Motreff, Pascal; Ravan, Ramin; Leclercq, Florence; Ennezat, Pierre-Vladimir; Ferrières, Jean; Simon, Tabassome; Danchin, Nicolas
Objective In acute coronary syndromes, switching between thienopyridines is frequent. The aims of the study were to assess the association between switching practices and quality of care. Methods Registry study performed in 213 French public university, public non-academic and private hospitals. All consecutive patients admitted for acute myocardial infarction (MI; <48 hours) between 1/10/2010 and 30/11/2010 were eligible. Clinical and biological data were recorded up to 12 months follow-up. Results Among 4101 patients receiving thienopyridines, a switch was performed in 868 (21.2%): 678 (16.5%) from clopidogrel to prasugrel and 190 (4.6%) from prasugrel to clopidogrel. Predictors of switch were ST segment elevation MI presentation, admission to a cardiology unit, previous percutaneous coronary intervention, younger age, body weight >60 kg, no history of stroke, cardiac arrest, anaemia or renal dysfunction. In patients with a switch, eligibility for prasugrel was >82% and appropriate use of a switch was 86% from clopidogrel to prasugrel and 20% from prasugrel to clopidogrel. Quality indicators scored higher in the group with a switch and also in centres where the switch rate was higher. Conclusions As applied in the French Registry on Acute ST-elevation and non ST-elevation Myocardial Infarction (FAST-MI) registry, switching from one P2Y12 inhibitor to another led to a more appropriate prescription and was associated with higher scores on indicators of quality of care. PMID:27252877
Mumford, Virginia; Greenfield, David; Hogden, Anne; Forde, Kevin; Westbrook, Johanna; Braithwaite, Jeffrey
Objectives To assess the costs of hospital accreditation in Australia. Design Mixed methods design incorporating: stakeholder analysis; survey design and implementation; activity-based costs analysis; and expert panel review. Setting Acute care hospitals accredited by the Australian Council for Health Care Standards. Participants Six acute public hospitals across four States. Results Accreditation costs varied from 0.03% to 0.60% of total hospital operating costs per year, averaged across the 4-year accreditation cycle. Relatively higher costs were associated with the surveys years and with smaller facilities. At a national level these costs translate to $A36.83 million, equivalent to 0.1% of acute public hospital recurrent expenditure in the 2012 fiscal year. Conclusions This is the first time accreditation costs have been independently evaluated across a wide range of hospitals and highlights the additional cost burden for smaller facilities. A better understanding of the costs allows policymakers to assess alternative accreditation and other quality improvement strategies, and understand their impact across a range of facilities. This methodology can be adapted to assess international accreditation programmes. PMID:26351190
Digby, Geneviève C; Keenan, Sean P; Parker, Christopher M; Sinuff, Tasnim; Burns, Karen E; Mehta, Sangeeta; Ronco, Juan J; Kutsogiannis, Demetrios J; Rose, Louise; Ayas, Najib T; Berthiaume, Luc R; D’Arsigny, Christine L; Stollery, Daniel E; Muscedere, John
BACKGROUND: The extent of noninvasive ventilation (NIV) use for patients with acute respiratory failure in Canadian hospitals, indications for use and associated outcomes are unknown. OBJECTIVE: To describe NIV practice variation in the acute setting. METHODS: A prospective observational study involving 11 Canadian tertiary care centres was performed. Data regarding NIV indication, mode and outcomes were collected for all adults (>16 years of age) treated with NIV for acute respiratory failure during a four-week period (between February and August 2011). Logistic regression with site as a random effect was used to examine the association between preselected predictors and mortality or intubation. RESULTS: A total of 330 patients (mean [± SD] 30±12 per centre) were included. The most common indications for NIV initiation were pulmonary edema (104 [31.5%]) and chronic obstructive pulmonary disease (99 [30.0%]). Significant differences in indications for NIV use across sites, specialty of ordering physician and location of NIV initiation were noted. Although intubation rates were not statistically different among sites (range 10.3% to 45.4%), mortality varied significantly (range 6.7% to 54.5%; P=0.006). In multivariate analysis, the most significant independent predictor of avoiding intubation was do-not-resuscitate status (OR 0.11 [95% CI 0.03 to 0.37]). CONCLUSION: Significant variability existed in NIV use and associated outcomes among Canadian tertiary care centres. Assignment of do-not-resuscitate status prevented intubation. PMID:26469155
Lagman, Ruth L; Walsh, Declan; Davis, Mellar P; Young, Brett
The All Patient Refined-Diagnostic Related Group (APR-DRG) is a modification of the traditional DRG that adds four classes of illness severity and four classes of mortality risk. The APR-DRG is a more accurate assessment of the complexity of care. When individuals with advanced illness are admitted to an acute inpatient palliative medicine unit, there may be a perception that they receive less intense acute care. Most of these patients, however, are multisymptomatic, have several comorbidities, and are older. For all patients admitted to the unit, a guide was followed by staff physicians to document clinical information that included the site(s) of malignancy, site(s) of metastases, disease complications, disease-related symptoms, and comorbidities. We then prospectively compared DRGs, APR-DRGs, and case mix index (CMI) from January 1-June 30, 2003, and February 1-July 31,2004, before and after the use of the guide. The overall mean severity of illness (ASOI) increased by 25% (P < 0.05). The mean CMI increased by 12% (P < 0.05). The average length of stay over the same period increased slightly from 8.97 to 9.56 days. Systematic documentation of clinical findings using a specific tool for patients admitted to an acute inpatient palliative medicine unit based on APR-DRG classifications captured a higher severity of illness and may better reflect resource utilization.
Isohanni, I; Nieminen, P; Isohanni, M
Traditional custodial care in mental hospitals has given way to brief hospitalizations and a variety of active inpatient treatment milieus, eg, therapeutic communities. But can only well-educated patients utilize this kind of complex, even demanding form of psychosocial care? A total of 1,538 patients and their first admissions from 1977 to 1993 at a closed therapeutic community ward at the Department of Psychiatry, University of Oulu (Finland) were assessed to analyze the association of the patient's educational level with some treatment and outcome characteristics. Educational levels were non-professional education (46% of all patients), lower professional (39%) and higher professional education (15%). There were no statistically significant differences in the treatment and outcome variables of patients in any educational level. The result indicates the achievement of one treatment goal on the therapeutic community model, ie, patient equality in spite of different educational status. This result may be especially important for less educated persons.
Background Community acupuncture is a recent innovation in acupuncture service delivery in the U.S. that aims to improve access to care through low-cost treatments in group-based settings. Patients at community acupuncture clinics represent a broader socioeconomic spectrum and receive more frequent treatments compared to acupuncture users nationwide. As a relatively new model of acupuncture in the U.S., little is known about the experiences of patients at community acupuncture clinics and whether quality of care is compromised through this high-volume model. The aim of this study was to assess patients’ perspectives on the care received through community acupuncture clinics. Methods The investigators conducted qualitative, thematic analysis of written comments from an observational, cross-sectional survey of clients of the Working Class Acupuncture clinics in Portland, Oregon. The survey included an open-ended question for respondents to share comments about their experiences with community acupuncture. Comments were received from 265 community acupuncture patients. Results Qualitative analysis of written comments identified two primary themes that elucidate patients’ perspectives on quality of care: 1) aspects of health care delivery unique to community acupuncture, and 2) patient engagement in health care. Patients identified unique aspects of community acupuncture, including structures that facilitate access, processes that make treatments more comfortable and effective and holistic outcomes including physical improvements, enhanced quality of life, and empowerment. The group setting, community-based locations, and low cost were highlighted as aspects of this model that allow patients to access acupuncture. Conclusions Patients’ perspectives on the values and experiences unique to community acupuncture offer insights on the quality of care received in these settings. The group setting, community-based locations, and low cost of this model potentially
Rosas, Scott R; Behar, Lenore B; Hydaker, William M
Establishing a system of care requires communities to identify ways to successfully implement strategies and support positive outcomes for children and their families. Such community transformation is complex and communities vary in terms of their readiness for implementing sustainable community interventions. Assessing community readiness and guiding implementation, specifically for the funded communities implementing a system of care, requires a well-designed tool with sound psychometric properties. This scale development study used the results of a previously published concept mapping study to create, administer, and assess the psychometric characteristics of the System of Care Readiness and Implementation Measurement Scale (SOC-RIMS). The results indicate the SOC-RIMS possesses excellent internal consistency characteristics, measures clearly discernible dimensions of community readiness, and demonstrates the target constructs exist within a broad network of content. The SOC-RIMS can be a useful part of a comprehensive assessment in communities where system of care practices, principles, and philosophies are implemented and evaluated.
Ikai, Tomoki; Suzuki, Tomio; Oshima, Tamiki; Kanayama, Hitomi; Kusaka, Yukinori; Hayashi, Hiroyuki; Terasawa, Hidekazu
Studies of aspirational ideals of medical care generally focus on patients rather than on ordinary people receiving or not receiving medications at the time of interview. The literature has not accurately conveyed the distinct ideals in individual communities or undertaken inter-regional comparisons. This current qualitative study focused on ideal medical care as perceived by residents of distinct Japanese communities in their everyday lives. Between December 2011 and November 2012, one-on-one and group-based semi-structured interviews were conducted with 105 individuals, each of whom had continuously lived for 20 years or more in one of the four types of communities classified as either 'metropolitan area', 'provincial city', 'mountain/fishing village' or 'remote island' in Japan. Interviews were transcribed from digital audio recordings and then analysed (in tandem with non-verbal data including participants' appearances, attitudes and interview atmospheres) using constructivist grounded theory, in which we could get the voice and mind of the participant concerning ideal medical care. The common themes observed among the four community types included 'peace of mind because of the availability of medical care' and 'trust in medical professionals'. Themes that were characteristic of urban communities were the tendency to focus on the content of medical care, including 'high-level medical care', 'elimination of unnecessary medical care' and 'faster, cheaper medical care', whereas those that were characteristic of rural communities were the tendency to focus on lifestyle-oriented medical care such as 'support for local lifestyles', 'locally appropriate standards of medical care' and 'being free from dependence on medical care'. The sense of ideal medical care in urban communities tended to centre around the satisfaction with the content of medical care, whereas that in rural communities tended to centre around the ability to lead a secure life. By considering
Mkandawire, Wanangwa C; Muula, Adamson S
The main objective was to determine motivating factors for community care givers (CCGs), the services they provided to the community, and to identify sources of CCGs' material supplies. A cross sectional qualitative study was done using in-depth key informant interviews with community cares givers and traditional leaders. Analysis was based on themes utilizing content analysis. Most of the CCGs were housewives. Intrinsic motivating factors included feelings of empathy, altruism and religious convictions. Extrinsic motivators were rarely mentioned and these included expected opportunities for loans to start businesses, recognition by the community and eventual employment. The services that CCGs provided in their communities included; offering psycho-spiritual support, providing clothes, food and money to the under-privileged and paying school fees for orphans. In many instances the community care givers were spending from their own personal resources to help the under-privileged, while support from non-governmental organizations could only be sourced erratically. Mobilising resources from the local community through contributions was not seen a viable option. Intrinsic factors are an important motivator for community health volunteers CCGs in the peri-urban area of Blantyre. There is need for community groups to explore the feasibility of tapping from local material and financial resources.
Young, John P.; And Others
A critical review of literature on factors affecting nurse staffing in acute care hospitals, with particular regard for the consequences of a movement from team nursing to primary nursing care, was conducted. The literature search revealed a need for more research on the philosophy of nursing and nursing goals and policy as they relate to nurse…
ITO, HIROTO; SETOYA, YUTARO; SUZUKI, YURIKO
This paper summarizes the findings for the East and South East Asia Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Im-plementation of Community Mental Health Care. The paper presents a description of the region, an overview of mental health policies, a critical ap-praisal of community mental health services developed, and a discussion of the key obstacles and challenges. The main recommendations address the needs to campaign to reduce stigma, integrate care within the general health care system, prioritize target groups, strengthen leadership in policy mak-ing, and devise effective funding and economic incentives. PMID:23024679
Reader, Tom W; Gillespie, Alex; Mannell, Jenevieve
Despite the technological and organisational advances of 21st century health-care systems, care scandals and burgeoning complaints from patients have raised concerns about patient neglect in hospitals. This article reviews the concept of patient neglect and the role of community health psychology in understanding its occurrence. Patient neglect has previously been conceptualised as a problem associated with hospital staff attitudes and behaviours, with regulation and training cited as solutions. Yet, a community health psychology perspective shows that the wider symbolic, material and relational aspects of care are crucial for understanding why patient neglect occurs and for outlining new solutions to augment existing interventions.
Maxson, Emily R; Jain, Sachin H; McKethan, Aaron N; Brammer, Craig; Buntin, Melinda Beeuwkes; Cronin, Kelly; Mostashari, Farzad; Blumenthal, David
The Beacon Community Program, authorized under the 2009 American Recovery and Reinvestment Act (ARRA), aims to demonstrate the potential for health information technology to enable local improvements in health care quality, cost efficiency, and population health. If successful, these communitywide efforts will yield important lessons that will assist other communities seeking to harness technology to achieve and sustain health care improvements. This paper highlights key programmatic details that reflect the meaningful use of technology in the fifteen Beacon communities. It describes the innovations they propose and provides insight into current and future challenges.
... often believe that the health care staff have negative attitudes toward them, use unclear technical terms, and ... the community’s duty and obligation. Caregivers benefit from social support, maintaining social activities and roles, and psychological interventions ...
Yokoe, Deborah S.; Anderson, Deverick J.; Berenholtz, Sean M.; Calfee, David P.; Dubberke, Erik R.; Ellingson, Katherine D.; Gerding, Dale N.; Haas, Janet P.; Kaye, Keith S.; Klompas, Michael; Lo, Evelyn; Marschall, Jonas; Mermel, Leonard A.; Nicolle, Lindsay E.; Salgado, Cassandra D.; Bryant, Kristina; Classen, David; Crist, Katrina; Deloney, Valerie M.; Fishman, Neil O.; Foster, Nancy; Goldmann, Donald A.; Humphreys, Eve; Jernigan, John A.; Padberg, Jennifer; Perl, Trish M.; Podgorny, Kelly; Septimus, Edward J.; VanAmringe, Margaret; Weaver, Tom; Weinstein, Robert A.; Wise, Robert; Maragakis, Lisa L.
Since the publication of “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals” in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS). PMID:25026611
Han, Angela; Conway, Laurie J; Moore, Christine; McCreight, Liz; Ragan, Kelsey; So, Jannice; Borgundvaag, Emily; Larocque, Mike; Coleman, Brenda L; McGeer, Allison
OBJECTIVE To explore the frequency of hand hygiene opportunities (HHOs) in multiple units of an acute-care hospital. DESIGN Prospective observational study. SETTING The adult intensive care unit (ICU), medical and surgical step-down units, medical and surgical units, and the postpartum mother-baby unit (MBU) of an academic acute-care hospital during May-August 2013, May-July 2014, and June-August 2015. PARTICIPANTS Healthcare workers (HCWs). METHODS HHOs were recorded using direct observation in 1-hour intervals following Public Health Ontario guidelines. The frequency and distribution of HHOs per patient hour were determined for each unit according to time of day, indication, and profession. RESULTS In total, 3,422 HHOs were identified during 586 hours of observation. The mean numbers of HHOs per patient hour in the ICU were similar to those in the medical and surgical step-down units during the day and night, which were higher than the rates observed in medical and surgical units and the MBU. The rate of HHOs during the night significantly decreased compared with day (P92% of HHOs on medical and surgical units, compared to 67% of HHOs on the MBU. CONCLUSIONS Assessment of hand hygiene compliance using product utilization data requires knowledge of the appropriate opportunities for hand hygiene. We have provided a detailed characterization of these estimates across a wide range of inpatient settings as well as an examination of temporal variations in HHOs. Infect Control Hosp Epidemiol 2017;38:411-416.
This paper provides the results of the Survey-2000 measuring Intranet and its potential in health care. The survey measured the levels of Internet and Intranet existence and usage in acute care hospitals. Business-to-business electronic commerce and electronic commerce for customers were measured. Since the Intranet was not studied in survey-1997, no comparisons could be made. Therefore the results were presented and discussed. The Intranet data were compared with the Internet data and statistically significant differences were presented and analyzed. This information will assist hospitals to plan Internet and Intranet technology. This is the third of three articles based upon the results of the Survey-2000. Readers are referred to prior articles by the author, which discusses the survey design and provides a tutorial on technology transfer in acute care hospitals.(1) The first article based upon the survey results discusses technology transfer, system design approaches, user involvement, and decision-making purposes. (2) The second article based upon the survey results discusses distribution of Internet usage and rating of Internet usage applied to specific applications. Homepages, advertising, and electronic commerce are discussed from an Internet perspective.
Hogan, D B; Fox, R A
Attempts to prove the usefulness of geriatric consultation teams (GCT) in acute-care settings have been inconclusive. We have completed a prospective, controlled trial of a GCT in an acute-care setting, aiming our interventions at a specific subgroup of elderly patients. One hundred and thirty-two out of 352 (37.5%) patients met the inclusion criteria with 66 each being assigned to the intervention and the control groups. There were no significant differences in baseline characteristics between the two groups. Patients in the intervention group received follow-up after discharge from hospital by the geriatric service. We found that the intervention was associated with improved 6-month survival (p less than 0.01), improved Barthel Index at 1 year (p less than 0.01), and a trend towards decreased reliance on institutional care (hospital or nursing home) during the year of follow-up. The benefits occurred principally in patients who were discharged to a nursing home. Our findings support the utility of GCT and highlight the importance of focusing the intervention and providing follow-up after discharge from hospital.
Chreiman, Kristen M; Kim, Patrick K; Garbovsky, Lyudmila A; Schweickert, William D
The intraosseous (IO) access initiative at an urban university adult level 1 trauma center began from the need for a more expeditious vascular access route to rescue patients in extremis. The goal of this project was a multidisciplinary approach to problem solving to increase access of IO catheters to rescue patients in all care areas. The initiative became a collaborative effort between nursing, physicians, and pharmacy to embark on an acute care endeavor to standardize IO access. This is a descriptive analysis of processes to effectively develop collaborative strategies to navigate hospital systems and successfully implement multilayered initiatives. Administration should empower nurse to advance their practice to include IO for patient rescue. Intraosseous access may expedite resuscitative efforts in patients in extremis who lack venous access or where additional venous access is required for life-saving therapies. Limiting IO dwell time may facilitate timely definitive venous access. Continued education and training by offering IO skill laboratory refreshers and annual e-learning didactic is optimal for maintaining proficiency and knowledge. More research opportunities exist to determine medication safety and efficacy in adult patients in the acute care setting.
Yokoe, Deborah S; Anderson, Deverick J; Berenholtz, Sean M; Calfee, David P; Dubberke, Erik R; Ellingson, Katherine D; Gerding, Dale N; Haas, Janet P; Kaye, Keith S; Klompas, Michael; Lo, Evelyn; Marschall, Jonas; Mermel, Leonard A; Nicolle, Lindsay E; Salgado, Cassandra D; Bryant, Kristina; Classen, David; Crist, Katrina; Deloney, Valerie M; Fishman, Neil O; Foster, Nancy; Goldmann, Donald A; Humphreys, Eve; Jernigan, John A; Padberg, Jennifer; Perl, Trish M; Podgorny, Kelly; Septimus, Edward J; VanAmringe, Margaret; Weaver, Tom; Weinstein, Robert A; Wise, Robert; Maragakis, Lisa L
Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).
Yokoe, Deborah S; Anderson, Deverick J; Berenholtz, Sean M; Calfee, David P; Dubberke, Erik R; Ellingson, Katherine D; Gerding, Dale N; Haas, Janet P; Kaye, Keith S; Klompas, Michael; Lo, Evelyn; Marschall, Jonas; Mermel, Leonard A; Nicolle, Lindsay E; Salgado, Cassandra D; Bryant, Kristina; Classen, David; Crist, Katrina; Deloney, Valerie M; Fishman, Neil O; Foster, Nancy; Goldmann, Donald A; Humphreys, Eve; Jernigan, John A; Padberg, Jennifer; Perl, Trish M; Podgorny, Kelly; Septimus, Edward J; VanAmringe, Margaret; Weaver, Tom; Weinstein, Robert A; Wise, Robert; Maragakis, Lisa L
Since the publication of "A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" in 2008, prevention of healthcare-associated infections (HAIs) has become a national priority. Despite improvements, preventable HAIs continue to occur. The 2014 updates to the Compendium were created to provide acute care hospitals with up-to-date, practical, expert guidance to assist in prioritizing and implementing their HAI prevention efforts. They are the product of a highly collaborative effort led by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise, including the Centers for Disease Control and Prevention (CDC), the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society (PIDS), the Society for Critical Care Medicine (SCCM), the Society for Hospital Medicine (SHM), and the Surgical Infection Society (SIS).
Armfield, Nigel R; Donovan, Tim; Bensink, Mark E; Smith, Anthony C
Telemedicine was used as a substitute for the telephone (usual care) for some acute care consultations from nurseries at four peripheral hospitals in Queensland. Over a 12-month study period, there were 19 cases of neonatal teleconsultation. Five (26%) cases of avoided infant transport were confirmed by independent assessment, four of which were avoided helicopter retrievals. We conducted two analyses. In the first, the actual costs of providing telemedicine at the study sites were compared with the actual savings associated with confirmed avoided infant transport and nursery costs. There was a net saving to the health system of 54,400 Australian Dollars (AUD) associated with the use of telemedicine over the 12-month period. In the second analysis, we estimated the potential savings that might have been achieved if telemedicine had been used for all retrieval consultations from the study sites. The total projected costs were AUD 64,969 while the projected savings were AUD 271,042, i.e. a projected net saving to the health system of AUD 206,073 through the use of telemedicine. A sensitivity analysis suggested that the threshold proportion of retrievals needed to generate telemedicine-related savings under the study conditions was 5%. The findings suggest that from the health-service perspective, the use of telemedicine for acute care neonatal consultation has substantial economic benefits.
Kasper, Matthew R; Blair, Patrick J; Touch, Sok; Sokhal, Buth; Yasuda, Chadwick Y; Williams, Maya; Richards, Allen L; Burgess, Timothy H; Wierzba, Thomas F; Putnam, Shannon D
The agents of human febrile illness can vary by region and country suggesting that diagnosis, treatment, and control programs need to be based on a methodical evaluation of area-specific etiologies. From December 2006 to December 2009, 9,997 individuals presenting with acute febrile illness at nine health care clinics in south-central Cambodia were enrolled in a study to elucidate the etiologies. Upon enrollment, respiratory specimens, whole blood, and serum were collected. Testing was performed for viral, bacterial, and parasitic pathogens. Etiologies were identified in 38.0% of patients. Influenza was the most frequent pathogen, followed by dengue, malaria, and bacterial pathogens isolated from blood culture. In addition, 3.5% of enrolled patients were infected with more than one pathogen. Our data provide the first systematic assessment of the etiologies of acute febrile illness in south-central Cambodia. Data from syndromic-based surveillance studies can help guide public health responses in developing nations.
Wilkin, Holley A; Tannebaum, Michael A; Cohen, Elizabeth L; Leslie, Travie; Williams, Nora; Haley, Leon L
Access to continuous care through a primary care provider is associated with improved health outcomes, but many communities rely on emergency departments (EDs) for both emergent and non-emergent health problems. This article describes one portion of a community-based participatory research project and investigates the type of education that might be needed as part of a larger intervention to encourage use of a local primary care clinic. In this article we examine how people who live in a low-income urban community and the healthcare workers who serve them conceptualize 'emergency medical condition'. We conducted forum and focus group discussions with 52 community members and individual interviews with 32 healthcare workers. Our findings indicate that while community members share a common general definition of what constitutes a medical emergency, they also desire better guidelines for how to assess health problems as requiring emergency versus primary care. Pain, uncertainty and anxiety tend to influence their choice to use EDs rather than availability of primary care. Implications for increasing primary care use are discussed.
Adamson, Wallace C; DeVries, Andrea R
Background Expansion of virtual health care—real-time video consultation with a physician via the Internet—will continue as use of mobile devices and patient demand for immediate, convenient access to care grow. Objective The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions. Methods A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy. Results A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%, P=.99) and RHC visits (28.59%, P=.51). During the episode, lab rates for virtual visits (12.56%) were lower than in-person locations (RHC: 36.79%, P<.001; UCC: 39.01%, P<.001; ED: 53.15%, P<.001; PCP: 37.40%, P<.001), and imaging rates for virtual visits (6.62%) were typically lower than in-person locations
Fang, Yu; Yang, Shimin; Feng, Bianling; Ni, Yufei; Zhang, Kanghuai
The aim of this study was to explore the perceptions of community pharmacists towards the concept of pharmaceutical care, implementing frequencies of pharmaceutical care, and barriers to implementation of pharmaceutical care in China. A 38-item self-completion pre-tested questionnaire was administered to a quota sample of 130 pharmacists in community pharmacies in Xi'an, Shaanxi Province, northwest China in April 2008. Main outcome measures included understanding of pharmaceutical care; perceived frequency of pharmaceutical care activities; attitude towards pharmaceutical care; barriers to implementation of pharmaceutical care. A response rate of 77.7% (101/130) was achieved. The data were analysed descriptively. Factor analysis was used to explore potential barriers to the provision of pharmaceutical care. Respondents' understanding of the definition of pharmaceutical care was not entirely satisfactory: it was widely but incorrectly seen as a medication counselling service and many pharmacists appeared to misunderstand their role in the process. Respondents spent most of their work time performing prescription checks and providing patients with directions for drug administration, dosage, and precautions, but they tended to ignore health promotion within and outside of pharmacy settings. Factor analysis suggested four factors influencing the implementation of pharmaceutical care in the surveyed community pharmacies: lack of external conditions for developing or providing pharmaceutical care, lack of time and skills, absence of information and economic incentive, and lack of full support from other health professionals, with a cumulative variance of 64.7%. Cronbach's alpha for the four factors was 0.71, 0.72, 0.69 and 0.74, respectively. Although the respondent pharmacists had a certain degree of understanding of the definition, aim, function and use of pharmaceutical care, and carried out some activities currently, a range of barriers need to be overcome before
Hyde, Sandra Teresa
In this article, I explore a Chinese residential therapeutic community I call Sunlight in order to understand its quotidian therapies, its fraught nature binding China's past with its future, and the to care for the self under postsocialism. Reviewing Sunlight ethnographically allows for broader theoretical exploration into how China's economic transition created tensions between capitalism, socialism, and communism; between individual and community, care and coercion, and discipline and freedom. Sunlight blended democratic, communal, and communist values that in several ways transition drug addicts into a market-socialist society. In focusing on the socialist transition to capitalism much work concentrates on the neoliberal transition as the only path out of communism rather than exploring its exceptions. In exploring China as an exception, I ask: What do the residents, peer-educators and administrators reveal in their stories and reactions to community-based therapeutics of care and what happens when their notions of care clash?
Leite, Renata; Hudson, Christine; West, Lynn; Carpenter, Elizabeth; Andrews, Jeannette O.
Objectives To assess the oral health (OH) needs and barriers to OH care in Gullah African American communities. Methods A community advisory board was formed to guide the research study. Five focus groups (n=27) were conducted to explore the OH needs/barriers. Participants completed demographic surveys and participated in discussions facilitated by open-ended questions. All sessions were audio-recorded, transcribed and analyzed using NVivo8. Results Facilitators of OH included positive experiences and modeling. Fear and access to care were the most cited barriers. Tooth extraction was the dental treatment of choice. Intervention recommendations included improving clinic access, using the churches to socially influence receipt of OH care, providing group educational sessions with OH specialists, and having local “lay people” to provide support and to help navigate OH care systems. Conclusions The design of a multi-level culturally and locally relevant intervention may lead to a decrease in OH disparities in Gullah communities. PMID:23793251
Villaseñor, Sally; Walker, Tara; Fetters, Lisa; McCoy, Maryanne
The study sought to determine the barriers to e-prescribing particular to the acute care setting, the educational and motivational needs of acute care providers, and the optimal process for incentive, education, and implementation of e-prescribing. A theoretically based survey instrument was adapted from previous work. Four domains were assessed: finesse, intent to use, perceived usefulness, and perceived ease of use. The survey was offered to a group of acute care providers. The educational and motivational needs of acute care providers are different from those in primary care. Perceived barriers centered on uncertain pharmacy hours, unconfirmed transmittal, and accidental transmission to wrong pharmacy. Healthcare providers with more self-assessed knowledge of e-prescribing are more likely to use e-prescribing. Providers with fewer years in practice seem to have greater knowledge of e-prescribing. Providing education and exposure to e-prescribing has the potential to decrease perception of barriers and increase perceived usefulness for acute care providers. Software redesign may be needed to remove barriers associated with uncertain pharmacy hours, controlled substance prescribing, transmittal confirmation, and bidirectional communication needs, thereby improving motivation to e-prescribe.
Miller, Craig; Cushley, Claire; Redler, Kasey; Mitchell, Claire; Aynsley Day, Elizabeth; Mansfield, Helen; Nye, Abigail
Admissions for exacerbations of chronic obstructive pulmonary disease (COPD) present a significant proportion of patients in the acute medical take. The British Thoracic Society (BTS) provides guidelines for time specific interventions, that should be delivered to those with an acute exacerbation of COPD through the admission care bundle. These include correct diagnosis, correct assessment of oxygenation, early administration of treatment, recognition of respiratory failure, and specialist review. Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) chose improvement in acute COPD care to be a local Commissioning for Quality and Innovation (CQUIN) scheme, which enables commissioners to reward excellence by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. The effects of initiatives put in place by senior clinicians had waned, and further improvements were required to meet the CQUIN target. The aim of the scheme was to improve compliance with the BTS guidelines and CQUIN scheme for patients admitted with an exacerbation of COPD. Specific bundle paperwork to be used for all patients admitted to the Trust with an exacerbation of COPD was introduced to the Trust in June 2014, with training and education of medical staff at that time. This had improved compliance rates from 10% to 63% by September 2014. Compliance with each intervention was audited through the examination of notes of patients admitted with an exacerbation of COPD. Compliance rates had plateaued over the last three months, and so a focus group involving junior medical staff met in September 2014 to try to increase awareness further, in order to drive greater improvements in care, and meet the CQUIN requirements. Their strategies were implemented, and then compliance with the CQUIN requirements was reaudited as described above. The December 2014 audit results showed a further improvement in overall COPD care, with 73% of patients
Miller, Craig; Cushley, Claire; Redler, Kasey; Mitchell, Claire; Aynsley Day, Elizabeth; Mansfield, Helen; Nye, Abigail
Admissions for exacerbations of chronic obstructive pulmonary disease (COPD) present a significant proportion of patients in the acute medical take. The British Thoracic Society (BTS) provides guidelines for time specific interventions, that should be delivered to those with an acute exacerbation of COPD through the admission care bundle. These include correct diagnosis, correct assessment of oxygenation, early administration of treatment, recognition of respiratory failure, and specialist review. Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) chose improvement in acute COPD care to be a local Commissioning for Quality and Innovation (CQUIN) scheme, which enables commissioners to reward excellence by linking a proportion of English healthcare providers’ income to the achievement of local quality improvement goals. The effects of initiatives put in place by senior clinicians had waned, and further improvements were required to meet the CQUIN target. The aim of the scheme was to improve compliance with the BTS guidelines and CQUIN scheme for patients admitted with an exacerbation of COPD. Specific bundle paperwork to be used for all patients admitted to the Trust with an exacerbation of COPD was introduced to the Trust in June 2014, with training and education of medical staff at that time. This had improved compliance rates from 10% to 63% by September 2014. Compliance with each intervention was audited through the examination of notes of patients admitted with an exacerbation of COPD. Compliance rates had plateaued over the last three months, and so a focus group involving junior medical staff met in September 2014 to try to increase awareness further, in order to drive greater improvements in care, and meet the CQUIN requirements. Their strategies were implemented, and then compliance with the CQUIN requirements was reaudited as described above. The December 2014 audit results showed a further improvement in overall COPD care, with 73% of patients
Bridges, Jackie; Nicholson, Caroline; Maben, Jill; Pope, Catherine; Flatley, Mary; Wilkinson, Charlotte; Meyer, Julienne; Tziggili, Maria
Aims To synthesize evidence and knowledge from published research about nurses' experiences of nurse-patient relationships with adult patients in general, acute inpatient hospital settings. Background While primary research on nurses' experiences has been reported, it has not been previously synthesized. Design Meta-ethnography. Data sources Published literature from Australia, Europe, and North America, written in English between January 1999–October 2009 was identified from databases: CINAHL, Medline, British Nursing Index and PsycINFO. Review methods Qualitative studies describing nurses' experiences of the nurse-patient relationship in acute hospital settings were reviewed and synthesized using the meta-ethnographic method. Results Sixteen primary studies (18 papers) were appraised as high quality and met the inclusion criteria. The findings show that while nurses aspire to develop therapeutic relationships with patients, the organizational setting at a unit level is strongly associated with nurses' capacity to build and sustain these relationships. The organizational conditions of critical care settings appear best suited to forming therapeutic relationships, while nurses working on general wards are more likely to report moral distress resulting from delivering unsatisfactory care. General ward nurses can then withdraw from attempting to emotionally engage with patients. Conclusion The findings of this meta-ethnography draw together the evidence from several qualitative studies and articulate how the organizational setting at a unit level can strongly influence nurses' capacity to build and sustain therapeutic relationships with patients. Service improvements need to focus on how to optimize the organizational conditions that support nurses in their relational work with patients. PMID:23163719
Hillmann, Steffi; Wiedmann, Silke; Fraser, Alec; Baeza, Juan; Rudd, Anthony; Norrving, Bo; Asplund, Kjell; Niewada, Maciej; Dennis, Martin; Hermanek, Peter; Wolfe, Charles D. A.; Heuschmann, Peter U.
Background. Data on potential variations in delivery of appropriate stroke care over time are scarce. We investigated temporal changes in the quality of acute hospital stroke care across five national audits in Europe over a period of six years. Methods. Data were derived from national stroke audits in Germany, Poland, Scotland, Sweden, and England/Wales/Northern Ireland participating within the European Implementation Score (EIS) collaboration. Temporal changes in predefined quality indicators with comparable information between the audits were investigated. Multivariable logistic regression analyses were performed to estimate adherence to quality indicators over time. Results. Between 2004 and 2009, individual data from 542,112 patients treated in 538 centers participating continuously over the study period were included. In most audits, the proportions of patients who were treated on a SU, were screened for dysphagia, and received thrombolytic treatment increased over time and ranged from 2-fold to almost 4-fold increase in patients receiving thrombolytic therapy in 2009 compared to 2004. Conclusions. A general trend towards a better quality of stroke care defined by standardized quality indicators was observed over time. The association between introducing a specific measure and higher adherence over time might indicate that monitoring of stroke care performance contributes to improving quality of care. PMID:26783519
Mossialos, Elias; Courtin, Emilie; Naci, Huseyin; Benrimoj, Shalom; Bouvy, Marcel; Farris, Karen; Noyce, Peter; Sketris, Ingrid
Community pharmacists are the third largest healthcare professional group in the world after physicians and nurses. Despite their considerable training, community pharmacists are the only health professionals who are not primarily rewarded for delivering health care and hence are under-utilized as public health professionals. An emerging consensus among academics, professional organizations, and policymakers is that community pharmacists, who work outside of hospital settings, should adopt an expanded role in order to contribute to the safe, effective, and efficient use of drugs-particularly when caring for people with multiple chronic conditions. Community pharmacists could help to improve health by reducing drug-related adverse events and promoting better medication adherence, which in turn may help in reducing unnecessary provider visits, hospitalizations, and readmissions while strengthening integrated primary care delivery across the health system. This paper reviews recent strategies to expand the role of community pharmacists in Australia, Canada, England, the Netherlands, Scotland, and the United States. The developments achieved or under way in these countries carry lessons for policymakers world-wide, where progress thus far in expanding the role of community pharmacists has been more limited. Future policies should focus on effectively integrating community pharmacists into primary care; developing a shared vision for different levels of pharmacist services; and devising new incentive mechanisms for improving quality and outcomes.
Cheong, Chin Yee; Tan, Jane An Qi; Foong, Yi-Lin; Koh, Hui Mien; Chen, Denise Zhen Yue; Tan, Jessie Joon Chen; Ng, Chong Jin; Yap, Philip
Background/Aims The acute hospital ward can be unfamiliar and stressful for older patients with impaired cognition, rendering them prone to agitation and resistive to care. Extant literature shows that music therapy can enhance engagement and mood, thereby ameliorating agitated behaviours. This pilot study evaluates the impact of a creative music therapy (CMT) programme on mood and engagement in older patients with delirium and/or dementia (PtDD) in an acute care setting. We hypothesize that CMT improves engagement and pleasure in these patients. Methods Twenty-five PtDD (age 86.5 ± 5.7 years, MMSE 6/30 ± 5.4) were observed for 90 min (30 min before, 30 min during, and 30 min after music therapy) on 3 consecutive days: day 1 (control condition without music) and days 2 and 3 (with CMT). Music interventions included music improvisation such as spontaneous music making and playing familiar songs of patient's choice. The main outcome measures were mood and engagement assessed with the Menorah Park Engagement Scale (MPES) and Observed Emotion Rating Scale (OERS). Results Wilcoxon signed-rank test showed a statistically significant positive change in constructive and passive engagement (Z = 3.383, p = 0.01) in MPES and pleasure and general alertness (Z = 3.188,p = 0.01) in OERS during CMT. The average pleasure ratings of days 2 and 3 were higher than those of day 1 (Z = 2.466, p = 0.014). Negative engagement (Z = 2.582, p = 0.01) and affect (Z = 2.004, p = 0.045) were both lower during CMT compared to no music. Conclusion These results suggest that CMT holds much promise to improve mood and engagement of PtDD in an acute hospital setting. CMT can also be scheduled into the patients' daily routines or incorporated into other areas of care to increase patient compliance and cooperation. PMID:27489560
Islam, Nadia; Nadkarni, Smiti Kapadia; Zahn, Deborah; Skillman, Megan; Kwon, Simona C.; Trinh-Shevrin, Chau
Context The Patient Protection and Affordable Care Act’s (PPACA) emphasis on community-based initiatives affords a unique opportunity to disseminate and scale up evidence-based community health worker (CHW) models that integrate CHWs within health care delivery teams and programs. Community health workers have unique access and local knowledge that can inform program development and evaluation, improve service delivery and care coordination, and expand health care access. As a member of the PPACA-defined health care workforce, CHWs have the potential to positively impact numerous programs and reduce costs. Objective This article discusses different strategies for integrating CHW models within PPACA implementation through facilitated enrollment strategies, patient-centered medical homes, coordination and expansion of health information technology (HIT) efforts, and also discusses payment options for such integration. Results Title V of the PPACA outlines a plan to improve access to and delivery of health care services for all individuals, particularly low-income, underserved, uninsured, minority, health disparity, and rural populations. Community health workers’ role as trusted community leaders can facilitate accurate data collection, program enrollment, and provision of culturally and linguistically appropriate, patient- and family-centered care. Because CHWs already support disease management and care coordination services, they will be critical to delivering and expanding patient-centered medical homes and Health Home services, especially for communities that suffer disproportionately from multiple chronic diseases. Community health workers’ unique expertise in conducting outreach make them well positioned to help enroll people in Medicaid or insurance offered by Health Benefit Exchanges. New payment models provide opportunities to fund and sustain CHWs. Conclusion Community health workers can support the effective implementation of PPACA if the capacity
Dykes, Patricia C.; Benoit, Angela; Chang, Frank; Gallagher, Joan; Li, Qi; Spurr, Cindy; McGrath, E. Jan; Kilroy, Susan M.; Prater, Marita
The transition from paper to electronic documentation systems in acute care settings is often gradual and characterized by a period in which paper and electronic processes coexist. Intermediate technologies are needed to “bridge” the gap between paper and electronic systems as a means to improve work flow efficiency through data acquisition at the point of care in structured formats to inform decision support and facilitate reuse. The purpose of this paper is to report on the findings of a study conducted on three acute care units at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston, MA to evaluate the feasibility of digital pen and paper technology as a means to capture vital sign data in the context of acute care workflows and to make data available in a flow sheet in the electronic medical record. PMID:17238337
Fábrega, Emilio; Mieses, Miguel Ángel; Terán, Alvaro; Moraleja, Irene; Casafont, Fernando; Crespo, Javier; Pons-Romero, Fernando
Previous retrospective study (1992 to 2000) performed in Spain showed that drug toxicity, viral hepatitis, and indeterminate etiology were the most prevalent causes of acute liver failure (ALF). In the last decade, there is no information about ALF in our country. For these reasons we analyze retrospectively, in a ten-year period (2000 to 2010), the presumed causes, clinical characteristics, course, and outcome of ALF in a Spanish community. Causes of ALF were indeterminate in 4 patients (24%), acute hepatitis B infection in 4 patients (24%), drug or toxic reactions in 4 patients (24%), including one case of acetaminophen overdose, followed by miscellaneous causes. The overall short-term survival (6 weeks after admission) was 65%. Liver transplantation was performed in 11 patients with a survival of 82%. Despite fulfilling criteria, 2 patients were not transplanted because of contraindications; they both died. In summary, acute hepatitis B and indeterminate cause are still being the most frequent causes of ALF in our region, and patients with ALF have an excellent chance of survival after emergency liver transplantation. Acetaminophen overdose still represents a very rare cause of ALF in our community. PMID:24024035
Smith, Christopher D; Robert, Stefanie
The use of novel psychoactive substances ('legal highs' or 'designer drugs') is increasing worldwide. Patients misusing such substances have been reported to experience severe or prolonged side effects requiring admission to acute or critical care wards. These complications can be life threatening if misdiagnosed or mismanaged. As physicians have traditionally had less involvement with the management of such patients compared with their colleagues in emergency departments an update in the management of such patients is indicated. Here we present a summary of the management of those novel substances with the potential for serious complications based on a review of current literature.
Daggenvoorde, Thea; Geerling, Bart; Goossens, Peter J J
Patients with a bipolar disorder and currently experiencing acute mania often require hospitalization. We explored patient problems, desired patient outcomes, and nursing interventions by individually interviewing 22 nurses. Qualitative content analysis gave a top five of patients problems, desired patient outcomes and nursing interventions, identified as most important in the interviews. We then conducted three focus group meetings to gain greater insight into these results. Intensive nursing care is needed, fine-tuning on the patient as a unique person is essential, taking into account the nature and severity of the manic symptoms of the patient.
Polgar, Michael F; Cabassa, Leopoldo J; Morrissey, Joseph P
Young people between the ages of 16 and 25 who experience mental health problems experience transitions and need help from a variety of organizations. Organizations promote continuity of care by assisting young adults with developmental, service, and systemic transitions. Providers offer specific services to help transitions and also form cooperative relationships with other community organizations. Results from a survey of 100 service providers in one community describe organizational attributes and practices which are associated with continuity of care in a regional system for young adults. Data analyses show that full-service organizations which practice cultural competence offer more specific services that foster continuity of care. Larger, full-service organizations are also more likely to have more extensive and collaborative inter-organizational networks that help young adults continue care over time within the regional system of care.
Sanders, Jim; Solberg, Bill; Gauger, Michael
For 10 years the Medical College of Wisconsin and Columbia St. Mary's Hospital have joined together in a partnership to work within some of Milwaukee's most impoverished neighborhoods. Beginning simply by providing health care through a free clinic, the partnership soon was confronted with numerous examples of barriers to care being experienced by patients. A community-based participatory action process allowed the local population to give voice to the local realities of barriers to care. Here we combine our anecdotal clinical experience, the neighborhood's input, and an example of a successful program from a low-resource international setting to create a novel approach to treating chronic disease in uninsured populations. This model of care has been successful for 2 reasons. First, the model shows good health outcomes at low cost. Second, solid community partnerships with care providers, churches, and other groups have been formed in support of the model, ensuring its credibility and sustainability.
Polgar, By Michael F.; Cabassa, Leopoldo J.; Morrissey, Joseph P.
Young people between the ages of 16 and 25 who experience mental health problems experience transitions and need help from a variety of organizations. Organizations promote continuity of care by assisting young adults with developmental, service, and systemic transitions. Providers offer specific services to help transitions and also form cooperative relationships with other community organizations. Results from a survey of 100 service providers in one community describe organizational attributes and practices which are associated with continuity of care in a regional system for young adults. Data analyses show that full-service organizations which practice cultural competence offer more specific services that foster continuity of care. Larger, full-service organizations are also more likely to have more extensive and collaborative inter-organizational networks that help young adults continue care over time within the regional system of care. PMID:24833485
Chung, Bowen; Ngo, Victoria; Ong, Michael; Pulido, Esmeralda; Jones, Felica; Gilmore, James; Mtume, Norma; Johnson, Megan Dwight; Tang, Lingqi; Wells, Kenneth; Sherbourne, Cathy; Miranda, Jeanne
Objective Community Engagement and Planning (CEP) could improve dissemination of depression quality improvement in under-resourced communities; but its effects on provider training participation relative to more standard technical assistance or Resources for Services (RS) are unknown. To compare effects of CEP, which trains networks of healthcare and social-community agencies jointly, and RS, which provides technical support to individual programs, on program and staff-level participation in depression quality improvement trainings. Methods Matched programs from healthcare and social-community programs in two communities were randomized to RS or CEP. Data were from 1622 eligible staff members from 95 enrolled programs. Measures: Primary outcomes: for programs, any staff trained; and for staff, total hours of training. Secondary outcomes: training in specific depression collaborative care components. Results CEP programs relative to RS were more likely to participate in any trainings across sectors (p<.001) and from social-community sectors (p<.001), but not from healthcare. Among staff participating in trainings, CEP relative to RS had greater mean training hours (p<.001) overall and for each depression care component (cognitive behavioral therapy, care management, other trainings, p<.001) except medication management. Conclusions Compared with RS, CEP to implement depression quality improvement increased program and staff training participation overall. CEP had a greater effect on any staff training participation within social-community sectors than RS, but not within healthcare. CEP may be an effective strategy to promote staff participation in depression improvement in under-resourced communities. PMID:25930037
Hacıkamiloglu, Ezgi; Utku, Ezgi Simsek; Cukurova, Zafer; Keskinkilic, Bekir; Topcu, Ibrahim; Gultekin, Murat; Silbermann, Michael
The Middle East has been struggling with basic issues of cancer care, and in specific, palliative care, at the primary health care level in the communities. The Middle East Cancer Consortium designated this issue as the highest priority of its activities in the region. Following basic and advanced courses and national and international workshops, local governments recognized the essentiality of developing palliative care services in their respective countries. As the result of these training activities, in 2010, the Ministry of Health in Turkey initiated a novel program whereby population-based and home-based palliative care teams were developed throughout the country, including peripheral regions in the countries where appropriate care was not available. This initiative led to a dramatic increase in the number of cancer patients receiving palliative care at their homes. The Turkish initiative can serve as a model to other countries in the Middle East and beyond it.
Argan, Mehpare Tokay; Argan, Metin; Suher, Idil K.
Like in all areas, virtual communities make their presence felt in the area of healthcare too. Virtual communities play an important role in healthcare in terms of gathering information on healthcare, sharing of personal interests and providing social support. Virtual communities provide a way for a group of peers to communicate with each other.…
Background Although detained youth evidence increased rates of mental illness, relatively few adolescents utilize mental health care upon release from detention. Thus, the goal of this study is to understand the process of mental health care engagement upon community reentry for mentally-ill detained youth. Methods Qualitative interviews were conducted with 19 youth and caregiver dyads (39 participants) recruited from four Midwest counties affiliated with a state-wide mental health screening project. Previously detained youth (ages 11–17), who had elevated scores on a validated mental health screening measure, and a caregiver were interviewed 30 days post release. A critical realist perspective was used to identify themes on the detention and reentry experiences that impacted youth mental health care acquisition. Results Youth perceived detention as a crisis event and having detention-based mental health care increased their motivation to seek mental health care at reentry. Caregivers described receiving very little information regarding their child during detention and felt “out of the loop,” which resulted in mental health care utilization difficulty. Upon community reentry, long wait periods between detention release and initial contact with court or probation officers were associated with decreased motivation for youth to seek care. However, systemic coordination between the family, court and mental health system facilitated mental health care connection. Conclusions Utilizing mental health care services can be a daunting process, particularly for youth upon community reentry from detention. The current study illustrates that individual, family-specific and systemic issues interact to facilitate or impair mental health care utilization. As such, in order to aid youth in accessing mental health care at detention release, systemic coordination efforts are necessary. The systematic coordination among caregivers, youth, and individuals within the justice
Bone, Eric; Grono, Shawn; Johnson, David H; Johnson, Marcia
One assumption of pandemic planning is that, during an influenza outbreak, acute care facilities may be quickly overrun with patients and as such must prepare in advance. In order to operationalise one component of a pandemic plan, Capital Health in Edmonton, Alberta, piloted a mobile triage centre facility (portable isolation containment systems) and tested pandemic influenza triage and assessment guidelines in the winter of 2006-07. The mobile model provided emergency department surge capacity for communicable disease emergencies with scalable deployment capabilities. The deployable module has several advantages over a fixed structure like a community facility. The triage facility is a location for short-term treatments, such as intravenous therapy, prescriptions, medication distribution, and self-care education, which are needed during a pandemic influenza outbreak. Decanting infectious patients away from the emergency department protects a highly-vulnerable hospitalised group from viral transmission. Based on the pilot, it is found that community triage centres are a viable support option for emergency departments in an urban setting during pandemic influenza.
Mercurio, Mark R
Much attention has been paid in recent years to the conflict that may occur when patients or their families insist on a therapy that the physician feels would be futile. In 1999 the Council on Ethical and Judicial Affairs of the American Medical Association recommended that all health-care institutions adopt a policy on medical futility that follows a fair process. Development of such a policy has proved problematic for many hospitals. The Conscientious Practice Policy at Lawrence & Memorial Hospital was developed as a response to the AMA recommendation. It outlines a specific process to be followed in the event that a physician wishes to refuse to provide a requested therapy, whether that refusal is based on perceived futility or other concerns. The policy was subsequently modified slightly and adopted by two other Connecticut acute care hospitals.
Mark, Barbara A; Jones, Cheryl Bland; Lindley, Lisa; Ozcan, Yasar A
Using an innovative statistical approach-data envelopment analysis-the authors examined the technical efficiency of 226 medical, surgical, and medical-surgical nursing units in 118 randomly selected acute care hospitals. The authors used the inputs of registered nurse, licensed practical nurse, and unlicensed hours of care; operating expenses; and number of beds on the unit. Outputs included case mix adjusted discharges, patient satisfaction (as a quality measure), and the rates of medication errors and patient falls (as measures of patient safety). This study found that 60% of units were operating at less than full efficiency. Key areas for improvement included slight reductions in labor hours and large reductions in medication errors and falls. The study findings indicate the importance of improving patient safety as a mechanism to simultaneously improve nursing unit efficiency.
Gargano, J W; Freeland, A L; Morrison, M A; Stevens, K; Zajac, L; Wolkon, A; Hightower, A; Miller, M D; Brunkard, J M
The drinking water infrastructure in the United States is ageing; extreme weather events place additional stress on water systems that can lead to interruptions in the delivery of safe drinking water. We investigated the association between household exposures to water service problems and acute gastrointestinal illness (AGI) and acute respiratory illness (ARI) in Alabama communities that experienced a freeze-related community-wide water emergency. Following the water emergency, investigators conducted a household survey. Logistic regression models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for self-reported AGI and ARI by water exposures. AGI was higher in households that lost water service for ⩾7 days (aPR 2·4, 95% CI 1·1-5·2) and experienced low water pressure for ⩾7 days (aPR 3·6, 95% CI 1·4-9·0) compared to households that experienced normal service and pressure; prevalence of AGI increased with increasing duration of water service interruptions. Investments in the ageing drinking water infrastructure are needed to prevent future low-pressure events and to maintain uninterrupted access to the fundamental public health protection provided by safe water supplies. Households and communities need to increase their awareness of and preparedness for water emergencies to mitigate adverse health impacts.
Majowicz, S. E.; Doré, K.; Flint, J. A.; Edge, V. L.; Read, S.; Buffett, M. C.; McEwen, S.; McNab, W. B.; Stacey, D.; Sockett, P.; Wilson, J. B.
To estimate the magnitude and distribution of self-reported, acute gastrointestinal illness in a Canadian-based population, we conducted a retrospective, cross-sectional telephone survey of approximately 3500 randomly selected residents of the city of Hamilton (Ontario, Canada) from February 2001 to February 2002. The observed monthly prevalence was 10% (95 % CI 9.94-10.14) and the incidence rate was 1.3 (95 % CI 1.1-1.4) episodes per person-year; this is within the range of estimates from other developed countries. The prevalence was higher in females and in those aged < 10 years and 20-24 years. Overall, prevalence peaked in April and October, but a different temporal distribution was observed for those aged < 10 years. Although these data were derived from one community, they demonstrate that the epidemiology of acute gastrointestinal illness in a Canadian-based population is similar to that reported for other developed countries. PMID:15310162
O'Dea, Angela; O'Connor, Paul; Keogh, Ivan
The healthcare industry has seen an increase in the adoption of team training, such as crew resource management (CRM), to improve teamwork and coordination within acute care medical teams. A meta-analysis was carried out in order to quantify the effects of CRM training on reactions, learning, behaviour and clinical care outcomes. Biases in the research evidence are identified and recommendations for training development and evaluation are presented. PUBMED, EMBASE and PsychInfo were systematically searched for all relevant papers. Peer reviewed papers published in English between January 1985 and September 2013, which present empirically based studies focusing on interventions to improve team effectiveness in acute health care domains, were included. A total of 20 CRM-type team training evaluation studies were found to fulfil the a priori criteria for inclusion in the meta-analysis. Overall, CRM trained participants responded positively to CRM (mean score 4.25 out of a maximum of 5), the training had large effects on participants' knowledge (d=1.05), a small effect on attitudes (d=0.22) and a large effect on behaviours (d=1.25). There was insufficient evidence to support an effect on clinical care outcomes or long term impacts. The findings support the premise that CRM training can positively impact teamwork in healthcare and provide estimates of the expected effects of training. However, there is a need for greater precision in outcome assessment, improved standardisation of methods and measures, and more robust research design. Stronger evidence of effectiveness will require multi-level, multicentre, multispecialty and longitudinal studies.
Hunter, Erin C; Callaghan-Koru, Jennifer A; Al Mahmud, Abdullah; Shah, Rashed; Farzin, Azadeh; Cristofalo, Elizabeth A; Akhter, Sadika; Baqui, Abdullah H
Bangladesh has one of the world's highest rates of low birth weight along with prevalent traditional care practices that leave newborns highly vulnerable to hypothermia, infection, and early death. We conducted formative research to explore existing newborn care practices in rural Bangladesh with an emphasis on thermal protection, and to identify potential facilitators, barriers, and recommendations for the community level delivery of kangaroo mother care (CKMC). Forty in-depth interviews and 14 focus group discussions were conducted between September and December 2012. Participants included pregnant women and mothers, husbands, maternal and paternal grandmothers, traditional birth attendants, village doctors, traditional healers, pharmacy men, religious leaders, community leaders, and formal healthcare providers. Audio recordings were transcribed and translated into English, and the textual data were analyzed using the Framework Approach. We find that harmful newborn care practices, such as delayed wrapping and early initiation of bathing, are changing as more biomedical advice from formal healthcare providers is reaching the community through word-of-mouth and television campaigns. While the goal of CKMC was relatively easily understood and accepted by many of the participants, logistical and to a lesser extent ideological barriers exist that may keep the practice from being adopted easily. Women feel a sense of inevitable responsibility for household duties despite the desire to provide the best care for their new babies. Our findings showed that participants appreciated CKMC as an appropriate treatment method for ill babies, but were less accepting of it as a protective method of caring for seemingly healthy newborns during the first few days of life. Participants highlighted the necessity of receiving help from family members and witnessing other women performing CKMC with positive outcomes if they are to adopt the behavior themselves. Focusing intervention
Patel, Kavita; Boutwell, Amy; Brockmann, Bradley W; Rich, Josiah D
Under the Affordable Care Act, up to thirteen million adults have the opportunity to obtain health insurance through an expansion of the Medicaid program. A great deal of effort is currently being devoted to eligibility verification, outreach, and enrollment. We look beyond these important first-phase challenges to consider what people who are transitioning back to the community after incarceration need to receive effective care. It will be possible to deliver cost-effective, high-quality care to this population only if assistance is coordinated between the correctional facility and the community, and across diverse treatment and support organizations in the community. This article discusses several examples of successful coordination of care for formerly incarcerated people, such as Project Bridge and the Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS) program in Rhode Island and the Transitions Clinic program that operates in ten US cities. To promote broader adoption of successful models, we offer four policy recommendations for overcoming barriers to integrating individuals into sustained, community-based care following their release from incarceration.
Kohan, Shahnaz; Sayyedi, Marziyeh; Nekuei, Nafisehsadat; Yousefi, Hojatollah
Background: Midwifery cares take place in diverse communities with different ethnics groups. Therefore, midwifery cares could be planned wisely and principally based on women's and their families’ changeable demands which focus on social and cultural issues. This qualitative study explored the midwives’ experiences of care in the community. Materials and Methods: This qualitative study was conducted by descriptive phenomenological approach. The subjects, selected by purposive sampling, comprised 13 midwives employed in Isfahan, Iran. Semi-structured interviews were audio-taped, transcribed, and simultaneously analyzed through Colaizzi's method. Results: With descriptive analysis of participants’ experiences, three main themes were explored (personal characteristics of the community midwife, social determinants of women's health, and achieving community-based midwifery skills). Conclusions: Knowledge of women's social status, gender inequality in health, and existence of social health risk factors for women in their community helps midwives to provide reproductive health care based on clients’ needs and demands. Therefore, midwives should enhance the quality of their care through integrating professional skills with a full understanding of the social context. PMID:25709700
White, Richard; Swales, Beverley; Butcher, Martyn
The development of infection in a burn can lead to poor healing outcomes and possibly sepsis. Although most patients with burns treated in the primary care setting are unlikely to develop life-threatening infections, clinicians would still benefit from an understanding of the factors that may increase the risk of infection, signs and symptoms of infection, and when to seek specialist advice.
Services for people with mental retardation in the Netherlands are examined, with emphasis on normalization, placement options including group homes and institutionalization, guidance for families through the Social Pedological Service, and the care of mental illness in mentally retarded persons through special diagnostic and treatment centers.…
Richie, Mary Fern; And Others
Psychiatric nursing faculty practice offers the academic nurse opportunity to generate salary support and integrate students into the real world of mental health care. It promotes scholarship and knowledge-building and has a direct impact on the lives of patients. (Author/JOW)
Toombs, Austin Lewis
Recent scholarship in Human-Computer Interaction, science and technology studies, and design research has focused on hacker communities as sites of innovation and entrepreneurship, novel forms of education, and the democratization of technological production. However, hacking practices are more than new technical practices; they are also…
Anderson, Daren R; St Hilaire, Daniel; Flinter, Margaret
Care coordination is a core element of the Patient-Centered Medical Home and requires an effective, well educated nursing staff. A greater understanding of roles and tasks currently being carried out by nurses in primary care is needed to help practices determine how best to implement care coordination and transform into PCMHs. We conducted an observational study of primary care nursing in a Community Health Center by creating a classification schema for nursing responsibilities, directly observing and tracking nurses' work, and categorizing their activities. Ten nurses in eight different practice sites were observed for a total of 61 hours. The vast majority of nursing time was spent in vaccine and medication administration; telephone work; and charting and paper work, while only 15% of their time was spent in activity that was classified broadly as care coordination. Care coordination work appeared to be subsumed by other daily tasks, many of which could have been accomplished by other, lesser trained members of the health care team. Practices looking to implement care coordination need a detailed look at work flow, task assignments, and a critical assessment of staffing, adhering to the principal of each team member working to the highest level of his or her education and license. Care coordination represents a distinct responsibility that requires dedicated nursing time, separate from the day to day tasks in a busy practice. To fully support these new functions, reimbursement models are needed that support such non visit-based work and provide incentives to coordinate and manage complex cases, achieve improved clinical outcomes and enhance efficiency of the health system. This article describes our study methods, data collection, and analysis, results, and discussion about reorganizing nursing roles to promote care coordination.
Smith, Anthony C; Youngberry, Karen; Mill, Julie; Kimble, Roy; Wootton, Richard
A virtual outpatient service has been established in Queensland for the delivery of post-acute burns care to children living in rural and remote areas of the state. The integration of telepaediatrics as a routine service has reduced the need for patient travel to the specialist burns unit situated in Brisbane. We have conducted 293 patient consultations over a period of 3 years. A retrospective review of our experience has shown that post-acute burns care can be delivered using videoconferencing, email and the telephone. Telepaediatric burns services have been valuable in two key areas. The first area involves a programme of routine specialist clinics via videoconference. The second area relates to ad-hoc patient consultations for collaborative management during acute presentations and at times of urgent clinical need. The families of patients have expressed a high degree of satisfaction with the service. Telepaediatric services have helped improve access to specialist services for people living in rural and remote communities throughout Queensland.
DeFelice, Nicholas B; Johnston, Jill E; Gibson, Jacqueline MacDonald
The magnitude and spatial variability of acute gastrointestinal illness (AGI) cases attributable to microbial contamination of U.S. community drinking water systems are not well characterized. We compared three approaches (drinking water attributable risk, quantitative microbial risk assessment, and population intervention model) to estimate the annual number of emergency department visits for AGI attributable to microorganisms in North Carolina community water systems. All three methods used 2007-2013 water monitoring and emergency department data obtained from state agencies. The drinking water attributable risk method, which was the basis for previous U.S. Environmental Protection Agency national risk assessments, estimated that 7.9% of annual emergency department visits for AGI are attributable to microbial contamination of community water systems. However, the other methods' estimates were more than 2 orders of magnitude lower, each attributing 0.047% of annual emergency department visits for AGI to community water system contamination. The differences in results between the drinking water attributable risk method, which has been the main basis for previous national risk estimates, and the other two approaches highlight the need to improve methods for estimating endemic waterborne disease risks, in order to prioritize investments to improve community drinking water systems.
In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.
Brink, Adrian John; Van Wyk, Johan; Moodley, V M; Corcoran, Craig; Ekermans, Pieter; Nutt, Louise; Boyles, Tom; Perovic, Olga; Feldman, Charles; Richards, Guy; Mendelson, Marc
Antibiotic resistance has increased worldwide to the extent that it is now regarded as a global public health crisis. Interventions to reduce excessive antibiotic prescribing to patients can reduce resistance and improve microbiological and clinical outcomes. Therefore, although improving outpatient antibiotic use is crucial, few data are provided on the key interventional components and the effectiveness of antibiotic stewardship in the primary care setting, in South Africa. The reasons driving the excessive prescription of antibiotics in the community are multifactorial but, perhaps most importantly, the overlapping clinical features of viral and bacterial infections dramatically reduce the ability of GPs to distinguish which patients would benefit from an antibiotic or not. As a consequence, the need for tools to reduce diagnostic uncertainty is critical. In this regard, besides clinical algorithms, a consensus of collaborators in European and UK consortia recently provided guidance for the use of C-reactive protein point-of-care testing in outpatients presenting with acute respiratory tract infections (ARTIs) and/or acute cough, if it is not clear after proper clinical assessment whether antibiotics should be prescribed or not. A targeted application of stewardship principles, including diagnostic stewardship as described in this review, to the ambulatory setting has the potential to affect the most common indications for systemic antibiotic use, in that the majority (80%) of antibiotic use occurs in the community, with ARTIs the most common indication.
Background The 23-valent polysaccharide pneumococcal vaccine (PPV-23) is recommended for elderly and high-risk people, although its effectiveness is controversial. Some studies have reported an increasing risk of acute vascular events among patients with pneumonia, and a recent case-control study has reported a reduction in the risk of myocardial infarction among patients vaccinated with PPV-23. Given that animal experiments have shown that pneumococcal vaccination reduces the extent of atherosclerotic lesions, it has been hypothesized that PPV-23 could protect against acute vascular events by an indirect effect preventing pneumonia or by a direct effect on oxidized low-density lipoproteins. The main objective of this study is to evaluate the clinical effectiveness of PPV-23 in reducing the risk of pneumonia and acute vascular events (related or nonrelated with prior pneumonia) in the general population over 60 years. Methods/Design Cohort study including 27,000 individuals 60 years or older assigned to nine Primary Care Centers in the region of Tarragona, Spain. According to the reception of PPV-23 before the start of the study, the study population will be divided into vaccinated and nonvaccinated groups, which will be followed during a consecutive 30-month period. Primary Care and Hospitals discharge databases will initially be used to identify study events (community-acquired pneumonia, hospitalisation for acute myocardial infarction and stroke), but all cases will be further validated by checking clinical records. Multivariable Cox regression analyses estimating hazard ratios (adjusted for age, sex and comorbidities) will be used to estimate vaccine effectiveness. Discussion The results of the study will contribute to clarify the controversial effect of the PPV-23 in preventing community-acquired pneumonia and they will be critical in determining the posible role of pneumococcal vaccination in cardiovascular prevention. PMID:20085658
Background. Thrombolytic therapy (rt-PA) is approved for ischemic stroke presenting within 4.5 hours of symptoms onset. The rate of utilization of rt-PA is not well described in developing countries. Objectives. Our study examined patient characteristics and outcomes in addition to barriers to rt-PA utilization in a tertiary care center in Beirut, Lebanon. Methods. A retrospective chart review of all adult patients admitted to the emergency department during a one-year period (June 1st, 2009, to June 1st, 2010) with a final discharge diagnosis of ischemic stroke was completed. Descriptive analysis was done followed by a comparison of two groups (IV rt-PA and no IV rt-PA). Results. During the study period, 87 patients met the inclusion criteria and thus were included in the study. The mean age was found to be 71.9 years (SD = 11.8). Most patients arrived by private transport (85.1%). Weakness and loss of speech were the most common presenting signs (56.3%). Thirty-three patients (37.9%) presented within 4.5 hours of symptom onset. Nine patients (10.3%, 95% CI (5.5–18.5)) received rt-PA. The two groups (rt-PA versus non rt-PA) had similar outcomes (mortality, symptomatic intracerebral hemorrhage, modified Rankin scale scores, and residual deficit at hospital discharge). Conclusion. In our setting, rt-PA utilization was higher than expected. Delayed presentation was the main barrier to rt-PA administration. Public education regarding stroke is needed to decrease time from symptoms onset to ED presentation and potentially improve outcomes further. PMID:25140255
Pérez Rodríguez, A E; González Ochoa, E; Bravo González, J R; Carlos Silva, L; Linton, T
The present work presents the study of morbidity due to acute respiratory infections (ARI) in areas of the town of Lisa in Ciudad Habana, and Isla Juventud (Cuba), to characterize different aspects of morbidity measured by health care attendance and to measure true morbidity. About 90% of consultations for ARI were first-time consultations, while their ratio to further consultations was 5.3. True morbidity rates (TMR), obtained trough active research, ranged from 110.4 to 163.4 cases per 1000 inhabitants, considerably higher than morbidity rates measured by primary care consultations (MRPCC) in the same time period. The true morbidity index (TMI), as measured by the ratio of the two previous rates, ranged from 5 to 15. A high proportion (47.6%) of cases reported no medical care attendance. These results provide approximate estimates of true morbidity in the study area, and allow the establishment of a new control program, also improving epidemiologic surveillance within primary care activities.
Vaughn, Jennifer E.; Buckley, Sarah A.; Walter, Roland B.
Patients with acute myeloid leukemia (AML) who receive intensive induction or re-induction chemotherapy with curative intent typically experience prolonged cytopenias upon completion of treatment. Due to concerns regarding infection and bleeding risk as well as significant transfusion and supportive care requirements, patients have historically remained in the hospital until blood count recovery—a period of approximately 30 days. The rising cost of AML care has prompted physicians to reconsider this practice, and a number of small studies have suggested the safety and feasibility of providing outpatient supportive care to patients following intensive AML (re-) induction therapy. Potential benefits include a significant reduction of healthcare costs, improvement in quality of life, and decreased risk of hospital-acquired infections. In this article, we will review the currently available literature regarding this practice and discuss questions to be addressed in future studies. In addition, we will consider some of the barriers that must be overcome by institutions interested in implementing an “early discharge” policy. While outpatient management of selected AML patients appears safe, careful planning is required in order to provide the necessary support, education and rapid management of serious complications that occur among this very vulnerable patient population. PMID:27101148
Bazemore, Andrew; Phillips, Robert L.; Etz, Rebecca S.; Stange, Kurt C.
Objectives. We sought to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities. Methods. We conducted 13 semistructured interviews in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard–defining organizations with influence over health care reform policies and implementation. We recorded the interviews and used an editing and immersion–crystallization analysis approach to identify themes. Results. We identified 4 themes: (1) affirmation of primary care as the foundation of a more effective health care system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas. Conclusions. Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health. PMID:22690969
Bohannon, R W; Kloter, K; Cooper, J
This retrospective study of patients with stroke was performed to describe the patients' functional independence on admission to and discharge from physical therapy treatment, determine whether significant functional recovery occurred during the treatment period, and identify independent variables correlating with recovery and outcome at discharge. The Functional Independence Measurement (FIM) system was used to score performance in bed mobility, transfers, locomotion, and stairs. Outcome was indicated by the discharge FIM scores and discharge habitat. The 105 patients whose acute care records were reviewed demonstrated significant improvements between admission and discharge in all functions. Among the variables that correlated significantly with recovery were number of treatments and admission FIM scores. Age and number of treatments correlated significantly with discharge habitat. All FIM scores (admission and discharge) correlated significantly with discharge habitat. Results suggest that FIM scores can be used to document the functional status of patients with stroke in an acute care setting and that the scores have value as predictors of recovery and outcome.
Chan, Regina; Molassiotis, Alexander; Chan, Eunice; Chan, Virene; Ho, Becky; Lai, Chit-ying; Lam, Pauline; Shit, Frances; Yiu, Ivy
A cross-sectional survey was conducted to investigate the nurses' knowledge of and compliance with Universal Precautions (UP) in an acute hospital in Hong Kong. A total of 450 nurses were randomly selected from a population of acute care nurses and 306 were successfully recruited in the study. The study revealed that the nurses' knowledge of UP was inadequate. In addition, UP was not only insufficiently and inappropriately applied, but also selectively practiced. Nearly all respondents knew that used needles should be disposed of in a sharps' box after injections. However, nurses had difficulty in distinguishing between deep body fluids and other general body secretions that are not considered infectious in UP. A high compliance was reported regarding hand-washing, disposal of needles and glove usage. However, the use of other protective wear such as masks and goggles was uncommon. The results also showed no significant relationships between the nurses' knowledge and compliance with UP. It is recommended that UP educational programmes need to consider attitudes in conjunction with empirical knowledge. Nurse managers and occupational health nurses should take a leadership role to ensure safe practices are used in the care of patients.
Zhou, Qi; Hong, Dan; Lu, Jun; Zheng, Defei; Ashwani, Neetica
In this study, we have analyzed both administrative and clinical data from our hospital during 2002 to 2012 to evaluate the influence of government medical policies on reducing abandonment treatment in pediatric patients with acute lymphoblastic leukemia. Two policies funding for the catastrophic diseases and the new rural cooperative medical care system (NRCMS) were initiated in 2005 and 2011, respectively. About 1151 children diagnosed with acute lymphoblastic leukemia were enrolled in our study during this period and 316 cases abandoned treatment. Statistical differences in sex, age, number of children in the family, and family financial status were observed. Of most importance, the medical insurance coverage was critical for reducing abandonment treatment. However, 92 cases abandoning treatment after relapse did not show significant difference either in medical insurance coverage or in duration from first complete remission. In conclusion, financial crisis was the main reason for abandoning treatment. Government-funded health care expenditure programs reduced families’ economic burden and thereby reduced the abandonment rate with resultant increased overall survival. PMID:25393454
Hodges, Helen F; Keeley, Ann C; Troyan, Patricia J
New nurses typically begin their practice in acute care settings in hospitals, where their work is characterized by time constraints, high safety risks for patients, and layers of complexity and difficult problems. Retention of experienced nurses is an issue central to patient safety. The purpose of this qualitative study was to explore the nature of professional resilience in new baccalaureate-prepared nurses in acute care settings and to extrapolate pedagogical strategies that can be developed to support resilience and career longevity. Findings revealed a common process of evolving resilience among participants. New nurses spend a significant amount of time learning their place in the social structure. With positive experiences, they begin to feel more competent with skills and relationships and become increasingly aware of discrepancies between their ideas of professional nursing and their actual experiences in the work setting. The risk of new nurses leaving their practice is constantly present during these struggles. Acceptable compromises yield a reconciliation of the current crisis, typically occurring long after formal precepting has ended. Personal growth is evident by the evolving clarity of professional identity, an edifying sense of purpose, and energy resources to move forward. For new nurses, professional resilience yields the capacity for self-protection, risk taking, and moving forward with reflective knowledge of self.
Forslund, Kerstin; Kihlgren, Mona; Ostman, Ingela; Sørlie, Venke
Acute chest pain is a common reason why people call an emergency medical dispatch (EMD) centre. We examined how patients with acute chest pain experience the emergency call and their pre-hospital care. A qualitative design was used with a phenomenological-hermeneutic approach. Thirteen patients were interviewed, three women and 10 men. The patients were grateful that their lives had been saved and in general were satisfied with their pre-hospital contact. Sometimes they felt that it took too long for the emergency operators to answer and to understand the urgency. They were in a life-threatening situation and their feeling of vulnerability and dependency was great. Time seemed to stand still while they were waiting for help during their traumatic experience. The situation was fraught with pain, fear and an experience of loneliness. A sense of individualized care is important to strengthen trust and confidence between the patient and the pre-hospital personnel. Patients were aware of what number to call to reach the EMD centre, but were uncertain about when to call. More lives can be saved if people do not hesitate to call for help.
Sanger, Patrick; Hartzler, Andrea; Lober, William B.; Evans, Heather L.; Pratt, Wanda
Many current mobile health applications (“apps”) and most previous research have been directed at management of chronic illnesses. However, little is known about patient preferences and design considerations for apps intended to help in a post-acute setting. Our team is developing an mHealth platform to engage patients in wound tracking to identify and manage surgical site infections (SSI) after hospital discharge. Post-discharge SSIs are a major source of morbidity and expense, and occur at a critical care transition when patients are physically and emotionally stressed. Through interviews with surgical patients who experienced SSI, we derived design considerations for such a post-acute care app. Key design qualities include: meeting basic accessibility, usability and security needs; encouraging patient-centeredness; facilitating better, more predictable communication; and supporting personalized management by providers. We illustrate our application of these guiding design considerations and propose a new framework for mHealth design based on illness duration and intensity. PMID:25954465
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.
Sonnenburg, Justin L.; Fischbach, Michael A.
We are never alone. Humans coexist with diverse microbial species that live within and upon us—our so-called microbiota. It is now clear that this microbial community is essentially another organ that plays a fundamental role in human physiology and disease. Basic and translational research efforts have begun to focus on deciphering mechanisms of microbiome function—and learning how to manipulate it to benefit human health. In this Perspective, we discuss therapeutic opportunities in the human microbiome. PMID:21490274
Qureshi, Adnan I; Chaudhry, Saqib A.; Connelly, Bo; Abott, Emily; Janjua, Tariq; Kim, Stanley H.; Miley, Jefferson T.; Rodriguez, Gustavo J.; Uzun, Guven; Watanabe, Masaki
of directives). Intravenous medication and defibrillation for cardiac arrest was withheld in 29% (compared with 19%) of the treatment decisions in the presence of advance health care directives. The two attorney raters found the description of acceptable outcome inadequate in 14 and 21 of 28 advance health care directives reviewed, respectively. The overall mean kappa for agreement regarding adequacy of documentation was modest (43%) for “does the advance health care directive specify which treatments the patient would choose, or refuse to receive if they were diagnosed with an acute, terminal condition?” and lowest (3%) for “description of acceptable outcome”. Conclusions We did not find any prominent differences in most “routine complexity,” “moderate complexity,” or “high complexity” treatment decisions in patient management in the presence of advance health care directives. Presence of advance health care directives also did not reduce the prominent variance among physicians in treatment decisions. PMID:23552508
Zeanah, P D; Morse, E V; Simon, P M; Stock, M; Pratt, J L; Sterne, S
Despite the growing success of school-based health care during the past two decades, the issue of providing reproductive health care at school-based health centers remains controversial. In this article, focus group data from three school-based centers in Louisiana, each in different stages of development, demonstrates how the controversies about reproductive health may frame more general concerns about school-based care. In addition, community readiness to address directly problematic sexual behavior relates not only to the specific needs and priorities of the community but to recognition of the negative effect of the consequences of sexual behavior such as pregnancy, high drop out, and absenteeism rates on a community's educational, rather than social, goals and values.
Simon, Melissa A.; Samaras, Athena T.; Nonzee, Narissa J.; Hajjar, Nadia; Frankovich, Carmi; Bularzik, Charito; Murphy, Kara; Endress, Richard; Tom, Laura S.; Dong, XinQi
Patient navigation is an internationally utilized, culturally grounded, and multifaceted strategy to optimize patients’ interface with the health-care team and system. The DuPage County Patient Navigation Collaborative (DPNC) is a campus–community partnership designed to improve access to care among uninsured breast and cervical cancer patients in DuPage County, IL. Importantly, the DPNC connects community-based social service delivery with the patient-centered medical home to achieve a community-nested patient-centered medical home model for cancer care. While the patient navigator experience has been qualitatively documented, the literature pertaining to patient navigation has largely focused on efficacy outcomes and program cost effectiveness. Here, we uniquely highlight stories of women enrolled in the DPNC, told from the perspective of patient navigators, to shed light on the myriad barriers that DPNC patients faced and document the strategies DPNC patient navigators implemented. PMID:27594792
Asarnow, Joan Rosenbaum; Miranda, Jeanne
This article reviews the literature on interventions and services for depression and suicide prevention among adolescents, with the goals of placing this science within the context of current changing health care environments and highlighting innovative models for improving health and mental health. We examine the: challenges and opportunities offered by new initiatives and legislation designed to transform the U.S. health and mental healthcare systems; summarize knowledge regarding the treatment of depression and suicidality/self-harm in adolescents; and describe innovative models for partnering with health systems and communities. This review demonstrates that treatment models and service delivery strategies are currently available for increasing evidence-based care, particularly for depression, and concludes with recommendations for future research and quality improvement initiatives aimed at inspiring additional efforts to put science to work, bridge science and community practice, and develop strategies for partnering with communities to improve care, mental health, and well-being among adolescents. PMID:24437432
Refuting the widely held belief that the child care crisis in America is irresolvableor that it can be resolved by simply relying on market forcesthis book presents an alternative vision for ensuring that American families with children will have access to high-quality, affordable child care, shifting the perception of the issue as primarily one…
Muncer, Steven J; Hannon, Bronagh C; Goodrich, Joanna; Cornwell, Jocelyn
Objective To evaluate the impact of Schwartz Center Rounds, a multi-disciplinary forum to reflect on the emotional consequences of working in healthcare, on the staff of a large acute general hospital over a three-year period. Design Evaluation data following each Round were collected routinely from all staff attending over this period and analysed quantitatively and qualitatively. Setting An integrated university teaching trust with both acute hospital and community services in the North East of England. Participants Over the three-year period of the study, 795 participant evaluation forms were returned by staff attending the Rounds. Main outcome measures A standard evaluation form completed at the end of each Round by those present, including ratings on a five-point scale against each of eight statements and an opportunity to offer additional free text comments. Results The findings show a very positive response to all aspects of the Rounds by staff who attended. The most highly rated statement was: ‘I have gained insight into how others think/feel in caring for patients’. This was reinforced by the qualitative analysis in which the primary theme was found to be Insight. There were no significant differences between disciplines/staff groups, indicating that all staff whether clinical or non-clinical responded to the Rounds equally positively. Conclusions Schwartz Rounds are highly valued by staff from all disciplines, and by managers and other non-clinicians as well as clinicians. They appear to have the potential to increase understanding between different staff, and so to reduce isolation and provide support. PMID:28050259
Kim, B. K. Elizabeth; Gloppen, Kari M.; Rhew, Isaac C.; Oesterle, Sabrina; Hawkins, J. David
Many interventions seeking to reduce problem behaviors and promote healthy youth development target both risk and protective factors, yet few studies have examined the effect of preventive interventions on overall levels of protection community wide. In a community-randomized controlled trial, this study tested the effect of Communities That Care (CTC) on protective factors in 24 communities across 7 states. Data on protective factors were collected from a panel of 4,407 youths in CTC and control communities followed from Grade 5 through Grade 8. Hierarchical linear modeling compared mean levels of 15 protective factors derived from the social development model in CTC and control communities in Grade 8, adjusted for individual and community characteristics and baseline levels of protective factors in Grade 5. Global test statistics were calculated to examine effects on protection overall and by domain. Analyses across all protective factors found significantly higher levels of overall protection in CTC compared to control communities. Analyses by domain found significantly higher levels of protection in CTC than control communities in the community, school, and peer/individual domains, but not in the family domain. Significantly higher levels of opportunities for prosocial involvement in the community, recognition for prosocial involvement in school, interaction with prosocial peers, and social skills among CTC compared to control youth contributed to the overall and domain specific results. This is consistent with CTC’s theory of change, which posits that strengthening protective factors is a mechanism through which CTC prevents behavior problems. PMID:25366931
Background This paper focuses on the sustainability of existing palliative care teams that provide home-based care in a shared care model. For the purposes of this study, following Evashwick and Ory (2003), sustainability is understood and approached as the ability to continue the program over time. Understanding factors that influence the sustainability of teams and ways to mitigate these factors is paramount to improving the longevity and quality of service delivery models of this kind. Methods Using qualitative data collected in interviews, the aim of this study is twofold: (1) to explore the factors that affect the sustainability of the teams at three different scales, and; (2) based on the results of this study, to propose a set of recommendations that will contribute to the sustainability of PC teams. Results Sustainability was conceptualized from two angles: internal and external. An overview of external sustainability was provided and the merging of data from all participant groups showed that the sustainability of teams was largely dependent on actors and organizations at the local (community), regional (Local Health Integration Network or LHIN) and provincial scales. The three scales are not self-contained or singular entities but rather are connected. Integration and collaboration within and between scales is necessary, as community capacity will inevitably reach its threshold without support of the province, which provides funding to the LHIN. While the community continues to advocate for the teams, in the long-term, they will need additional supports from the LHIN and province. The province has the authority and capacity to engrain its support for teams through a formal strategy. The recommendations are presented based on scale to better illustrate how actors and organizations could move forward. Conclusions This study may inform program and policy specific to strategic ways to improve the provision of team-based palliative home care using a shared
Dosani, Aliyah; Oliver, Lynnette May; Lodha, Abhay K; Young, Marilyn
Purpose In Alberta, the high occurrence of late preterm infants and early hospital discharge of mother-infant dyads has implications for postpartum care in the community. Shortened hospital stay and complexities surrounding the care of biologically and developmentally immature late preterm infants heighten anxiety and fears. Our descriptive phenomenological study explores mothers’ experience of caring for their late preterm infants in the community. Methods Eleven mothers were interviewed using a semi-structured interview guide. Interview transcripts were analysed using an interpretive thematic approach. Findings The mothers’ hospital experience informed their perspective that being a late preterm infant was not a “big deal,” and they tended to treat their infant as normal. “Feeding was really problem,” especially the variability in feeding effectiveness, which was not anticipated. Failing to recognize late preterm infants’ feeding distress exemplified lack of knowledge of feeding cues and tendencies to either rationalize or minimize feeding concerns. Public health nurses represent a source of informational support for managing neonatal morbidities associated with being late preterm; however, maternal experiences with public health nurses varied. Some nurses used a directive style that overwhelmed certain mothers. Seeing multiple public health nurses and care providers was not always effective, given inconsistent and contradictory guidance to care. These new and changing situations increased maternal anxiety and stress and influenced maternal confidence in care. Fathers, family, and friends were important sources of emotional support. Conclusion After discharge, mothers report their lack of preparation to meet the special needs of their late preterm infants. Current approaches to community-based care can threaten maternal confidence in care. New models and pathways of care for late preterm infants and their families need to be responsive to the
Rhyne, Robert L.; Hertzman, Philip A.
The Russian health care system historically has not relied on medical evidence to guide practice, uses centralized management, and is burdened by overspecialization. In 1999, a community health partnership was established between Sarov, Russia, and Los Alamos, NM, 2 cities linked by their nuclear weapons histories. Health problems addressed include asthma and diabetes, pediatric dental caries, low prevalence of breastfeeding, and adolescent drug abuse and sexually transmitted diseases. A community-oriented primary care approach was adopted that includes (1) implementing a “train the trainers” strategy to educate health professionals and lay people, (2) adapting established clinical practice guidelines based on local resources, (3) restricting use of expensive or limited resources, and (4) securing commitments from local government for expendable supplies and medications. PMID:12406797
Christianson, Jon B; Feldman, Roger
When first implemented in Minneapolis and St. Paul, Minnesota, the Buyers Health Care Action Group's (BHCAG) purchasing approach received considerable attention as an employer-managed, consumer-driven health care model embodying many of the principles of managed competition. First BHCAG and, later, a for-profit management company attempted to export this model to other communities. Their efforts were met with resistance from local hospitals and, in many cases, apathy by employers who were expected to be supportive. This experience underscores several difficulties that appear to be inherent in implementing purchasing models based on competing care systems. It also, once again, suggests caution in drawing lessons from community-level experiments in purchasing health care.
Jandorf, Lina; Freemantle, Hurdley; Sly, Jamilia; Ellison, Jennie; Wong, Carrie R.; Villagra, Cristina; Hong, Joseph; Kaleya, Sara; Poultney, Madrid; Villegas, Carmen; Brenner, Barbara; Bickell, Nina
In the largely African American and Hispanic communities of East and Central Harlem in New York City (NYC), health inequities are glaring. Mortality from cancer is 20–30 % higher than in Manhattan and 30–40 % higher than rates in the general population in NYC. Despite advances in risk assessment, early detection, treatment, and survivorship, individuals in Harlem and similar urban communities are not benefiting equally. Guided by community-based participatory research, this study serves as an important step in understanding cancer care needs and the range of factors that impact the disparate rates of cancer in East and Central Harlem. Forty individual interviews were conducted with community leaders and residents. Major themes included: need for appropriate supportive services; health care access and financial challenges; beliefs related to stigma, trust, and accountability; and the impact of the physical environment on health. Education was seen as a critical area of need and intervention. PMID:23108854
The complexity of our health care environment and organizations requires a management style that moves beyond control to empowerment. Even though this complexity minimizes our ability to control events, many organizations are still preoccupied with the illusion of control. This restrains the performance of our health care organizations. Some of the contributing factors supporting this illusion are bureaucracy, scientific methodology, individualism, and our confusion of management with leadership. The concept of "community" is discussed from an organizational perspective. It is suggested that we can improve the performance of our organizations by rediscovering the values of community.
Arthur, Michael W.; Hawkins, J. David; Brown, Eric C.; Briney, John S.; Oesterle, Sabrina; Abbott, Robert D.
Although advances in prevention science over the past two decades have produced a growing list of tested and effective programs and policies for preventing adolescent delinquency and drug use, widespread dissemination and high-quality implementation of effective programs and policies in communities has not been achieved. The Community Youth…
Rolls, Kaye Denise; Hansen, Margaret; Jackson, Debra; Elliott, Doug
Social media platforms can create virtual communities, enabling healthcare professionals to network with a broad range of colleagues and facilitate knowledge exchange. In 2003, an Australian state health department established an intensive care mailing list to address the professional isolation experienced by senior intensive care nurses. This article describes the social network created within this virtual community by examining how the membership profile evolved from 2003 to 2009. A retrospective descriptive design was used. The data source was a deidentified member database. Since 2003, 1340 healthcare professionals subscribed to the virtual community with 78% of these (n = 1042) still members at the end of 2009. The membership profile has evolved from a single-state nurse-specific network to an Australia-wide multidisciplinary and multiorganizational intensive care network. The uptake and retention of membership by intensive care clinicians indicated that they appeared to value involvement in this virtual community. For healthcare organizations, a virtual community may be a communications option for minimizing professional and organizational barriers and promoting knowledge flow. Further research is, however, required to demonstrate a link between these broader social networks, enabling the exchange of knowledge and improved patient outcomes.
Fort, Jane G; McClellan, Linda
An important national health care effort is elimination of racial and ethnic disparities in six specific conditions: infant mortality, cancer screening and management, cardiovascular disease, diabetes, human immunodeficiency virus infection, and child and adult immunizations. To address this concern, several health entities in Nashville, Tennessee responded to a grant initiative from the Centers for Disease Control and Prevention to develop a Racial and Ethnic Approaches to Community Health (REACH) demonstration project. The resulting award is the Nashville REACH 2010 Project, charged to develop sustainable methods to reduce and, in time, eliminate racial and ethnic disparities in cardiovascular disease and diabetes in the North Nashville community, where mortality rates of these diseases are substantially higher than in other parts of the county. As one of its many interests, the project included potential health care providers to receive and disseminate messages about disease prevention and health education. The present paper describes the community-campus partnership between the Nashville REACH 2010 project and the post-baccalaureate program of Meharry Medical College, a partnership that enfolded Meharry's pre-professional health care students into the community-based participatory service research project to increase the awareness and sensitivity of future minority health care providers to issues in minority and poor, underserved populations and to increase potential providers' familiarity with the processes involved in community-based participatory research.
An audit was undertaken of people with a diagnosis of breast cancer who were referred to a community palliative care specialist nursing team over a 12-month period, to explore the reasons for referral to the service and the duration of involvement with the service. Breast cancer patients accounted for 10% of the total referrals to the specialist service, with symptom management (including pain control) and emotional support being the main reasons for referral. The majority of people referred with breast cancer had metastatic breast cancer (87%); interestingly, 13% had primary breast cancer. The mean duration of intervention was 3 months and 1 week. Referrals seemed to occur late in patients' disease trajectories, and total numbers were lower than might be expected. It may be concluded that there is scope for the specialist palliative care team to be a more integral part of care for patients with metastatic breast cancer.
Solorio, Rosa; Bansal, Aasthaa; Comstock, Bryan; Ulatowski, Krista; Barker, Sara
Purpose To evaluate the impact of a clinic-based chronic care coordinator (CCC) intervention on quality of diabetes care, health outcomes and health service utilization within six community health centers serving predominantly low-income Hispanic and non-Hispanic white patients. Methods We used a retrospective cohort study design with a 12-month pre- and 12-month postintervention analysis to evaluate the effect of the CCC intervention and examined: (1) the frequency of testing for glycated hemoglobin (HbAIC), cholesterol LDL level, and microalbumin screen and frequency of retinal and foot exam; (2) outcomes for HbAIC levels, lipid, and blood pressure control; and (3) health care service utilization. Patients with diabetes who received the CCC intervention (n = 329) were compared to a propensity score adjusted control group who are not exposed to the CCC intervention (n = 329). All of the data came from Electronic Medical Record. Four separate sets of analyses were conducted to demonstrate the effect of propensity score matching on results. Results The CCC intervention led to improvements in process measures, including more laboratory checks for HbAIC levels, microalbuminuria screens, retinal and foot exams and also increased primary care visits. However, the intervention did not improve metabolic control. Conclusions CCC interventions offer promise in improving process measures within community health centers but need to be modified to improve metabolic control. PMID:25355532
with mental health problems to care in order to promote successful re-integration into a productive, civilian life. One reintegration domain that is...student veterans ’ mental health needs as they reintegrate and attend two-year community colleges. A concurrent challenge is that many returning student...Linking these suffering student veterans to quality care is critical to their educational success on the new GI bill and their successful re
Uyeno, Jennifer; Heck, Carol S.
ABSTRACT Purpose: To examine discharge planning of patients in general internal medicine units in Ontario acute-care hospitals from the perspective of physiotherapists. Methods: A cross-sectional study using an online questionnaire was sent to participants in November 2011. Respondents' demographic characteristics and ranking of factors were analyzed using descriptive statistics; t-tests were performed to determine between-group differences (based on demographic characteristics). Responses to open-ended questions were coded to identify themes. Results: Mobility status was identified as the key factor in determining discharge readiness; other factors included the availability of social support and community resources. While inter-professional communication was identified as important, processes were often informal. Discharge policies, timely availability of other discharge options, and pressure for early discharge were identified as affecting discharge planning. Respondents also noted a lack of training in discharge planning; accounts of ethical dilemmas experienced by respondents supported these themes. Conclusions: Physiotherapists consider many factors beyond the patient's physical function during the discharge planning process. The improvement of team communication and resource allocation should be considered to deal with the realities of discharge planning. PMID:25125778
Sittig, Dean F; Guappone, Ken; Campbell, Emily M; Dykstra, Richard H; Ash, Joan S
We developed and fielded a survey to help clinical information system designers, developers, and implementers better understand the infusion level, or the extent and sophistication of CPOE feature availability and use by clinicians within acute care hospitals across the United States of America. In the 176 responding hospitals, we found that CPOE had been in place a median of 5 years and that the median percentage of orders entered electronically was 90.5%. Greater than 96% of the sites used CPOE to enter pharmacy, laboratory and imaging orders; 82% were able to access all aspects of the clinical information system with a single sign-on; 86% of the respondents had order sets, drug-drug interaction warnings, and pop-up alerts even though nearly all hospitals were community hospitals with commercial systems; and 90% had a CPOE committee with a clinician representative in place. While CPOE has not been widely adopted after over 30 years of experimentation, there is still much that can be learned from this relatively small number of highly infused (with CPOE and clinical decision support) organizations.
Morozova, Olga; Azbel, Lyuba; Grishaev, Yevgeny; Dvoryak, Sergii; Wickersham, Jeffrey A.; Altice, Frederick L.
Purpose The study aims to assess reentry challenges faced by Ukrainian prisoners and to determine the factors associated with having a greater number of challenges in order to suggest pre- and post-release interventions with the aim of facilitating community reintegration. Design/methodology/approach A representative national cross-sectional study with a sample size of 402 prisoners was conducted among imprisoned adults within six months of release. The study consisted of interviews and biological testing for infectious diseases. Anticipated reentry challenges were assessed using a structured questionnaire. Findings The most difficult and relatively important challenges identified were finding a job or a stable source of income and staying out of prison following release. Risk-specific challenges pertinent to drug users and HIV-infected individuals were assessed as difficult, but generally less important. Similarly, challenges associated with reducing drug relapse were ranked as less important, with only 0.6 percent identifying opioid substitution therapy as a helpful measure. In the multivariate analysis, having a greater number of challenges is associated with previous incarcerations, drug use immediately before incarceration and lower levels of social support. Practical implications To facilitate community re-integration, it is vital to design interventions aimed at reducing recidivism and improvement of social support through comprehensive case management as well as to improve understanding about and address drug dependence issues among inmates by implementing evidence-based treatment both within prisons and after release. Originality/value This is the first comprehensive assessment of community reentry challenges by prisoners in the former Soviet Union. PMID:25152767
Alexander, Gregory L; Alwan, Majd; Batshon, Lynne; Bloom, Shawn M; Brennan, Richard D; Derr, John F; Dougherty, Michelle; Gruhn, Peter; Kirby, Annessa; Manard, Barbara; Raiford, Robin; Serio, Ingrid Johnson
The LTPAC (Long Term Post Acute Care) Health Information Technology (HIT) Collaborative consists of an alliance of long-term services and post-acute care stakeholders. Members of the collaborative are actively promoting HIT innovations in long-term care settings because IT adoption for health care institutions in the United States has become a high priority. One method used to actively promote HIT is providing expert comments on important documents addressing HIT adoption. Recently, the Office of the National Coordinator for HIT released a draft of the Federal Health Information Technology Strategic Plan 2011-2015 for public comment. The following brief is intended to inform about recommendations and comments made by the Collaborative on the strategic plan.
Garets, D E
Healthcare providers are increasingly faced with the need to develop comprehensive, clinically-oriented, community-focused information systems in order to remain financially viable and meet the information demands of healthcare consumers. Some providers interface and integrate their disparate information systems on their own. Others form integrated delivery systems that take advantage of economies of scale from an enterprise approach to information technology management. Still others form health information networks that allow them to pool information technology resources while pursuing independent business goals.
Sharan, Alok D; Millhouse, Paul W; West, Michael E; Schroeder, Gregory D; Vaccaro, Alexander R
The passage of the Patient Protection and Affordable Care Act in March 2010 has resulted in dramatic changes to the delivery of health care in the United States toward a value-based system. While this is a significant change from the previous model, it presents an opportunity for high-quality health care providers to improve patient outcomes while also increasing revenue. However, those that lack a clear strategy to effectively implement change and communicate the increased value to the patients likely will suffer, regardless of how successful or prestigious they seem today.
Turner-Cobb, J.M.; Smith, P.C.; Ramchandani, P.; Begen, F.M.; Padkin, A.
There is a growing awareness amongst critical care practitioners that the impact of intensive care medicine extends beyond the patient to include the psychological impact on close family members. Several studies have addressed the needs of relatives within the intensive care context but the psychobiological impact of the experience has largely been ignored. Such impact is important in respect to health and well-being of the relative, with potential to influence patient recovery. The current feasibility study aimed to examine the acute psychobiological impact of the intensive care experience on relatives. Using a mixed methods approach, quantitative and qualitative data were collected simultaneously. Six relatives of patients admitted to the intensive care unit (ICU) of a District General Hospital, were assessed within 48 h of admission. Qualitative data were provided from semi-structured interviews analysed using interpretative phenomenological analysis. Quantitative data were collected using a range of standardised self-report questionnaires measuring coping responses, emotion, trauma symptoms and social support, and through sampling of diurnal salivary cortisol as a biomarker of stress. Four themes were identified from interview: the ICU environment, emotional responses, family relationships and support. Questionnaires identified high levels of anxiety, depression and trauma symptoms; the most commonly utilised coping techniques were acceptance, seeking support through advice and information, and substance use. Social support emerged as a key factor with focused inner circle support relating to family and ICU staff. Depressed mood and avoidance were linked to greater mean cortisol levels across the day. Greater social network and coping via self-distraction were related to lower evening cortisol, indicating them as protective factors in the ICU context. The experience of ICU has a psychological and physiological impact on relatives, suggesting the importance of
Harper, Sherilee L.; Edge, Victoria L.; Ford, James; Thomas, M. Kate; Pearl, David; Shirley, Jamal; McEwen, Scott A.
Background The incidence of self-reported acute gastrointestinal illness (AGI) in Rigolet, Nunatsiavut, and Iqaluit, Nunavut, is higher than reported elsewhere in Canada; as such, understanding AGI-related healthcare use is important for healthcare provision, public health practice and surveillance of AGI. Objectives This study described symptoms, severity and duration of self-reported AGI in the general population and examined the incidence and factors associated with healthcare utilization for AGI in these 2 Inuit communities. Design Cross-sectional survey data were analysed using multivariable exact logistic regression to examine factors associated with individuals’ self-reported healthcare and over-the-counter (OTC) medication utilization related to AGI symptoms. Results In Rigolet, few AGI cases used healthcare services [4.8% (95% CI=1.5–14.4%)]; in Iqaluit, some cases used healthcare services [16.9% (95% CI=11.2–24.7%)]. Missing traditional activities due to AGI (OR=3.8; 95% CI=1.18–12.4) and taking OTC medication for AGI symptoms (OR=3.8; 95% CI=1.2–15.1) were associated with increased odds of using healthcare services in Iqaluit. In both communities, AGI severity and secondary symptoms (extreme tiredness, headache, muscle pains, chills) were significantly associated with increased odds of taking OTC medication. Conclusions While rates of self-reported AGI were higher in Inuit communities compared to non-Inuit communities in Canada, there were lower rates of AGI-related healthcare use in Inuit communities compared to other regions in Canada. As such, the rates of healthcare use for a given disease can differ between Inuit and non-Inuit communities, and caution should be exercised in making comparisons between Inuit and non-Inuit health outcomes based solely on clinic records and healthcare use. PMID:26001982
Brown Wilson, Christine
Within the literature, the formation of therapeutic relationships between professionals, older people and others significant to them in their lives has been considered as central to current care philosophies. Furthermore, relationships between staff, residents and their families have emerged within the literature as fundamental to the experiences of life within the community of a care home. This paper reports part of a wider study that explored relationships between residents, families and staff. The aim of this paper is to contribute to an understanding of the factors that may be significant in the formation of relationships in care homes, and how this may support the development of community. Three case studies of care homes were undertaken using a constructivist approach. Constructivist methodology seeks to share multiple perceptions between participants with the aim of creating a joint construction. This process supported the development of shared meanings as views and ideas were shared between participants using interviews, participant observation and focus groups. The key factors influencing relationships that emerged were leadership, continuity of staff, personal philosophy of staff and contribution of residents and families. This paper suggests that considering how the style of leadership influences the organisation of care may be a useful starting point in developing community within care homes.
Stock, David; Cowie, Cassandra; Chan, Vincy; Colantonio, Angela; Wodchis, Walter P.; Alter, David; Cullen, Nora
Background: Delayed discharge, captured as alternate-level-of-care days, represents inefficient use of high-demand acute care resources and results in potentially poorer patient outcomes. We performed a study to determine the extent of alternate-level-of-care days among patients who survived hypoxic-ischemic brain injury in inpatient hospital care in Ontario and to identify predictors of alternate-level-of-care use in this population. Methods: A population-based cohort of acute care survivors of hypoxic-ischemic brain injury aged 20 years or more from 2002/03 through 2011/12 was identified. We used 2 case definitions, the more specific identifying patients with a most responsible diagnosis of "anoxic brain damage," and the more sensitive capturing additional likely causative conditions as the most responsible diagnosis. Multivariable zero-inflated negative binomial regression was used to estimate independent effects on the relative incidence of alternate-level-of-care days. Results: We identified 491 patients using the specific case definition and 669 patients using the extended case definition. After deaths were excluded, 232 patients (47.2%) and 278 patients (41.6%), respectively, had at least 1 alternate-level-of-care day (median 20 and 19 d, respectively). In both cohorts, decreasing age, no special care unit hours and acute care episode earlier in the study period were predictive of increased alternate-level-of-care days relative to length of stay. Discharge disposition and psychiatric/behavioural comorbidity were most predictive of having any alternate-level-of-care days. Interpretation: Patients with hypoxic-ischemic brain injury had a greater proportion of alternate-level-of-care days than has been reported for patients with other types of acquired brain injury. This finding suggests that substantial barriers to appropriate discharge exist for this population. Predictors of increased alternate-level-of-care days were also shown to be unique. Further study
Schellong, Julia; Epple, Franziska; Weidner, Kerstin; Möllering, Andrea
A non-neglectable portion of people that have fled to Germany have been subjected to expulsion, violence, torture and grave human loss. In some of them, signs of secondary mental problems are obvious. In the light of the efforts at integration, these diseases must not be neglected. Outlined are the federal legal requirements and how the cost coverage, as well as the admission to health care system, is structured. Additionally, 2 exemplary regional models for psychosomatic health care are being introduced: Dresden's "Stepped Care Model for Psychologically Vulnerable Refugees" includes phased offers for prevention and treatment of acute mental crises, as well as somatoform disorders in refugees and their volunteer helpers. The PSZ in Bielefeld unites already existing expertise of social work and trauma therapy to form a shared project and favors, among other things, training courses and the instruction of language mediators. The local circumstances and differences lead to individual, sometimes totally new solutions. Already existing clinical care offers as well as concepts of trauma therapy are focal points for the development of a comprehensive health care provision. Most effective is a combination of medicinal care, psychosocial networking and psychosomatic treatment. For a working health care provision without parallel structures it is indispensible to use expertise in trauma therapy that is already in place. While being very resource-saving psychosomatic centers offer targeted applications in the network of all actors in refugee care especially when combined with well-trained volunteers and language mediators, informed on the issue of trauma.
... and less likely to be in the West. Definitions Dementia special care units: A distinct unit, wing, ... have a unit or wing meeting the above definition and residents can be separately enumerated. The 2010 ...
Vukoja, Marija; Kashyap, Rahul; Gavrilovic, Srdjan; Dong, Yue; Kilickaya, Oguz; Gajic, Ognjen
Processes to ensure world-wide best-practice for critical care delivery are likely to minimize preventable death, disability and costly complications for any healthcare system's sickest patients, but no large-scale efforts have so far been undertaken towards these goals. The advances in medical informatics and human factors engineering have provided possibility for novel and user-friendly clinical decision support tools that can be applied in a complex and busy hospital setting. To facilitate timely and accurate best-practice delivery in critically ill patients international group of intensive care unit (ICU) physicians and researchers developed a simple decision support tool: Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). The tool has been refined and tested in high fidelity simulated clinical environment and has been shown to improve performance of clinical providers faced with simulated emergencies. The aim of this international educational intervention is to implement CERTAIN into clinical practice in hospital settings with variable resources (included those in low income countries) and evaluate the impact of the tool on the care processes and patient outcomes. To accomplish our aims, CERTAIN will be uniformly available on either mobile or fixed computing devices (as well as a backup paper version) and applied in a standardized manner in the ICUs of diverse hospitals. To ensure the effectiveness of the proposed intervention, access to CERTAIN is coupled with structured training of bedside ICU providers.
Cowin, Leanne S
Poor collegial relations can cause communication breakdown, staff attrition and difficulties attracting new nursing staff. Underestimating the potential power of nursing team relationships means that opportunities to create better working environments and increase the quality of nursing care can be missed. Previous research on improving collegiality indicates that professionalism and work satisfaction increases and that staff attrition decreases. This study explores challenges, strengths and strategies used in nursing team communication in order to build collegial relationships. A qualitative approach was employed to gather nurses experiences and discussion of communication within their nursing teams and a constant comparison method was utilised for data analysis. A convenience sampling technique was employed to access both Registered Nurses and Enrolled Nurses to partake in six focus groups. Thirty mostly female nurses (ratio of 5:1) participated in the study. Inclusion criteria consisted of being a nurse currently working in acute care settings and the exclusion criteria included nursing staff currently working in closed specialty units (i.e. intensive care units). Results revealed three main themes: (1) externalisation and internalisation of nursing team communication breakdown, (2) the importance of collegiality for retention of nurses and (3) loss of respect, and civility across the healthcare workplace. A clear division between hierarchies of nurses was apparent in how nursing team communication was delivered and managed. Open, respectful and collegial communication is essential in today's dynamic and complex health environments. The nurses in this study highlighted how important nursing communication can be to work motivation and how leadership fosters teamwork.
Vuokila-Oikkonen, P; Janhonen, S; Vaisanen, L
The cooperative team meeting is one of the most important interventions in psychiatric care. The purpose of this study was to describe the participation of patients and significant others in cooperative team meetings in terms of unspoken stories. The narrative approach focused on storytelling. The data consisted of videotaped cooperative team meetings (n = 11) in two acute closed psychiatric wards. The QRS NVivo computer program and the Holistic Content Reading method were used. During the process of analysis, the spoken and unspoken stories were analysed at the same time. According to the results, while there was some evident shared-rhythm cooperation (the topics of discussion were shared and the participants had eye contact), there were many instances where the interaction was controlled and defined by health care professionals. This lack of shared rhythm in cooperation, as defined in terms of storytelling, was manifested as monologue and the following practices: the health care professionals controlled the storytelling by sticking to their opinions, by giving the floor or by pointing with a finger and visually scanning the participants, by interrupting the speaker or by allowing the other experts to sit passively. Implications for mental health nursing practice are discussed.
DeCourtney, Christine A; Jones, Kristina; Merriman, Melanie P; Heavener, Nina; Branch, P Kay
End-of-life programs that provide an option for patients to die at home are available in most U.S. communities. However, Alaska Natives living in remote Alaska villages often die alone in hospitals and nursing homes hundreds of miles away from home. The Bristol Bay Area Health Corporation (BBAHC), a tribal organization, is the sole provider of comprehensive primary care services to 34 Alaska Native villages located within a 46,000 square mile area in southwest Alaska. The closest tertiary care hospital is 329 air miles away in Anchorage. Because of the high cost of, and difficulties encountered in trying to deliver end-of-life care services to remote communities, a village-focused, culturally sensitive, volunteer and primary care program combined with a regionally based physician and home health nurse to deliver multi-disciplinary palliative care was developed. The Helping Hands Program blends cultural practices with contemporary palliative care medicine to allow Alaska Natives and others living in remote communities to be cared for at home through the end of life. Since the program was implemented in 1999, the percentage of home deaths for selected causes has changed from 33% in 1997 to 77% in 2001. The Anchorage-based Alaska Native Tribal Health Consortium (ANTHC) and the Alaska Native Medical Center (ANMC) have recognized the importance and success of the BBAHC program and are investigating expanding the program to other parts of Alaska. Centralizing the program in Anchorage will allow staff trained in palliative care to travel to regional Alaska Native hospitals to help train health care professionals.
South, Jane; Darby, Frances; Bagnall, Anne-Marie; White, Alan
Within the UK, there is growing recognition that individuals will need to take increased responsibility for managing their own health for there to be improvements in population health. The current evidence base on self care interventions reflects an interest in enhancing self care knowledge, skills and behaviour in relation to the management of long-term conditions. In contrast,