Using Infant Massage Following a Mother's Unfavorable Neonatal Intensive Care Unit Experiences: A Case Study

ERIC Educational Resources Information Center

Lappin, Grace

2005-01-01

The purpose of this case study was to explore the synchronous behaviors enacted by mother and infant with blindness. In the study, a mother's less than optimal experience with the neonatal intensive care unit (NICU) had a profound effect not only on her and her infant son, who was born 3 months prematurely and was visually impaired, but also on…

Work climate in Mexican hemodialysis units: a cross-sectional study.

PubMed

Rojas Russell, M; Tirado Gómez, L L; Pacheco Domínguez, R L; Escamilla Santiago, R; López Cervantes, M

2011-01-01

The work climate (WC) affects the performance of service providers and has an impact on the care provided to users. This is important in the case of conditions that affect the quality of life, as is the case of chronic kidney disease (CKD) treated with haemodialysis. In Mexico, the demand for the care of CKD cases is increasing and the haemodialysis offer is limited. The purpose of this study was to describe and compare the WC in public, private and social security haemodialysis units in Mexico and to validate a tool to measure WC in haemodialysis units (HU). 372 professionals from 84 HU in 27 states were interviewed using a questionnaire. This included questions about the WC, quality of care and structure and organisation of the HU. Variables were compared by type of institution and profession. Significant correlations were observed between the WC and indicators of the quality of care. Nine out of fourteen variables presented important differences by type of unit, with a better perception of WC in private units and a poorer perception in social security ones. The perception of WC relies on the organisation and planning of the institutions, as well as on their infrastructure. In the case of Social Security HU in Mexico, these appear to be the areas that require improvement in order to encourage a better work climate.

Catheter-related Saccharomyces cerevisiae Fungemia Following Saccharomyces boulardii Probiotic Treatment: In a child in intensive care unit and review of the literature.

PubMed

Atıcı, Serkan; Soysal, Ahmet; Karadeniz Cerit, Kıvılcım; Yılmaz, Şerife; Aksu, Burak; Kıyan, Gürsu; Bakır, Mustafa

2017-03-01

Although Saccharomyces boulardii is usually a non-pathogenic fungus, in rare occasions it can cause invasive infection in children. We present the case of an 8-year-old patient in pediatric surgical intensive care unit who developed S. cerevisiae fungemia following probiotic treatment containing S. boulardii . Caspofungin was not effective in this case and he was treated with amphotericin B. We want to emphasize that physicians should be careful about probiotic usage in critically ill patients.

The physical environment and patients' activities and care: A comparative case study at three newly built stroke units.

PubMed

Anåker, Anna; von Koch, Lena; Sjöstrand, Christina; Heylighen, Ann; Elf, Marie

2018-04-20

To explore and compare the impact of the physical environment on patients' activities and care at three newly built stroke units. Receiving care in a stroke unit instead of in a general ward reduces the odds of death, dependency and institutionalized care. In stroke units, the design of the physical environment should support evidence-based care. Studies on patients' activities in relation to the design of the physical environment of stroke units are scarce. This work is a comparative descriptive case study. Patients (N = 55) who had a confirmed diagnosis of stroke were recruited from three newly built stroke units in Sweden. The units were examined by non-participant observation using two types of data collection: behavioural mapping analysed with descriptive statistics and field note taking analysed with deductive content analysis. Data were collected from April 2013 - December 2015. The units differed in the patients' levels of physical activity, the proportion of the day that patients spent with health professionals and family presence. Patients were more physically active in a unit with a combination of single and multi-bed room designs than in a unit with an entirely single-room design. Stroke units that were easy to navigate and offered variations in the physical environment had an impact on patients' activities and care. Patients' activity levels and interactions appeared to vary with the design of the physical environments of stroke units. Stroke guidelines focused on health status assessments, avoidance of bed-rest and early rehabilitation require a supportive physical environment. © 2018 The Authors. Journal of Advanced Nursing Published by John Wiley & Sons Ltd.

Urine output on an intensive care unit: case-control study.

PubMed

Solomon, Anthony W; Kirwan, Christopher J; Alexander, Neal D E; Nimako, Kofi; Jurukov, Angela; Forth, Rebecca J; Rahman, Tony M

2010-12-14

To compare urine output between junior doctors in an intensive care unit and the patients for whom they are responsible. Case-control study. General intensive care unit in a tertiary referral hospital. 18 junior doctors responsible for clerking patients on weekday day shifts in the unit from 23 March to 23 April 2009 volunteered as "cases." Controls were the patients in the unit clerked by those doctors. Exclusion criteria (for both groups) were pregnancy, baseline estimated glomerular filtration rate <15 ml/min/1.73 m(2), and renal replacement therapy. Oliguria (defined as mean urine output <0.5 ml/kg/hour over six or more hours of measurement) and urine output (in ml/kg/hour) as a continuous variable. Doctors were classed as oliguric and "at risk" of acute kidney injury on 19 (22%) of 87 shifts in which urine output was measured, and oliguric to the point of being "in injury" on one (1%) further shift. Data were available for 208 of 209 controls matched to cases in the data collection period; 13 of these were excluded because the control was receiving renal replacement therapy. Doctors were more likely to be oliguric than their patients (odds ratio 1.99, 95% confidence interval 1.08 to 3.68, P=0.03). For each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was 0.27 (0.12 to 0.58, P=0.001). Mortality among doctors was astonishingly low, at 0% (0% to 18%). Managing our own fluid balance is more difficult than managing it in our patients. We should drink more water. Modifications to the criteria for acute kidney injury could be needed for the assessment of junior doctors in an intensive care unit.

Patient-driven resource planning of a health care facility evacuation.

PubMed

Petinaux, Bruno; Yadav, Kabir

2013-04-01

The evacuation of a health care facility is a complex undertaking, especially if done in an immediate fashion, ie, within minutes. Patient factors, such as continuous medical care needs, mobility, and comprehension, will affect the efficiency of the evacuation and translate into evacuation resource needs. Prior evacuation resource estimates are 30 years old. Utilizing a cross-sectional survey of charge nurses of the clinical units in an urban, academic, adult trauma health care facility (HCF), the evacuation needs of hospitalized patients were assessed periodically over a two-year period. Survey data were collected on 2,050 patients. Units with patients having low continuous medical care needs during an emergency evacuation were the postpartum, psychiatry, rehabilitation medicine, surgical, and preoperative anesthesia care units, the Emergency Department, and Labor and Delivery Department (with the exception of patients in Stage II labor). Units with patients having high continuous medical care needs during an evacuation included the neonatal and adult intensive care units, special procedures unit, and operating and post-anesthesia care units. With the exception of the neonate group, 908 (47%) of the patients would be able to walk out of the facility, 492 (25.5%) would require a wheelchair, and 530 (27.5%) would require a stretcher to exit the HCF. A total of 1,639 patients (84.9%) were deemed able to comprehend the need to evacuate and to follow directions; the remainder were sedated, blind, or deaf. The charge nurses also determined that 17 (6.9%) of the 248 adult intensive care unit patients were too ill to survive an evacuation, and that in 10 (16.4%) of the 61 ongoing surgery cases, stopping the case was not considered to be safe. Heath care facilities can utilize the results of this study to model their anticipated resource requirements for an emergency evacuation. This will permit the Incident Management Team to mobilize the necessary resources both within the facility and the community to provide for the safest evacuation of patients.

PP165. Treatment approaches for preeclampsia: A sample from a big city of a developing country.

PubMed

De Oliveira, L; Rocha, R M; Da Silva, L L; Rosas, C F; Korkes, H; Sass, N

2012-07-01

Preeclampsia is a major cause of maternal morbidity and mortality worldwide, mainly in developing countries. Here we show an example of how is the clinical condition of these patients when they are referred from first care units to a tertiary care teaching maternity in the city of São Paulo, Brazil. To evaluate how has been the approach for preeclamptic women in a big city of Brazil, an example of developing country. This is a retrospective study that evaluated 41 patients that were referred to our hospital from August 2010 to December 2011. In most of the cases patients were referred due to elevations in blood pressure. The diagnosis of preeclampsia was based on the ISSHP recommendations. The diagnosis of severe preeclampsia was based either on clinical symptoms and/or laboratory parameters. Fetal distress was defined when Doppler velocimetry assessment demonstrated abnormal parameters (centralization with abnormal diastolic blood flow at umbilical arteries). Severe preeclampsia was diagnosed in 26 cases (63.4%) and 34 patients were treated with magnesium sulfate (82.9%). One case of eclampsia (2.4%) and five cases of "Abruptio Placentae" (12.1%) were registered. Fetal distress was diagnosed at the moment of admission in 13 cases (31.7%) and two of these fetuses ended in stillbirth (4.8%). Neonatal death occurred in three cases (7.3%), mainly due to extreme preterm delivery. Other outcomes are reported in the following table. ICU: Intensive Care Unit. This is a good example of how has been the approach of preeclamptic women in a big city of Brazil. Our results suggest that a special concern about the moment of referring these patients to tertiary care units should be taken by doctors at first care units. Copyright © 2012. Published by Elsevier B.V.

Unique manifestations of catecholamine release in malignant pheochromocytoma: an experience within an inpatient palliative care unit.

PubMed

Coupe, Nicholas Anthony; Lacey, Judith; Sanderson, Christine

2012-05-01

Malignant pheochromocytoma is a rare disorder. We describe the case of a 41-year-old female with disseminated metastatic pheochromocytoma who was admitted for ongoing palliative and supportive care within an inpatient palliative care unit. Predominant symptoms included severe gastrointestinal pseudo-obstruction and orthostatic hypotension Pseudo-obstruction management included percutaneous enterogastric and percutaneous enterojejunostomy tubes for gastric decompression and delivery of nutrition, respectively. Debilitating symptoms of orthostatic hypotension were mitigated with judicious fluid balance and appropriate use of adrenergic blocking agents. The potential for metoclopramide to worsen symptoms also was a significant component of management. The case presents rare features of this unusual disease and is unique for its setting within the confines of a palliative care unit. Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.

Personal, Occupational, and Public Health Perspectives on Dealing with the First Case of Influenza A (H1N1) in the United Arab Emirates

PubMed Central

Shah, Syed M.; Blair, Iain; Hashmey, Rayhan; Sheek-Hussein, Mahmoud

2011-01-01

New epidemics of infectious diseases often involve health care workers. In this short communication we present a case report of a health care professional who became the first case of influenza H1N1 virus to be notified in the United Arab Emirates. There are several issues related to workplace considerations and general public health, including preventive measures, the need for isolation of the patient, dealing with contacts, return to work, and communication with the workforce. PMID:22953191

[Economic evaluation of nosocomial infections in pediatric intensive care units in Lithuania].

PubMed

Gurskis, Vaidotas; Kėvalas, Rimantas; Kerienė, Virginija; Vaitkaitienė, Eglė; Miciulevičienė, Jolanta; Dagys, Algirdas; Ašembergienė, Jolanta; Grinkevičiūtė, Dovilė

2010-01-01

The aim of this study was to estimate direct costs related to nosocomial infection in three pediatric intensive care units in Lithuania and to overview the effectiveness of preventive programs of nosocomial infections. A prospective empirical surveillance study was launched in 3 Lithuanian pediatric intensive care units during the period of January 2005 to December 2007. Using the method of targeted selection, all children aged from 1 month and 18 years, treated in pediatric intensive care units for more than 48 hours, were enrolled into the study. Direct costs of nosocomial infections in pediatric intensive care units were calculated for each patient and each case of nosocomial infection. For calculation of average expenditures per patient-day, data from nosocomial infection registry and from analysis of hospital income for services provided at pediatric intensive care units according to price-list of health care price approved by the order of the Minister of Health of the Republic of Lithuanian (No. V-802, October 27, 2005) were used. According to length of stay, costs of intensive care services, and costs caused by nosocomial infections, all the patients were divided into two groups: those who did and did not acquire an infection. For the evaluation of economic efficiency, the patients were divided into other two groups: pre- and postintervention groups. All economic evaluation was made in national currency (litas). The data of 755 patients were used. Multiple linear regression analysis (R(2)=0.47) revealed a 6.32-day increase (95% CI, 4.32-8.33; P=0.003) in hospital stay in a pediatric intensive care unit if a patient acquired nosocomial infection. Costs related to nosocomial infections for one patient made up 5215.47 litas (95% CI, 3565.00-6874.19). Average costs caused by one nosocomial infection case were 4070.61 litas (95% CI, 2782.44-5365.22). Nosocomial infection prevention programs (interventions) gave a total economical effect of 20046.14 litas. Prevention of one patient from nosocomial infection caused a reduction of 1336.41 litas, and one avoided nosocomial infection case resulted in a 1113.67-litas reduction; cost-to-effect ratio was 1:4. Total costs related to nosocomial infections in pediatric intensive care units were high. The implementation of nosocomial infection prevention program resulted in a positive economic effect - 1 litas spent for the prevention of nosocomial infections saved 4 litas.

A patient with autism and severe depression: medical and ethical challenges for an adolescent medicine unit.

PubMed

Skinner, S Rachel; Ng, Cindy; McDonald, Ann; Walters, Tamara

2005-10-17

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

Missed nursing care: the impact on intention to leave and turnover.

PubMed

Tschannen, Dana; Kalisch, Beatrice J; Lee, Kyung Hee

2010-12-01

The purpose of the study was to examine the relationship between missed nursing care, nurse turnover, and intention to leave. A cross-sectional study using the MISSCARE Survey was conducted. The sample comprised 110 patient-care units in 10 acute-care hospitals. Staffing data, turnover rates, and unit-level Case Mix Index were collected from the participating hospitals. Higher percentages of females on the unit were associated with lower turnover rates (beta = -.235, p = .010). Units with higher rates of missed care (beta = .302, p < .0001) and absenteeism (beta = .247, p = .034) had more staff with intention to leave. Units with nursing staffwho worked overtime (beta = -.283, p = .001) and who were over 35 years of age (beta = -.270, p = .050) were less likely to have staff with intention to leave. By minimizing missed nursing care, organizations may be able to improve satisfaction and reduce intention to leave (and subsequent turnover).

[Case management in long-term care--the task of individual related and family-oriented support for people in need of care and its realization through the reform of long-term care insurance].

PubMed

Klie, Thomas; Monzer, Michael

2008-04-01

The introduction of standardized Case Management structures to improve coordination and cooperation of all involved in care, such as cost units, service providers, voluntary organizations, families and the different occupational categories involved in nursing, is the main concern of the current reform of German long-term care insurance. In this article, demands on Case Management in care are enunciated and the basics found in expert talks, needed for efficient support of care, assembled. In doing so, the role and function of Case Management is differentiated, the different levels (case, organizational and system levels) distinguished and options and conditions needed to settle such an organization are introduced.

Association between Pseudomonas aeruginosa positive water samples and healthcare-associated cases: nine-year study at one university hospital.

PubMed

Lefebvre, A; Bertrand, X; Quantin, C; Vanhems, P; Lucet, J-C; Nuemi, G; Astruc, K; Chavanet, P; Aho-Glélé, L S

2017-07-01

To study the association between the results of water samples and Pseudomonas aeruginosa healthcare-associated cases in a French university hospital. Generalized Estimating Equations were used on complete case and imputed datasets. The spatial unit was the building and the time unit was the quarter. For the period 2004-2013, 2932 water samples were studied; 17% were positive for P. aeruginosa. A higher incidence of P. aeruginosa cases was associated with a higher proportion of positive water samples (P=0.056 in complete case analysis and P=0.031 with the imputed dataset). The association was no longer observed when haematology and intensive care units were excluded, but was significant in analyses of data concerning intensive care units alone (P<0.001). This study suggests that water outlet contamination in hospitals can lead to an increase in healthcare-associated P. aeruginosa cases in wards dealing with susceptible patients, but does not play a significant role in other wards. Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Changes in case-mix and outcomes of critically ill patients in an Australian tertiary intensive care unit.

PubMed

Williams, T A; Ho, K M; Dobb, G J; Finn, J C; Knuiman, M W; Webb, S A R

2010-07-01

Critical care service is expensive and the demand for such service is increasing in many developed countries. This study aimed to assess the changes in characteristics of critically ill patients and their effect on long-term outcome. This cohort study utilised linked data between the intensive care unit database and state-wide morbidity and mortality databases. Logistic and Cox regression was used to examine hospital survival and five-year survival of 22,298 intensive care unit patients, respectively. There was a significant increase in age, severity of illness and Charlson Comorbidity Index of the patients over a 16-year study period. Although hospital mortality and median length of intensive care unit and hospital stay remained unchanged, one- and five-year survival had significantly improved with time, after adjusting for age, gender; severity of illness, organ failure, comorbidity, 'new' cancer and diagnostic group. Stratified analyses showed that the improvement in five-year survival was particularly strong among patients admitted after cardiac surgery (P = 0.001). In conclusion, although critical care service is increasingly being provided to patients with a higher severity of acute and chronic illnesses, long-term survival outcome has improved with time suggesting that critical care service may still be cost-effectiveness despite the changes in case-mix.

Editor's Choice - Acute Cardiovascular Care Association Position Paper on Intensive Cardiovascular Care Units: An update on their definition, structure, organisation and function.

PubMed

Bonnefoy-Cudraz, Eric; Bueno, Hector; Casella, Gianni; De Maria, Elia; Fitzsimons, Donna; Halvorsen, Sigrun; Hassager, Christian; Iakobishvili, Zaza; Magdy, Ahmed; Marandi, Toomas; Mimoso, Jorge; Parkhomenko, Alexander; Price, Susana; Rokyta, Richard; Roubille, Francois; Serpytis, Pranas; Shimony, Avi; Stepinska, Janina; Tint, Diana; Trendafilova, Elina; Tubaro, Marco; Vrints, Christiaan; Walker, David; Zahger, Doron; Zima, Endre; Zukermann, Robert; Lettino, Maddalena

2018-02-01

Acute cardiovascular care has progressed considerably since the last position paper was published 10 years ago. It is now a well-defined, complex field with demanding multidisciplinary teamworking. The Acute Cardiovascular Care Association has provided this update of the 2005 position paper on acute cardiovascular care organisation, using a multinational working group. The patient population has changed, and intensive cardiovascular care units now manage a large range of conditions from those simply requiring specialised monitoring, to critical cardiovascular diseases with associated multi-organ failure. To describe better intensive cardiovascular care units case mix, acuity of care has been divided into three levels, and then defining intensive cardiovascular care unit functional organisation. For each level of intensive cardiovascular care unit, this document presents the aims of the units, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region/area. This update emphasises cardiologist training, referring to the recently updated Acute Cardiovascular Care Association core curriculum on acute cardiovascular care. The training of nurses in acute cardiovascular care is additionally addressed. Intensive cardiovascular care unit expertise is not limited to within the unit's geographical boundaries, extending to different specialties and subspecialties of cardiology and other specialties in order to optimally manage the wide scope of acute cardiovascular conditions in frequently highly complex patients. This position paper therefore addresses the need for the inclusion of acute cardiac care and intensive cardiovascular care units within a hospital network, linking university medical centres, large community hospitals, and smaller hospitals with more limited capabilities.

Role of More Active Identification of Brain-Dead Cases in Increasing Organ Donation.

PubMed

Sadegh Beigee, Farahnaz; Mohsenzadeh, Mojtaba; Shahryari, Shagin; Mojtabaee, Meysam

2017-02-01

Organ donor shortage is a worldwide problem, resulting in 10% to 30% mortality rates for patients on wait lists for organ transplant. For brain-dead patients in Iran, it is mandatory for intensive care unit patients with Glasgow Coma Scale below 5/15 to be reported to an organ procurement unit. However, this process has not been functioning effectively. Here, we present the effects of changing the strategies on detecting brain-dead cases on the organ donor pool. From March 2015 to March 2016, we changed our strategy in active detection of brain-dead cases. Since March 2015, our newly established protocol for active detection of brain-dead cases includes the following changes: (1) instead of calling high-volume intensive care units 3 times per week, we switched to calling every day in the morning; (2) instead of calling low-volume intensive care units 1 time per week, we switched to calling 3 times per week; (3) we included intensive care units (cardiac and general), neurosurgery, and emergency departments, as well as nursing supervisor offices, in our call and visit lists; and (4) we increased visits to wards by our trained staff as inspectors. From March 2015 to March 2016, the number of reported suspected brain-dead cases has increased from 224 to 460 per year, with proven brain death increasing from 180 to 306 cases. The actual number of donors has also increased, from 116 to 165 donations (53% increase) over 1 year. More proactive strategies have had significant effects on brain-dead detection, resulting in significantly increased donor pools and organ donations. In countries with low cooperation of hospital staff, more proactive engagement in detecting brain-dead cases is a good solution to prevent loss of potential organ donors, with a final result of decreasing wait list mortality.

Patient engagement: four case studies that highlight the potential for improved health outcomes and reduced costs.

PubMed

Laurance, Jeremy; Henderson, Sarah; Howitt, Peter J; Matar, Mariam; Al Kuwari, Hanan; Edgman-Levitan, Susan; Darzi, Ara

2014-09-01

The energy of patients and members of the public worldwide who care about improving health is a huge, but still largely unrecognized and untapped, resource. The aim of patient engagement is to shift the clinical paradigm from determining "what is the matter?" to discovering "what matters to you?" This article presents four case studies from around the world that highlight the proven and potential abilities of increased patient engagement to improve health outcomes and reduce costs, while extending the reach of treatment and diagnostic programs into the community. The cases are an online mental health community in the United Kingdom, a genetic screening program in the United Arab Emirates, a World Health Organization checklist for new mothers, and a hospital-based patient engagement initiative in the United States. Evidence from these and similar endeavors suggests that closer collaboration on the part of patients, families, health care providers, health care systems, and policy makers at multiple levels could help diverse nations provide more effective and population-appropriate health care with fewer resources. Project HOPE—The People-to-People Health Foundation, Inc.

Nurses' performance on primary care in the National Health Service in England.

PubMed

Toso, Beatriz Rosana Gonçalves de Oliveira; Filippon, Jonathan; Giovanella, Ligia

2016-01-01

To analyze the expansion of nursing roles in primary care in the English National Health Service and the implications for professional practice. qualitative research in case study format, held in London, England, in six primary care units. Data were obtained through interviews with nine nurses. After the thematic data analysis, two units emerged: the nurses' performance characteristics and effects of the expansion of nursing roles. expansion of nurses' roles: consultation, diagnosis and drug therapy, case management and monitoring of chronic conditions. Repercussions: for the user, there was improved access, communication and comprehensive care, increased duration of consultations, resulting in greater adherence; for nurses, there was the expansion of professional skills, knowledge and professional recognition; to the health care system, it resulted in cost savings. benefits in expanding nursing roles, were visible, contributing to primary care quality.

A synopsis of current haemophilia care in Hong Kong.

PubMed

Au, W Y; Lee, Vincent; Kho, Bonnie; Ling, Alvin S C; Chan, Desmond; Chan, Eric Y T; Chan, Godfrey C F; Cheung, Winnie W W; Lau, C W; Lee, C Y; Li, Rever C H; Li, C K; Lin, S Y; Mak, Vivien; Sun, Lina; Wong, Kris H F; Wong, Raymond; Yau, Jeffrey; Yuen, H L

2011-06-01

To provide a synopsis of current haemophilia care in Hong Kong. Retrospective survey. All haematology units of the Hospital Authority in Hong Kong. All patients with haemophilia A and haemophilia B. To date, there were 222 mild-to-severe haemophilia patients (192 type A, 30 type B) under regular public care in Hong Kong (43% were considered severe, 33% moderate, and 24% mild), which gave a crude prevalence of 6.8/100 000 male inhabitants. A total of 12.8 million units of Factor VIII and 3 million units of Factor IX were prescribed annually. This amounts to 1.83 units of FVIII per capita of the population, which is comparable to that of other developed countries. Leading causes of mortality were human immunodeficiency virus-related complications (10 cases) and cerebral bleeding (2 cases). The life expectancy of patients with severe haemophilia in Hong Kong is improving; currently the oldest patient is 60 years old. Such improved survival may be due to enhanced factor availability, prompt treatment of bleeding episodes at home, safer factor products, and better antiviral treatment. Primary prophylaxis is the accepted standard of care for severe and moderate cases, and "Factor First" has become hospital policy. However, 12 patients continue to present treatment challenges, due to the documented presence of factor inhibitors. In all, 28, 100, and 14 cases respectively were positive for human immunodeficiency virus, hepatitis C virus, and hepatitis B virus; the youngest patients with the corresponding infections being 28, 13, and 22 years old. Comprehensive care with dedicated physiotherapy, surgical support, and radionucleotide synovectomy may reduce morbidity further. A multidisciplinary approach can further improve the future care for haemophilia patients in Hong Kong.

[The response of the intensive care units during the influenza A H1N1 pandemic: the experience in Chiapas, Mexico].

PubMed

Volkow, Patricia; Bautista, Edgar; de la Rosa, Margarita; Manzano, Graciela; Muñoz-Torrico, Marcela Verónica; Pérez-Padilla, Rogelio

2011-01-01

Respiratory virus epidemics had highlighted the importance of the Intensive Care Unit (ICU) to save life of severe cases. ICU functioning and outcomes depends on infrastructure and trained healthcare personnel. In Chiapas, a Southern state in Mexico,an area to care for severe H1N1 cases on respiratory distress during the second H1N1-2009 outbreak, had to be habilitated.This had to be done without sufficient equipment and ICU un-experienced healthcare workers. It was possible to improve its performance through training and standardizing attention care processes for critically ill patients. In preparation for the next pandemic it is essential to designate hospitals with preexistent ICU where to refer severe cases and avoid improvisations.The experience in Chiapas showed that standardization of medical care processes are clue and in case of an overwhelming emergency it is possible to habilitate an ICU although it is imperative to take advantage from installed facilities in each city with the official authority.

Root causes for late presentation of severe neonatal hyperbilirubinaemia in Egypt.

PubMed

Iskander, I; Gamaleldin, R; Kabbani, M

2012-08-01

This study aimed to understand the reasons for late presentation of cases of severe neonatal hyperbilirubinaemia. We administered a questionnaire to parents of 130 infants with severe jaundice admitted to Cairo University Children's Hospital neonatal intensive care unit at age > or = 6 days over an 18-month period. Although 125 infants (96.2%) were delivered in a health care facility, no discharge physical examination was performed in 99/125 cases (79.2%). No parent was given instructions about neonatal jaundice and no follow-up appointments were scheduled. Parents of 109 infants sought medical advice prior to hospital readmission; most babies were assessed clinically, but serum bilirubin was measured in only one-quarter of cases (28/109). Medical advice included placing the infant under a neon lamp at home (87/109 cases), advice to supplement breastfeeding (75/109) and prescribed medications, including vitamins (15/109). Increasing the availability of inexpensive point-of-care diagnostic instruments and phototherapy units in health care facilities are urgently needed.

Women's experiences of nurse case management on a gynaecological oncology unit in a Swiss tertiary hospital. A thematic analysis.

PubMed

Grob, Silvia; Bläuer, Cornelia; Frei, Irena Anna

2017-12-01

Women with gynaecological cancer face various physical, social and emotional challenges concerning their health. Existing research shows that case management can improve patient satisfaction and reduce readmission rates. Although nurse case management was introduced on a gynaecological oncology unit in a Swiss university hospital in 2013, little is known about the experiences of female patients on a unit that uses this model of care. The aims were to explore women's experiences and to gain deeper understanding about hospital-based nurse case management on a gynaecological oncology unit and to qualitatively evaluate the concept of nurse case management. Sound research knowledge suggests that experiences are best explored with a qualitative research design. Ten participant interviews were conducted and inductively analysed between September 2014 and May 2015 as described by the thematic analysis method. Ethical approval was obtained, and the women signed a consent form. The first theme was named continuous relationship, with the nurse case manager as contact person and trusted partner. Study participants explained that friendliness and being present were essential qualities of nurse case management. Secondly, an essential support for women dealing with the situation of gynaecological cancer was described in the theme sharing information. The organisation of rehabilitation and other services by the nurse case management defined the third theme coordinating care. Trust was seen as the basis of the continuous relationship, marked by friendliness and presence of the nurse case manager. The helpful approach of persons practicing nurse case management made dealing with the situation of illness easier for women with gynaecological cancer. Coordination of information between the nurse case management and other healthcare services could be improved. Further evaluation is suggested to explore effects of the concept on family members. © 2017 Nordic College of Caring Science.

Nursing workload in public and private intensive care units

PubMed Central

Nogueira, Lilia de Souza; Koike, Karina Mitie; Sardinha, Débora Souza; Padilha, Katia Grillo; de Sousa, Regina Marcia Cardoso

2013-01-01

Objective This study sought to compare patients at public and private intensive care units according to the nursing workload and interventions provided. Methods This retrospective, comparative cohort study included 600 patients admitted to 4 intensive care units in São Paulo. The nursing workload and interventions were assessed using the Nursing Activities Score during the first and last 24 hours of the patient's stay at the intensive care unit. Pearson's chi-square test, Fisher's exact test, the Mann-Whitney test, and Student's t test were used to compare the patient groups. Results The average Nursing Activities Score upon admission to the intensive care unit was 61.9, with a score of 52.8 upon discharge. Significant differences were found among the patients at public and private intensive care units relative to the average Nursing Activities Score upon admission, as well as for 12 out of 23 nursing interventions performed during the first 24 hours of stay at the intensive care units. The patients at the public intensive care units exhibited a higher average score and overall more frequent nursing interventions, with the exception of those involved in the "care of drains", "mobilization and positioning", and "intravenous hyperalimentation". The groups also differed with regard to the evolution of the Nursing Activities Score among the total case series as well as the groups of survivors from the time of admission to discharge from the intensive care unit. Conclusion Patients admitted to public and private intensive care units exhibit differences in their nursing care demands, which may help managers with nursing manpower planning. PMID:24213086

Intentional intra-arterial injection of midazolam in a patient with status epilepticus in the Intensive Care Unit

PubMed Central

Ali, Muhammad Asghar; Yahya, Muhammad

2017-01-01

Fundamental medical care includes intravenous (IV) access which provides prompt resuscitation and reliable delivery of analgesics, antibiotics, and vasoactive medication. Difficult access populations, especially in critical area, continue to challenge providers to consider and utilize alternative means to provide IV access. Potential options under such circumstances include intramuscular, intraosseous, and intratracheal drug administration, but in extreme cases where no other options are available, intra-arterial route might be considered. We present a case where midazolam was intentionally injected intra-arterially to abort seizure activity in a patient with status epilepticus in the Intensive Care Unit. PMID:29033730

Upper gastrointestinal bleeding in severely burned patients: a case-control study to assess risk factors, causes, and outcome.

PubMed

Kim, Young Jin; Koh, Dong Hee; Park, Se Woo; Park, Sun Man; Choi, Min Ho; Jang, Hyun Joo; Kae, Sea Hyub; Lee, Jin; Byun, Hyun Woo

2014-01-01

To determine the risk factors, causes, and outcome of clinically important upper gastrointestinal bleeding that occurs in severely burned patients. The charts of all patients admitted to the burn intensive care unit were analyzed retrospectively over a 4-year period (from January 2006 to December 2009). Cases consisted of burned patients who developed upper gastrointestinal bleeding more than 24 hours after admission to the burn intensive care unit. Controls were a set of patients, in the burn intensive care unit, without upper gastrointestinal bleeding matched with cases for age and gender. Cases and controls were compared with respect to the risk factors of upper gastrointestinal bleeding and outcomes. During the study period, clinically important upper gastrointestinal bleeding occurred in 20 patients out of all 964 patients. The most common cause of upper gastrointestinal bleeding was duodenal ulcer (11 of 20 cases, 55%). In the multivariate analysis, mechanical ventilation (p = 0.044) and coagulopathy (p = 0.035) were found to be the independent predictors of upper gastrointestinal bleeding in severely burned patients. Upper gastrointestinal hemorrhage tends to occur more frequently after having prolonged mechanical ventilation and coagulopathy.

Case management in an acute-care hospital: collaborating for quality, cost-effective patient care.

PubMed

Grootveld, Kim; Wen, Victoria; Bather, Michelle; Park, Joan

2014-01-01

Case management has recently been advanced as a valuable component in achieving quality patient care that is also cost-effective. At St. Michael's Hospital, in Toronto, Ontario, case managers from a variety of professional backgrounds are central to a new care initiative--Rapid Assessment and Planning to Inform Disposition (RAPID)--in the General Internal Medicine (GIM) Unit that is designed to improve patient care and reconcile high emergency department volumes through "smart bed spacing." Involved in both planning and RAPID, GIM's case managers are the link between patient care and utilization management. These stewards of finite resources strive to make the best use of dollars spent while maintaining a commitment to quality care. Collaborating closely with physicians and others across the hospital, GIM's case managers have been instrumental in bringing about significant improvements in care coordination, utilization management and process redesign. Copyright © 2014 Longwoods Publishing.

Urine output on an intensive care unit: case-control study

PubMed Central

Kirwan, Christopher J; Alexander, Neal D E; Nimako, Kofi; Jurukov, Angela; Forth, Rebecca J; Rahman, Tony M

2010-01-01

Objective To compare urine output between junior doctors in an intensive care unit and the patients for whom they are responsible. Design Case-control study. Setting General intensive care unit in a tertiary referral hospital. Participants 18 junior doctors responsible for clerking patients on weekday day shifts in the unit from 23 March to 23 April 2009 volunteered as “cases.” Controls were the patients in the unit clerked by those doctors. Exclusion criteria (for both groups) were pregnancy, baseline estimated glomerular filtration rate <15 ml/min/1.73 m2, and renal replacement therapy. Main outcome measures Oliguria (defined as mean urine output <0.5 ml/kg/hour over six or more hours of measurement) and urine output (in ml/kg/hour) as a continuous variable. Results Doctors were classed as oliguric and “at risk” of acute kidney injury on 19 (22%) of 87 shifts in which urine output was measured, and oliguric to the point of being “in injury” on one (1%) further shift. Data were available for 208 of 209 controls matched to cases in the data collection period; 13 of these were excluded because the control was receiving renal replacement therapy. Doctors were more likely to be oliguric than their patients (odds ratio 1.99, 95% confidence interval 1.08 to 3.68, P=0.03). For each additional 1 ml/kg/hour mean urine output, the odds ratio for being a case rather than a control was 0.27 (0.12 to 0.58, P=0.001). Mortality among doctors was astonishingly low, at 0% (0% to 18%). Conclusions Managing our own fluid balance is more difficult than managing it in our patients. We should drink more water. Modifications to the criteria for acute kidney injury could be needed for the assessment of junior doctors in an intensive care unit. PMID:21156738

Knowledge translation: An interprofessional approach to integrating a pain consult team within an acute care unit.

PubMed

Feldman, Kira; Berall, Anna; Karuza, Jurgis; Senderovich, Helen; Perri, Giulia-Anna; Grossman, Daphna

2016-11-01

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.

Estimating the cost-effectiveness of stroke units in France compared with conventional care.

PubMed

Launois, R; Giroud, M; Mégnigbêto, A C; Le Lay, K; Présenté, G; Mahagne, M H; Durand, I; Gaudin, A F

2004-03-01

The incidence of stroke in France is estimated at between 120 000 and 150 000 cases per year. This modeling study assessed the clinical and economic benefits of establishing specialized stroke units compared with conventional care. Data from the Dijon stroke registry were used to determine healthcare trajectories according to the degree of autonomy and organization of patient care. The relative risks of death or institutionalization or death or dependence after passage through a stroke unit were compared with conventional care. These risks were then inserted with the costing data into a Markov model to estimate the cost-effectiveness of stroke units. Patients cared for in a stroke unit survive more trimesters without sequelae in the 5 years after hospitalization than those cared for conventionally (11.6 versus 8.28 trimesters). The mean cost per patient at 5 years was estimated at 30 983 for conventional care and 34 638 in a stroke unit. An incremental cost-effectiveness ratio for stroke units of 1359 per year of life gained without disability was estimated. The cost-effectiveness ratio for stroke units is much lower than the threshold (53 400 ) of acceptability recognized by the international scientific community. This finding justifies organizational changes in the management of stroke patients and the establishment of stroke units in France.

Special Plans and Operations: Assessment of DOD Wounded Warrior Matters - Fort Sam Houston

DTIC Science & Technology

2011-03-17

nurse case managers, and squad leaders • Assess WTB unit order and discipline • Develop comprehensive training programs for nurse case managers...consist of, but are not limited to, military cadre, physicians, nurses , TBI and behavioral health specialists such as psychologists and social workers...and access to care standards. Triad of Care At the nucleus of the WTU is the “Triad of Care,” which is comprised of a squad leader, a nurse case

[Outbreak of influenza A(H1N1)/2009: description of cases and crisis management in a ICU in Reunion Island].

PubMed

Parcevaux, M; Boisson, V; Lemant, J; Antok, E; Thibault, L; Garcia, C; Bugnon, O; Tixier, F; Belin, N; André, H; Michaud, A; Braunberger, E; Vandroux, D; Ocquidant, P; Rouanet, J F; Ingles, M; Filleul, L; Winer, A

2010-12-01

to describe the characteristics, treatment and outcome of critically ill patients with influenza A(H1N1) infection at St Pierre Hospital in Reunion Island during the 2009 outbreak, as well as the measures of care reorganization implemented to face them. prospective observational study of probable and confirmed cases of influenza A (H1N1)/2009 infection concerning hospitalized patients in a polyvalent intensive care unit (ICU). thirteen patients have been included between August and September 2009. Three (23 %) didn't have any medical history. The median age was 42 [22-69]. Eleven have required pulmonary ventilation for 10.3 days (± 8). Three (23 %) have developed an ARDS. Three patients (23 %) died. To cope with the influx of cases and considering our situation of geographic isolation, it has been needed to totally rework the organization of care: set-up of a specific welcoming channel, division into sectors of the department, opening of additional beds, new on-duty assignment, inter and intra hospital cooperation. reunion Island has been an experimental lab of crisis management during the H1N1/2009 epidemic, several months ahead of the mother country. To anticipate the reorganization of care in intensive care units during an outbreak period, particularly in small units or units isolated like ours, looks to us a must so to quietly face a sharp influx of patients. 2010 Elsevier Masson SAS. All rights reserved.

Incidence and prevalence of inflammatory bowel diseases in gastroenterology primary care setting.

PubMed

Tursi, Antonio; Elisei, Walter; Picchio, Marcello

2013-12-01

The incidence of inflammatory bowel diseases (IBDs) has markedly increased over the last years, but no epidemiological study has been performed in gastroenterology primary care setting. We describe the epidemiology of IBD in a gastroenterology primary care unit using its records as the primary data source. Case finding used predefined read codes to systematically search computer diagnostic and prescribing records from January 2009 to December 2012. A specialist diagnosis of Ulcerative colitis (UC), Crohn's disease (CD), inflammatory bowel disease unclassified (IBDU) or segmental colitis associated with diverticulosis (SCAD), based on clinical, histological or radiological findings, was a prerequisite for the inclusion in the study. Secondary, infective and apparent acute self-limiting colitis were excluded. We identified 176 patients with IBD in a population of 94,000 with a prevalence 187.2/100,000 (95% CI: 160.6-217.0). Between 2009 and 2012 there were 61 new cases. In particular, there were 23 new cases of UC, 19 new cases of CD, 15 new cases of SCAD, and 4 new cases of IBDU. The incidence of IBD was 16.2/100,000 (95% CI 12.5-20.7) per year. The incidence per year was 6/100,000 (95% CI 3.8 to 8.9) for UC, 5/100,000 (95% CI 3.0-7.7) for CD, 4/100,000 (95% CI 2.3-6.5) for SCAD, and 1/100,000 (95% CI 0.3-2.6) for IBDU. We assessed for the first time which is the prevalence and incidence of IBD in a gastroenterology primary care unit. This confirms that specialist primary care unit is a key factor in providing early diagnosis of chronic diseases. Copyright © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Organisational strategies and midwives' readiness to provide care for out of hospital births: an analysis from the birthplace organisational case studies.

PubMed

McCourt, Christine; Rayment, Juliet; Rance, Susanna; Sandall, Jane

2012-10-01

the objective of the Birthplace in England Case Studies was to explore the organisational and professional issues that may impact on the quality and safety of labour and birth care in different birth settings: Home, Freestanding Midwifery Unit, Alongside Midwifery Unit or Obstetric Unit. This analysis examines the factors affecting the readiness of community midwives to provide women with choice of out of hospital birth, using the findings from the Birthplace in England Case Studies. organisational ethnographic case studies, including interviews with professionals, key stakeholders, women and partners, observations of service processes and document review. a maximum variation sample of four maternity services in terms of configuration, region and population characteristics. All were selected from the Birthplace cohort study sample as services scoring 'best' or 'better' performing in the Health Care Commission survey of maternity services (HCC 2008). professionals and stakeholders (n=86), women (64), partners (6), plus 50 observations and 200 service documents. each service experienced challenges in providing an integrated service to support choice of place of birth. Deployment of community midwives was a particular concern. Community midwives and managers expressed lack of confidence in availability to cover home birth care in particular, with the exception of caseload midwifery and a 'hub and spoke' model of care. Community midwives and women's interviews indicated that many lacked home birth experience and confidence. Those in midwifery units expressed higher levels of support and confidence. maternity services need to consider and develop models for provision of a more integrated model of staffing across hospital and community boundaries. Copyright © 2012 Elsevier Ltd. All rights reserved.

Neonatal Early Warning Tools for recognising and responding to clinical deterioration in neonates cared for in the maternity setting: A retrospective case-control study.

PubMed

Paliwoda, Michelle; New, Karen; Bogossian, Fiona

2016-09-01

All newborns are at risk of deterioration as a result of failing to make the transition to extra uterine life. Signs of deterioration can be subtle and easily missed. It has been postulated that the use of an Early Warning Tool may assist clinicians in recognising and responding to signs of deterioration earlier in neonates, thereby preventing a serious adverse event. To examine whether observations from a Standard Observation Tool, applied to three neonatal Early Warning Tools, would hypothetically trigger an escalation of care more frequently than actual escalation of care using the Standard Observation Tool. A retrospective case-control study. A maternity unit in a tertiary public hospital in Australia. Neonates born in 2013 of greater than or equal to 34(+0) weeks gestation, admitted directly to the maternity ward from their birthing location and whose subsequent deterioration required admission to the neonatal unit, were identified as cases from databases of the study hospital. Each case was matched with three controls, inborn during the same period and who did not experience deterioration and neonatal unit admission. Clinical and physiological data recorded on a Standard Observation Tool, from time of admission to the maternity ward, for cases and controls were charted onto each of three Early Warning Tools. The primary outcome was whether the tool 'triggered an escalation of care'. Descriptive statistics (n, %, Mean and SD) were employed. Cases (n=26) comprised late preterm, early term and post-term neonates and matched by gestational age group with 3 controls (n=78). Overall, the Standard Observation Tool triggered an escalation of care for 92.3% of cases compared to the Early Warning Tools; New South Wales Health 80.8%, United Kingdom Newborn Early Warning Chart 57.7% and The Australian Capital Territory Neonatal Early Warning Score 11.5%. Subgroup analysis by gestational age found differences between the tools in hypothetically triggering an escalation of care. The Standard Observation Tool triggered an escalation of care more frequently than the Early Warning Tools, which may be as a result of behavioural data captured on the Standard Observation Tool and escalated, which could not be on the Early Warning Tools. Findings demonstrate that a single tool applied to all gestational age ranges may not be effective in identifying early deterioration or may over trigger an escalation of care. Further research is required into the sensitivity and specificity of Early Warning Tools in neonatal sub-populations. Copyright © 2016 Elsevier Ltd. All rights reserved.

Validation of the 'United Registries for Clinical Assessment and Research' [UR-CARE], a European Online Registry for Clinical Care and Research in Inflammatory Bowel Disease.

PubMed

Burisch, Johan; Gisbert, Javier P; Siegmund, Britta; Bettenworth, Dominik; Thomsen, Sandra Bohn; Cleynen, Isabelle; Cremer, Anneline; Ding, Nik John Sheng; Furfaro, Federica; Galanopoulos, Michail; Grunert, Philip Christian; Hanzel, Jurij; Ivanovski, Tamara Knezevic; Krustins, Eduards; Noor, Nurulamin; O'Morain, Neil; Rodríguez-Lago, Iago; Scharl, Michael; Tua, Julia; Uzzan, Mathieu; Ali Yassin, Nuha; Baert, Filip; Langholz, Ebbe

2018-04-27

The 'United Registries for Clinical Assessment and Research' [UR-CARE] database is an initiative of the European Crohn's and Colitis Organisation [ECCO] to facilitate daily patient care and research studies in inflammatory bowel disease [IBD]. Herein, we sought to validate the database by using fictional case histories of patients with IBD that were to be entered by observers of varying experience in IBD. Nineteen observers entered five patient case histories into the database. After 6 weeks, all observers entered the same case histories again. For each case history, 20 key variables were selected to calculate the accuracy for each observer. We assumed that the database was such that ≥ 90% of the entered data would be correct. The overall proportion of correctly entered data was calculated using a beta-binomial regression model to account for inter-observer variation and compared to the expected level of validity. Re-test reliability was assessed using McNemar's test. For all case histories, the overall proportion of correctly entered items and their confidence intervals included the target of 90% (Case 1: 92% [88-94%]; Case 2: 87% [83-91%]; Case 3: 93% [90-95%]; Case 4: 97% [94-99%]; Case 5: 91% [87-93%]). These numbers did not differ significantly from those found 6 weeks later [NcNemar's test p > 0.05]. The UR-CARE database appears to be feasible, valid and reliable as a tool and easy to use regardless of prior user experience and level of clinical IBD experience. UR-CARE has the potential to enhance future European collaborations regarding clinical research in IBD.

Lighting design in the neonatal intensive care unit: practical applications of scientific principles.

PubMed

White, Robert D

2004-06-01

Meeting the varied lighting needs of infants, caregivers, and families has become more complex as our understanding of visual development and perception and the effect of light on circadian rhythms advances. Optimal lighting strategies are discussed for new unit construction, as well as modifications to consider for existing units. In either case, the key concept is that lighting should be provided for the individual needs of each person, rather than the full-room lighting schemes previously used. Ideas gleaned from nonhospital settings, re-introduction of natural light into the neonatal intensive care unit, and new devices such as light-emitting diodes will dramatically change the lighting and visual environment of future neonatal intensive care units.

42 CFR 433.54 - Bona fide donations.

Code of Federal Regulations, 2014 CFR

2014-10-01

... health care provider; (2) Any related entity providing health care items and services; or (3) Other... behalf of individual health care providers to the State, county, or any other unit of local government... year in the case of a donation from any health care organizational entity. (e) To the extent that a...

Point-of-care controls for nosocomial legionellosis combined with chlorine dioxide potable water decontamination: a two-year survey at a Welsh teaching hospital.

PubMed

Hosein, I K; Hill, D W; Tan, T Y; Butchart, E G; Wilson, K; Finlay, G; Burge, S; Ribeiro, C D

2005-10-01

This study reports a two-year programme of attempted eradication of Legionella colonization in the potable water supply of a 1000-bed tertiary care teaching hospital in Wales. There was a simultaneous, point-of-care, sterile-water-only policy for all intensive care units (ICU) and bone marrow and renal transplant units in order to prevent acquisition of nosocomial Legionnaires' disease. The programme was initiated following a case of nosocomial pneumonia caused by Legionella pneumophila serogroup 1-Bellingham-like genotype A on the cardiac ICU. The case occurred 14 days after mitral and aortic valve replacement surgery. Clinical and epidemiological investigations implicated aspiration of hospital potable water as the mechanism of infection. Despite interventions with chlorine dioxide costing over 25000 UK pounds per annum, Legionella has remained persistently present in significant numbers (up to 20000 colony forming units/L) and with little reduction in the number of positive sites. Two further cases of nosocomial disease occurred over the following two-year period; in one case, aspiration of tap water was implicated again, and in the other case, instillation of contaminated water into the right main bronchus via a misplaced nasogastric tube was implicated. These cases arose because of inadvertent non-compliance with the sterile-water-only policy in high-risk locations. Enhanced clinical surveillance over the same two-year period detected no other cases of nosocomial disease. This study suggests that attempts at eradication of Legionella spp. from complex water systems may not be a cost-effective measure for prevention of nosocomial infections, and to the best of our knowledge is the first study from the UK to suggest that the introduction of a sterile-water-only policy for ICUs and other high-risk units may be a more cost-effective approach.

Abstracting ICU Nursing Care Quality Data From the Electronic Health Record.

PubMed

Seaman, Jennifer B; Evans, Anna C; Sciulli, Andrea M; Barnato, Amber E; Sereika, Susan M; Happ, Mary Beth

2017-09-01

The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen's kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.

The Phase of Illness Paradigm: A Checklist Centric Model to Improve Patient Care in the Burn Intensive Care Unit

DTIC Science & Technology

2014-04-01

6. PUBLICATIONS, ABSTRACTS, AND PRESENTATIONS: Submitted abstracts to the 2014 Military Health Research Symposium: 1. Pamplin, J.C., Murray...Intensive Care Unit ERMS/Log Number: 12340054 W81XWH-13-2-0011 PI: LTC Jeremy Pamplin, MD Org: The Geneva Foundation/San Antonio Military Medical Center...improve clinician work related quality of life. Approach and Military Relevance This multicenter, prospective, case-matched cohort study will improve the

[Calculation of standardised unit costs from a societal perspective for health economic evaluation].

PubMed

Bock, J-O; Brettschneider, C; Seidl, H; Bowles, D; Holle, R; Greiner, W; König, H H

2015-01-01

Due to demographic aging, economic evaluation of health care technologies for the elderly becomes more important. A standardised questionnaire to measure the health-related resource utilisation has been designed. The monetary valuation of the resource use documented by the questionnaire is a central step towards the determination of the corresponding costs. The aim of this paper is to provide unit costs for the resources in the questionnaire from a societal perspective. The unit costs are calculated pragmatically based on regularly published sources. Thus, an easy update is possible. This paper presents the calculated unit costs for outpatient medical care, inpatient care, informal and formal nursing care and pharmaceuticals from a societal perspective. The calculated unit costs can serve as a reference case in health economic evaluations and hence help to increase their comparability. © Georg Thieme Verlag KG Stuttgart · New York.

[Risk for the development of upper gastrointestinal bleeding in children in an intensive care unit].

PubMed

Gutiérrez-Gutiérrez, Glenda Karina; Villasís-Keever, Miguel Angel; González-Ortiz, Beatriz; Troconis-Trens, Germán; Tapia-Monge, Dora María; Flores-Calderón, Judith

2014-01-01

Although gastrointestinal tract bleeding can occur at any age, most studies trying to establish causes or risk factors for its development have been conducted in adults. The aim of this study was to determine risk factors in children admitted in a pediatric intensive care unit. A retrospective case-control study was conducted. Children who developed upper gastrointestinal bleeding children during their stay at the intensive care unit were considered the cases. Variables were obtained from medical records including age, sex, nutritional status, mechanical ventilation, use of nasogastric tube, development of complications, presence of coagulopathy, use of prophylaxis for upper gastrointestinal tract bleeding, fasting and use of steroids. Using a multivariate analysis, risk factors were identified, with odds ratios (OR) and 95 % confidence intervals (95 % CI) calculations. Out of 165 patients, 58 had upper gastrointestinal bleeding (35 %). Risk factors identified were prolonged clotting times (OR = 3.35), thrombocytopenia (OR = 2.39), development of sepsis (OR = 6.74) or pneumonia (OR = 4.37). Prophylaxis for upper gastrointestinal bleeding was not a protective factor. Upper gastrointestinal bleeding frequency in children hospitalized in an intensive care unit was high. Identifying risk factors should help to reduce upper gastrointestinal bleeding frequency.

Ethics and law in the intensive care unit.

PubMed

Danbury, C M; Waldmann, C S

2006-12-01

Intensive Care Medicine epitomises the difficulties inherent in modern medicine. In this chapter we examine some key medicolegal and ethical areas that are evolving. The principles of autonomy and consent are well established, but developments in UK caselaw have shown that the courts may be moving away from their traditional deference of the medical profession. We examine some recent cases and discuss the impact that these cases may have on practice in Intensive Care.

Reduction of seasonal influenza transmission among healthcare workers in an intensive care unit: a 4-year intervention study in Thailand.

PubMed

Apisarnthanarak, Anucha; Uyeki, Timothy M; Puthavathana, Pilaipan; Kitphati, Rungrueng; Mundy, Linda M

2010-10-01

To evaluate the feasibility and effectiveness of an influenza control bundle to minimize healthcare-associated seasonal influenza transmission among healthcare workers (HCWs) in an intensive care unit (ICU) equipped with central air conditioning. A quasi-experimental study was conducted in a 500-bed tertiary care center in Thailand from July 1, 2005, through June 30,2009. The medical ICU (MICU) implemented an influenza control bundle including healthcare worker (HCW) education, influenza screening of adult community-acquired pneumonia patients, antiviral treatment of patients and ill HCWs who tested positive for influenza, promotion of influenza vaccination among HCWs, and reinforcement of standard infection control policies. The surgical ICU (SICU) and coronary care unit (CCU) received no intervention. The numbers of influenza infections among HCWs during the pre- and postintervention periods were 18 cases in 5,294 HCW days and 0 cases in 5,336 HCW-days in the MICU (3.4 vs 0 cases per 1,000 HCW-days; P ! .001), 19 cases in 4,318 HCW-days and 20 cases in 4,348 HCW-days in the SICU (4.4 vs 4.6 cases per 1,000 HCW-days; Pp.80), and 18 cases in 5,000 HCW-days and 18 cases in 5,143 HCW-days in the CCU (3.6 vs 3.5 cases per 1,000 HCW-days; Pp.92), respectively. Outbreak-related influenza occurred in 7 MICUHCWs, 6 SICU HCWs, and 4 CCU HCWs before intervention and 0 MICU HCWs, 9 SICU HCWs, and 8 CCU HCWs after intervention.Before and after intervention, 25 (71%) and 35 (100%) of 35 MICU HCWs were vaccinated, respectively (P ! .001); HCW vaccination coverage did not change significantly in the SICU (21 [70%] of 30 vs 24 [80%] of 30; Pp.89) and CCU (19 [68%] of 28 vs 21 [75%]of 28; Pp.83). The estimated costs of US $6,471 per unit for postintervention outbreak investigations exceeded the intervention costs of US $4,969. A sustained influenza intervention bundle was associated with clinical and economic benefits to a Thai hospital.

Medication Abortion within a Student Health Care Clinic: A Review of the First 46 Consecutive Cases

ERIC Educational Resources Information Center

Godfrey, Emily M.; Bordoloi, Anita; Moorthie, Mydhili; Pela, Emily

2012-01-01

Objective: Medication abortion with mifepristone and misoprostol has been available in the United States since 2000. The authors reviewed the first 46 medication abortion cases conducted at a university-based student health care clinic to determine the safety and feasibility of medication abortion in this type of clinical setting. Participants:…

Implementation of a dedicated cardiovascular and stroke unit in a crowded emergency department of a tertiary public hospital in Brazil: effect on mortality rates.

PubMed

Nasi, Luiz A; Ferreira-Da-Silva, Andre L; Martins, Sheila C O; Furtado, Mariana V; Almeida, Andrea G; Brondani, Rosane; Wirth, Letícia; Kluck, Marisa; Polanczyk, Carisi A

2014-01-01

Emergency department (ED) care for acute vascular diseases faces the challenge of overcrowding. A vascular unit is a specialized, protocol-oriented unit in the ED with a team trained to manage acute vascular disorders, including stroke, coronary syndromes, pulmonary embolism (PE), and aortic diseases. The objective was to compare case fatality rates for selected cardiovascular conditions before and after the implementation of a vascular unit. Patients with the selected diagnoses admitted to the ED in two different time periods, 2002 through 2005 (before unit opening) and 2007 to 2010 (after vascular unit opening), were identified by ICD-10 codes, and their electronic records were reviewed. Case fatality rates were calculated and compared for both time periods. The period prior to unit implementation (2002 through 2005) included 4,164 patients, and the vascular unit period (2007 to 2010) included 6,280 patients. Overall, the case fatality rate for acute vascular conditions decreased from 9% to 7.3% with vascular unit implementation (p = 0.002). The in-hospital mortality rates for acute coronary syndrome (ACS) dropped from 6% to 3.8% (p = 0.003), and for acute PE dropped from 32.1% to 10.8% (p < 0.001). The stroke case-fatality rate did not decrease despite improvements in the quality of stroke health care indicators. The vascular unit strategy has the potential to reduce overall mortality for most acute vascular conditions. © 2013 by the Society for Academic Emergency Medicine.

Games policy makers and providers play: introducing case-mix-based payment to hospital chronic care units in Japan.

PubMed

Ikegami, Naoki

2009-06-01

Case-mix-based payment was developed for hospital chronic care units in Japan to replace the flat per diem rate and encourage the admission of patients with higher medical acuity and was part of a policy initiative to make the tariff more evidence based. However, although the criteria for grouping patients were developed from a statistical analysis of resource use, the tariff was subsequently set below costs, particularly for the groups with the lowest medical acuity, both because of the prime minister's decision to decrease total health expenditures and because of the health ministry's decision to target the reductions on chronic care units. Providers quickly adapted to the new payment system mainly by reclassifying their patients to higher medical acuity groups. Some hospitals reported high prevalence rates of urinary tract infections and pressure ulcers. The government responded by issuing directives to providers to calculate the prevalence rates and document the care that has been mandated for the patients at risk. However, in order to monitor compliance and to evaluate whether the patient is being billed for the appropriate case-mix group, the government must invest in developing a comprehensive patient-level database and in training staff for making on-site inspections.

Effects of intensivist coverage in a post-anaesthesia care unit on surgical patients' case mix and characteristics of the intensive care unit.

PubMed

Kastrup, Marc; Seeling, Matthes; Barthel, Stefan; Bloch, Andy; le Claire, Marie; Spies, Claudia; Scheller, Matthias; Braun, Jan

2012-07-18

There is an increasing demand for intensive care in hospitals, which can lead to capacity limitations in the intensive care unit (ICU). Due to postponement of elective surgery or delayed admission of emergency patients, outcome may be negatively influenced. To optimize the admission process to intensive care, the post-anaesthesia care unit (PACU) was staffed with intensivist coverage around the clock. The aim of this study is to demonstrate the impact of the PACU on the structure of ICU-patients and the contribution to overall hospital profit in terms of changes in the case mix index for all surgical patients. The administrative data of all surgical patients (n = 51,040) 20 months prior and 20 months after the introduction of a round-the-clock intensivist staffing of the PACU were evaluated and compared. The relative number of patients with longer length of stay (LOS) (more than seven days) in the ICU increased after the introduction of the PACU. The average monthly number of treatment days of patients staying less than 24 hours in the ICU decreased by about 50% (138.95 vs. 68.19 treatment days, P <0.005). The mean LOS in the PACU was 0.45 (± 0.41) days, compared to 0.27 (± 0.2) days prior to the implementation. The preoperative times in the hospital decreased significantly for all patients. The case mix index (CMI) per hospital day for all surgical patients was significantly higher after the introduction of a PACU: 0.286 (± 0.234) vs. 0.309 (± 0.272) P <0.001 CMI/hospital day. The introduction of a PACU and the staffing with intensive care staff might shorten the hospital LOS for surgical patients. The revenues for the hospital, as determined by the case mix index of the patients per hospital day, increased after the implementation of a PACU and more patients can be treated in the same time, due to a better use of resources.

Early Childhood Education and Care Policy in the United States of America. OECD Country Note.

ERIC Educational Resources Information Center

Organisation for Economic Cooperation and Development, Paris (France).

This paper is the result of an intensive case study by an Organisation for Economic Cooperation and Development (OECD) review team, whose purpose was to investigate early childhood education and care (ECEC) in the United States, 1 of 12 countries participating in the OECD review between 1998 and 2000. The paper draws on information provided by a…

Getting Down to Business: Day Care Center, Module 23. [Student Manual]. Entrepreneurship Training Components.

ERIC Educational Resources Information Center

Kingi, Marcella

This module on owning and operating a day care center is one of 36 in a series on entrepreneurship. The introduction tells the student what topics will be covered and suggests other modules to read in related occupations. Each unit includes student goals, a case study, and a discussion of the unit subject matter. Learning activities are divided…

Habilitation of very preterm infants at a Post Acute Care Inpatient Rehabilitation (PACIR) center after neonatal intensive care unit (NICU) discharge.

PubMed

Singh, Meenakshi; Parvez, Boriana; Banquet, Agnes; Kase, Jordan S

2018-02-20

To investigate whether Post-Acute Care Inpatient Rehabilitation (PACIR) admission after NICU stay affects the total length of stay (LOS) of very preterm (VPT: ≤30 weeks of gestation) infants. A retrospective case control study of VPT infants d/c'd from the NICU at Maria Fareri Children's Hospital (MFCH) to either a PACIR (Blythedale Children's Hospital: BH) for convalescent care (cases) or directly home (controls). 35 cases and 70 controls. Total LOS (MFCH + BH) was longer for cases [196 vs. 97 days]. At the time of d/c from MFCH, Special Health Care Needs (SHCN) amongst cases were greater than controls, however, became similar at the time of home d/c. The majority of cases achieved habilitation goals at the PACIR. Although LOS was longer for patients transferred to a PACIR, habilitation at BH Hospital reduced the SHCN at the time of home d/c amongst cases.

Lean Six Sigma to Reduce Intensive Care Unit Length of Stay and Costs in Prolonged Mechanical Ventilation.

PubMed

Trzeciak, Stephen; Mercincavage, Michael; Angelini, Cory; Cogliano, William; Damuth, Emily; Roberts, Brian W; Zanotti, Sergio; Mazzarelli, Anthony J

Patients with prolonged mechanical ventilation (PMV) represent important "outliers" of hospital length of stay (LOS) and costs (∼$26 billion annually in the United States). We tested the hypothesis that a Lean Six Sigma (LSS) approach for process improvement could reduce hospital LOS and the associated costs of care for patients with PMV. Before-and-after cohort study. Multidisciplinary intensive care unit (ICU) in an academic medical center. Adult patients admitted to the ICU and treated with PMV, as defined by diagnosis-related group (DRG). We implemented a clinical redesign intervention based on LSS principles. We identified eight distinct processes in preparing patients with PMV for post-acute care. Our clinical redesign included reengineering daily patient care rounds ("Lean ICU rounds") to reduce variation and waste in these processes. We compared hospital LOS and direct cost per case in patients with PMV before (2013) and after (2014) our LSS intervention. Among 259 patients with PMV (131 preintervention; 128 postintervention), median hospital LOS decreased by 24% during the intervention period (29 vs. 22 days, p < .001). Accordingly, median hospital direct cost per case decreased by 27% ($66,335 vs. $48,370, p < .001). We found that a LSS-based clinical redesign reduced hospital LOS and the costs of care for patients with PMV.

The organisation of critical care for burn patients in the UK: epidemiology and comparison of mortality prediction models.

PubMed

Toft-Petersen, A P; Ferrando-Vivas, P; Harrison, D A; Dunn, K; Rowan, K M

2018-05-15

In the UK, a network of specialist centres has been set up to provide critical care for burn patients. However, some burn patients are admitted to general intensive care units. Little is known about the casemix of these patients and how it compares with patients in specialist burn centres. It is not known whether burn-specific or generic risk prediction models perform better when applied to patients managed in intensive care units. We examined admissions for burns in the Case Mix Programme Database from April 2010 to March 2016. The casemix, activity and outcome in general and specialist burn intensive care units were compared and the fit of two burn-specific risk prediction models (revised Baux and Belgian Outcome in Burn Injury models) and one generic model (Intensive Care National Audit and Research Centre model) were compared. Patients in burn intensive care units had more extensive injuries compared with patients in general intensive care units (median (IQR [range]) burn surface area 16 (7-32 [0-98])% vs. 8 (1-18 [0-100])%, respectively) but in-hospital mortality was similar (22.8% vs. 19.0%, respectively). The discrimination and calibration of the generic Intensive Care National Audit and Research Centre model was superior to the revised Baux and Belgian Outcome in Burn Injury burn-specific models for patients managed on both specialist burn and general intensive care units. © 2018 The Association of Anaesthetists of Great Britain and Ireland.

Coping with Poor Prognosis in the Pediatric Intensive Care Unit.

ERIC Educational Resources Information Center

Waller, David A.; And Others

1979-01-01

The intensive care pediatrician who prophesies to parents that their child's illness is irreversible may encounter denial and hostility. Four cases are reported in which parents rejected their child's hopeless prognosis, counterprophesied miraculous cures, resolved to obtain exorcism, criticized the care, or accused nurses of neglect. Journal…

The organisational context of nursing care in stroke units: a case study approach.

PubMed

Burton, Christopher R; Fisher, Andrea; Green, Theresa L

2009-01-01

Internationally the stroke unit is recognised as the evidence-based model for patient management, although clarity about the effective components of stroke units is lacking. Whilst skilled nursing care has been proposed as one component, the theoretical and empirical basis for stroke nursing is limited. We attempted to explore the organisational context of stroke unit nursing, to determine those features that staff perceived to be important in facilitating high quality care. A case study approach was used, that included interviews with nurses and members of the multidisciplinary teams in two Canadian acute stroke units. A total of 20 interviews were completed, transcribed and analysed thematically using the Framework Approach. Trustworthiness was established through the review of themes and their interpretation by members of the stroke units. Nine themes that comprised an organisational context that supported the delivery of high quality nursing care in acute stroke units were identified, and provide a framework for organisational development. The study highlighted the importance of an overarching service model to guide the organisation of care and the development of specialist and advanced nursing roles. Whilst multidisciplinary working appears to be a key component of stroke unit nursing, various organisational challenges to its successful implementation were highlighted. In particular the consequence of differences in the therapeutic approach of nurses and therapy staff needs to be explored in greater depth. Successful teamwork appears to depend on opportunities for the development of relationships between team members as much as the use of formal communication systems and structures. A co-ordinated approach to education and training, clinical leadership, a commitment to research, and opportunities for role and practice development also appear to be key organisational features of stroke unit nursing. Recommendations for the development of stroke nursing leadership and future research into teamwork in stroke settings are made.

Epidemiology, clinical management, and outcomes of dogs involved in road traffic accidents in the United Kingdom (2009-2014).

PubMed

Harris, Georgina L; Brodbelt, David; Church, David; Humm, Karen; McGreevy, Paul D; Thomson, Peter C; O'Neill, Dan

2018-03-01

To estimate the prevalence and risk factors for road traffic accidents (RTA) in dogs and describe the management and outcome of these dogs attending primary-care veterinary practices in the United Kingdom. Retrospective cross-sectional study. Primary-care veterinary practices in the United Kingdom. The study population included 199,464 dogs attending 115 primary-care clinics across the United Kingdom. Electronic patient records of dogs attending practices participating in the VetCompass Programme were assessed against selection criteria used to define RTA cases. Cases identified as RTAs were identified and manually verified to calculate prevalence. Univariable and multivariable logistic regression methods were used to evaluate associations between risk factors and RTA. The prevalence of RTA was 0.41%. Of the RTA cases, 615 (74.9%) were purebred, 322 (39.2%) were female, and 285 (54.8%) were insured. The median age at RTA was 2.5 years. After accounting for the effects of other factors, younger dogs had increased odds of an RTA event: dogs aged under 3 years showed 2.9 times the odds and dogs aged between 6-9 years showed 1.8 times the odds of an RTA event compared with dogs aged over 14 years. Males had 1.4 times the odds of an RTA event compared with females. Overall, 22.9% of cases died from a cause associated with RTA. Of dogs with information available, 34.0% underwent diagnostic imaging, 29.4% received intravenous fluid-therapy, 71.1% received pain relief, 46.0% were hospitalized, and 15.6% had surgery performed under general anesthetic. This study identified important demographic factors associated with RTA in dogs, notably being young and male. © Veterinary Emergency and Critical Care Society 2018.

Case Study of High-Dose Ketamine for Treatment of Complex Regional Pain Syndrome in the Pediatric Intensive Care Unit.

PubMed

Pasek, Tracy Ann; Crowley, Kelli; Campese, Catherine; Lauer, Rachel; Yang, Charles

2017-06-01

Complex regional pain syndrome (CRPS) is a life-altering and debilitating chronic pain condition. The authors are presenting a case study of a female who received high-dose ketamine for the management of her CRPS. The innovative treatment lies not only within the pharmacologic management of her pain, but also in the fact that she was the first patient to be admitted to our pediatric intensive care unit solely for pain control. The primary component of the pharmacotherapy treatment strategy plan was escalating-dose ketamine infusion via patient-controlled-analgesia approved by the pharmacy and therapeutics committee guided therapy for this patient. The expertise of advanced practice nurses blended exquisitely to ensure patient and family-centered care and the coordination of care across the illness trajectory. The patient experienced positive outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Stroke treatment outcomes in hospitals with and without Stroke Units.

PubMed

Masjuan, J; Gállego Culleré, J; Ignacio García, E; Mira Solves, J J; Ollero Ortiz, A; Vidal de Francisco, D; López-Mesonero, L; Bestué, M; Albertí, O; Acebrón, F; Navarro Soler, I M

2017-10-23

Organisational capacity in terms of resources and care circuits to shorten response times in new stroke cases is key to obtaining positive outcomes. This study compares therapeutic approaches and treatment outcomes between traditional care centres (with stroke teams and no stroke unit) and centres with stroke units. We conducted a prospective, quasi-experimental study (without randomisation of the units analysed) to draw comparisons between 2 centres with stroke units and 4 centres providing traditional care through the neurology department, analysing a selection of agreed indicators for monitoring quality of stroke care. A total of 225 patients participated in the study. In addition, self-administered questionnaires were used to collect patients' evaluations of the service and healthcare received. Centres with stroke units showed shorter response times after symptom onset, both in the time taken to arrive at the centre and in the time elapsed from patient's arrival at the hospital to diagnostic imaging. Hospitals with stroke units had greater capacity to respond through the application of intravenous thrombolysis than centres delivering traditional neurological care. Centres with stroke units showed a better fit to the reference standards for stroke response time, as calculated in the Quick study, than centres providing traditional care through the neurology department. Copyright © 2017 Sociedad Española de Neurología. Publicado por Elsevier España, S.L.U. All rights reserved.

Investigation of Bioterrorism-Related Anthrax, United States, 2001: Epidemiologic Findings

PubMed Central

Raghunathan, Pratima L.; Bell, Beth P.; Brechner, Ross; Bresnitz, Eddy A.; Butler, Jay C.; Cetron, Marty; Cohen, Mitch; Doyle, Timothy; Fischer, Marc; Greene, Carolyn; Griffith, Kevin S.; Guarner, Jeannette; Hadler, James L.; Hayslett, James A.; Meyer, Richard; Petersen, Lyle R.; Phillips, Michael; Pinner, Robert; Popovic, Tanja; Quinn, Conrad P.; Reefhuis, Jennita; Reissman, Dori; Rosenstein, Nancy; Schuchat, Anne; Shieh, Wun-Ju; Siegal, Larry; Swerdlow, David L.; Tenover, Fred C.; Traeger, Marc; Ward, John W.; Weisfuse, Isaac; Wiersma, Steven; Yeskey, Kevin; Zaki, Sherif; Ashford, David A.; Perkins, Bradley A.; Ostroff, Steve; Hughes, James; Fleming, David; Koplan, Jeffrey P.; Gerberding, Julie L.

2002-01-01

In October 2001, the first inhalational anthrax case in the United States since 1976 was identified in a media company worker in Florida. A national investigation was initiated to identify additional cases and determine possible exposures to Bacillus anthracis. Surveillance was enhanced through health-care facilities, laboratories, and other means to identify cases, which were defined as clinically compatible illness with laboratory-confirmed B. anthracis infection. From October 4 to November 20, 2001, 22 cases of anthrax (11 inhalational, 11 cutaneous) were identified; 5 of the inhalational cases were fatal. Twenty (91%) case-patients were either mail handlers or were exposed to worksites where contaminated mail was processed or received. B. anthracis isolates from four powder-containing envelopes, 17 specimens from patients, and 106 environmental samples were indistinguishable by molecular subtyping. Illness and death occurred not only at targeted worksites, but also along the path of mail and in other settings. Continued vigilance for cases is needed among health-care providers and members of the public health and law enforcement communities. PMID:12396909

Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus

PubMed Central

Assiri, Abdullah; McGeer, Allison; Perl, Trish M.; Price, Connie S.; Al Rabeeah, Abdullah A.; Cummings, Derek A.T.; Alabdullatif, Zaki N.; Assad, Maher; Almulhim, Abdulmohsen; Makhdoom, Hatem; Madani, Hossam; Alhakeem, Rafat; Al-Tawfiq, Jaffar A.; Cotten, Matthew; Watson, Simon J.; Kellam, Paul; Zumla, Alimuddin I.; Memish, Ziad A.

2013-01-01

BACKGROUND In September 2012, the World Health Organization reported the first cases of pneumonia caused by the novel Middle East respiratory syndrome coronavirus (MERS-CoV). We describe a cluster of health care–acquired MERS-CoV infections. METHODS Medical records were reviewed for clinical and demographic information and determination of potential contacts and exposures. Case patients and contacts were interviewed. The incubation period and serial interval (the time between the successive onset of symptoms in a chain of transmission) were estimated. Viral RNA was sequenced. RESULTS Between April 1 and May 23, 2013, a total of 23 cases of MERS-CoV infection were reported in the eastern province of Saudi Arabia. Symptoms included fever in 20 patients (87%), cough in 20 (87%), shortness of breath in 11 (48%), and gastrointestinal symptoms in 8 (35%); 20 patients (87%) presented with abnormal chest radiographs. As of June 12, a total of 15 patients (65%) had died, 6 (26%) had recovered, and 2 (9%) remained hospitalized. The median incubation period was 5.2 days (95% confidence interval [CI], 1.9 to 14.7), and the serial interval was 7.6 days (95% CI, 2.5 to 23.1). A total of 21 of the 23 cases were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units in three different health care facilities. Sequencing data from four isolates revealed a single monophyletic clade. Among 217 household contacts and more than 200 health care worker contacts whom we identified, MERS-CoV infection developed in 5 family members (3 with laboratory-confirmed cases) and in 2 health care workers (both with laboratory-confirmed cases). CONCLUSIONS Person-to-person transmission of MERS-CoV can occur in health care settings and may be associated with considerable morbidity. Surveillance and infection-control measures are critical to a global public health response. PMID:23782161

Specimen plastic containers used to store expressed breast milk in neonatal care units: a case of precautionary principle.

PubMed

Blouin, Mélissa; Coulombe, Martin; Rhainds, Marc

2014-05-09

Breast milk is the only milk that meets both the nutritional and immunitary needs of infants. Since breastfeeding is widely promoted, public health measures to preserve the nutritional qualities of expressed breast milk (EBM) should be applied in hospital care settings. The Health Technology Assessment Unit (HTAU) of the Centre hospitalier universitaire de Québec was requested by the Neonatal Care Unit to assess the acceptability of a plastic specimen container, designed to harvest tissues and body fluids, for storing collected EBM. An evidence-based public health perspective approach was taken to evaluate the safety of the specimen container. The HTAU recommended that plastic specimen containers no longer be used for storing EBM and that other options should be evaluated for neonatal care units. These recommendations are in accordance with the public health precaution principle and with legal considerations.

Multiple nosocomial infections: a risk of modern intensive care.

PubMed

Leviten, D L; Shulman, S T

1980-03-01

Many components of modern medical care greatly predispose subjects to nosocomial infection. These include cancer chemotherapy, organ transplantation, immunosuppression, and intensive supportive care, particularly in conjunction with mechanical ventilatory support, invasive monitoring devices and prolonged central or peripheral intravenous therapy. The hazard of nosocomial infection associated with residence in a modern intensive care unit is dramatized by the case history of a near-drowning victim whose hospital course was complicated by an unusually large number and variety of nosocomial bacterial infections. Sixteen different bacterial organisms were isolated from cultures of blood, purulent thoracostomy tube drainage, or purulent tracheal secretions during the patient's prolonged hospital course. Factors which predisposed this patient to nosocomial infections included prolonged positive pressure mechanical ventilation, long-term broad spectrum antibiotics, indwelling arterial and central venous lines, violation of anatomic barriers by foreign bodies such as multiple thoracostomy tubes, and residence in an intensive care unit. This patient's case demonstrates that effective means to prevent nosocomial colonization and infection are urgently needed.

Measuring the performance of neonatal care units in Scotland.

PubMed

Field, Kamal; Emrouznejad, Ali

2003-08-01

Policy makers continue to debate whether or not to increase the share of health care expenditures in United Kingdom. On the other hand, the pressure of operating within tight budgets and the advances in technology are forcing more locally based hospitals to close. One that could be used by policy makers as a benchmark is the measure of relative performance of hospitals. Many researchers have examined the source of inefficiency in health sectors (see, for example, Harris et al., Oper. Res. Soc. 57:801-811, 2000, Ozcan et al., Med. Case 30:781-784, 1992; Ozcan et aL., J. Med. Syst. 20(3)141-150, 1996; and Grosskopf and Valdmanis, J. Health. Econ. 6:89-107, 1987 but there is no evidence of measuring performance of neonatal care units of Scottish hospitals in the DEA literature. The purpose of this paper is to measure both technical and scale efficiency using data envelopment analysis in a selection of 22 neonatal care units in Scotland. The analysis suggests that major inefficiency likely exists in health care production in United Kingdom. There is potential for improving productivity by 20%.

Piloting Medication Histories in a Pediatric Postanesthesia Care Unit.

PubMed

Lake, Nathan; Nawer, Humaira; Wagner, Deborah

2018-05-18

Develop a medication history process for pediatric postanesthesia care unit (PACU) patients to identify discrepancies between home and inpatient medications and prevent medication errors. Pilot an evidence-based practice change to perform PACU medication histories. Inpatients or surgical admissions to general care units at a pediatric tertiary care 348-bed hospital ages 2-18 years were included. Parents/guardians were asked about their child's prescription and over-the-counter medications, allergies, and adherence. Data included patient age, surgery, medication categories, and error classifications. Information was compared to the patient's medical record. From June to July 2016, 75 medication histories were performed, covering 44.6% of eligible cases within the period. Seventy-four discrepancies were found, the most frequent being omission. The medication category with the most errors was vitamins/herbals/supplements. The workflow designed assessed discrepancy frequency and type in surgical patients' medication lists when transitioning from the PACU to general care units. Copyright © 2018 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Herpes simplex virus type 2: Cluster of unrelated cases in an intensive care unit.

PubMed

Troché, Gilles; Marque Juillet, Stephanie; Burrel, Sonia; Boutolleau, David; Bédos, Jean-Pierre; Legriel, Stephane

2016-10-01

Herpes simplex viruses, which are associated with various clinical manifestations, can be transmitted to critically ill patients from other patients or health care staff. We report an apparent outbreak of mucocutaneous herpes simplex virus 2 infections (5 cases in 10 weeks). An epidemiologic investigation and genotype analysis showed no connections among the 5 cases. Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Stressors in the relatives of patients admitted to an intensive care unit.

PubMed

Barth, Angélica Adam; Weigel, Bruna Dorfey; Dummer, Claus Dieter; Machado, Kelly Campara; Tisott, Taís Montagner

2016-09-01

To identify and stratify the main stressors for the relatives of patients admitted to the adult intensive care unit of a teaching hospital. Cross-sectional descriptive study conducted with relatives of patients admitted to an intensive care unit from April to October 2014. The following materials were used: a questionnaire containing identification information and demographic data of the relatives, clinical data of the patients, and 25 stressors adapted from the Intensive Care Unit Environmental Stressor Scale. The degree of stress caused by each factor was determined on a scale of values from 1 to 4. The stressors were ranked based on the average score obtained. The main cause of admission to the intensive care unit was clinical in 36 (52.2%) cases. The main stressors were the patient being in a state of coma (3.15 ± 1.23), the patient being unable to speak (3.15 ± 1.20), and the reason for admission (3.00 ± 1.27). After removing the 27 (39.1%) coma patients from the analysis, the main stressors for the relatives were the reason for admission (2.75 ± 1.354), seeing the patient in the intensive care unit (2.51 ± 1.227), and the patient being unable to speak (2.50 ± 1.269). Difficulties in communication and in the relationship with the patient admitted to the intensive care unit were identified as the main stressors by their relatives, with the state of coma being predominant. By contrast, the environment, work routines, and relationship between the relatives and intensive care unit team had the least impact as stressors.

Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis

PubMed Central

Yi, Deokhee; Sutton, Matt; Chalkley, Martin; Sussex, Jon; Scott, Anthony

2009-01-01

Objective To examine whether the introduction of payment by results (a fixed tariff case mix based payment system) was associated with changes in key outcome variables measuring volume, cost, and quality of care between 2003/4 and 2005/6. Setting Acute care hospitals in England. Design Difference-in-differences analysis (using a control group created from trusts in England and providers in Scotland not implementing payment by results in the relevant years); retrospective analysis of patient level secondary data with fixed effects models. Data sources English hospital episode statistics and Scottish morbidity records for 2002/3 to 2005/6. Main outcome measures Changes in length of stay and proportion of day case admissions as a proxy for unit cost; growth in number of spells to measure increases in output; and changes in in-hospital mortality, 30 day post-surgical mortality, and emergency readmission after treatment for hip fracture as measures of impact on quality of care. Results Length of stay fell more quickly and the proportion of day cases increased more quickly where payment by results was implemented, suggesting a reduction in the unit costs of care associated with payment by results. Some evidence of an association between the introduction of payment by results and growth in acute hospital activity was found. Little measurable change occurred in the quality of care indicators used in this study that can be attributed to the introduction of payment by results. Conclusion Reductions in unit costs may have been achieved without detrimental impact on the quality of care, at least in as far as these are measured by the proxy variables used in this study. PMID:19713233

Explaining direct care resource use of nursing home residents: findings from time studies in four states.

PubMed

Arling, Greg; Kane, Robert L; Mueller, Christine; Lewis, Teresa

2007-04-01

To explain variation in direct care resource use (RU) of nursing home residents based on the Resource Utilization Groups III (RUG-III) classification system and other resident- and unit-level explanatory variables. Primary data were collected on 5,314 nursing home residents in 156 nursing units in 105 facilities from four states (CO, IN, MN, MS) from 1998 to 2004. Study Design. Nurses and other direct care staff recorded resident-specific and other time caring for all residents on sampled nursing units. Care time was linked to resident data from the Minimum Data Set assessment instrument. Major variables were: RUG-III group (34-group), other health and functional conditions, licensed and other professional minutes per day, unlicensed minutes per day, and direct care RU (wage-weighted minutes). Resident- and unit-level relationships were examined through hierarchical linear modeling. Time study data were recorded with hand-held computers, verified for accuracy by project staff at the data collection sites and then merged into resident and unit-level data sets. Resident care time and RU varied between and within nursing units. RUG-III group was related to RU; variables such as length of stay and unit percentage of high acuity residents also were significantly related. Case-mix indices (CMIs) constructed from study data displayed much less variation across RUG-III groups than CMIs from earlier time studies. Results from earlier time studies may not be representative of care patterns of Medicaid and private pay residents. New RUG-III CMIs should be developed to better reflect the relative costs of caring for these residents.

Acute respiratory distress syndrome: an audit of incidence and outcome in Scottish intensive care units.

PubMed

Hughes, M; MacKirdy, F N; Ross, J; Norrie, J; Grant, I S

2003-09-01

This prospective audit of incidence and outcome of the acute respiratory distress syndrome was conducted as part of the national audit of intensive care practice in Scotland. All patients with acute respiratory distress syndrome in 23 adult intensive care units were identified using the diagnostic criteria defined by the American-European Consensus Conference. Daily data collection was continued until death or intensive care unit discharge. Three hundred and sixty-nine patients were diagnosed with acute respiratory distress syndrome over the 8-month study period. The frequency of acute respiratory distress syndrome in the intensive care unit population was 8.1%; the incidence in the Scottish population was estimated at 16.0 cases.100,000(-1).year(-1). Intensive care unit mortality for acute respiratory distress syndrome was 53.1%, with a hospital mortality of 60.9%. In our national unselected population of critically ill patients, the overall outcome is comparable with published series (Acute Physiology and Chronic Health Evaluation II standardised mortality ratio = 0.99). However, mortality from acute respiratory distress syndrome in Scotland is substantially higher than in recent other series suggesting an improvement in outcome in this condition.

Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit.

PubMed

Blamoun, John; Alfakir, Maria; Rella, Marie E; Wojcik, Janice M; Solis, Roberto A; Anees Khan, M; DeBari, Vincent A

2009-03-01

The ventilator bundle (VB) includes a group of clinical maneuvers (head-of-bed elevation, "sedation vacation," deep vein thrombosis prophylaxis, and peptic ulcer disease prophylaxis) to improve outcomes in patients undergoing mechanical ventilation. We modified the standard VB in our medical intensive care unit to include a group of respiratory therapist-driven protocols and, postimplementation, observed a statistically significant (P = .0006) reduction in ventilator-associated pneumonia (VAP), from a median of 14.1 cases/10(3) ventilator-days (interquartile range [IQR] = 12.1 to 20.6) to 0 cases/10(3) ventilator-days (IQR = 0 to 1.1).

Case mix, outcome and activity for obstetric admissions to adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database

PubMed Central

2005-01-01

Introduction Risk prediction scores usually overestimate mortality in obstetric populations because mortality rates in this group are considerably lower than in others. Studies examining this effect were generally small and did not distinguish between obstetric and nonobstetric pathologies. We evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II model in obstetric admissions to critical care units contributing to the ICNARC Case Mix Programme. Methods All obstetric admissions were extracted from the ICNARC Case Mix Programme Database of 219,468 admissions to UK critical care units from 1995 to 2003 inclusive. Cases were divided into direct obstetric pathologies and indirect or coincidental pathologies, and compared with a control cohort of all women aged 16–50 years not included in the obstetric categories. The predictive ability of APACHE II was evaluated in the three groups. A prognostic model was developed for direct obstetric admissions to predict the risk for hospital mortality. A log-linear model was developed to predict the length of stay in the critical care unit. Results A total of 1452 direct obstetric admissions were identified, the most common pathologies being haemorrhage and hypertensive disorders of pregnancy. There were 278 admissions identified as indirect or coincidental and 22,938 in the nonpregnant control cohort. Hospital mortality rates were 2.2%, 6.0% and 19.6% for the direct obstetric group, the indirect or coincidental group, and the control cohort, respectively. Cox regression calibration analysis showed a reasonable fit of the APACHE II model for the nonpregnant control cohort (slope = 1.1, intercept = -0.1). However, the APACHE II model vastly overestimated mortality for obstetric admissions (mortality ratio = 0.25). Risk prediction modelling demonstrated that the Glasgow Coma Scale score was the best discriminator between survival and death in obstetric admissions. Conclusion This study confirms that APACHE II overestimates mortality in obstetric admissions to critical care units. This may be because of the physiological changes in pregnancy or the unique scoring profile of obstetric pathologies such as HELLP syndrome. It may be possible to recalibrate the APACHE II score for obstetric admissions or to devise an alternative score specifically for obstetric admissions.

Logistic-based patient grouping for multi-disciplinary treatment.

PubMed

Maruşter, Laura; Weijters, Ton; de Vries, Geerhard; van den Bosch, Antal; Daelemans, Walter

2002-01-01

Present-day healthcare witnesses a growing demand for coordination of patient care. Coordination is needed especially in those cases in which hospitals have structured healthcare into specialty-oriented units, while a substantial portion of patient care is not limited to single units. From a logistic point of view, this multi-disciplinary patient care creates a tension between controlling the hospital's units, and the need for a control of the patient flow between units. A possible solution is the creation of new units in which different specialties work together for specific groups of patients. A first step in this solution is to identify the salient patient groups in need of multi-disciplinary care. Grouping techniques seem to offer a solution. However, most grouping approaches in medicine are driven by a search for pathophysiological homogeneity. In this paper, we present an alternative logistic-driven grouping approach. The starting point of our approach is a database with medical cases for 3,603 patients with peripheral arterial vascular (PAV) diseases. For these medical cases, six basic logistic variables (such as the number of visits to different specialist) are selected. Using these logistic variables, clustering techniques are used to group the medical cases in logistically homogeneous groups. In our approach, the quality of the resulting grouping is not measured by statistical significance, but by (i) the usefulness of the grouping for the creation of new multi-disciplinary units; (ii) how well patients can be selected for treatment in the new units. Given a priori knowledge of a patient (e.g. age, diagnosis), machine learning techniques are employed to induce rules that can be used for the selection of the patients eligible for treatment in the new units. In the paper, we describe the results of the above-proposed methodology for patients with PAV diseases. Two groupings and the accompanied classification rule sets are presented. One grouping is based on all the logistic variables, and another grouping is based on two latent factors found by applying factor analysis. On the basis of the experimental results, we can conclude that it is possible to search for medical logistic homogenous groups (i) that can be characterized by rules based on the aggregated logistic variables; (ii) for which we can formulate rules to predict to which cluster new patients belong.

[Protocol to evaluate the effectiveness of a consciousness-raising and training intervention for primary care professionals, in order to improve detection of domestic violence (ISFVIDAP)].

PubMed

Fernández Alonso, M Carmen; Herrero Velázquez, Sonia; Cordero Guevara, José Aurelio; Maderuelo Fernández, José Angel; Madereuelo Fernández, José Angel; González Castro, María Luisa

2006-01-01

To evaluate the effectiveness of an intervention aimed at primary care physicians and nurses to improve the detection of domestic violence. Community intervention study with control, randomized in clusters, pragmatic, open, and with parallel groups. Primary care centres in Spain. Primary care physicians and nurses from the entire country who agree to participate in the study. UNIT OF ANALYSIS: The basic care team (BCT) of doctor and nurse looking after a list is the unit of analysis for evaluating the number of cases detected; and their clinical records are the units of analysis for evaluating recorded cases (suspicion and/or confirmation of mistreatment). Sixty eight BCT in each group (136 in the 2 groups) and 1700 clinical records per group (25 per BCT). Altogether, they will cover some 130,000 women of 14 and over. A short training programme with homogeneous training contents, aimed at raising the awareness of health professionals and teaching them how to identify risk factors, situations of special vulnerability and alarm signals. The programme also aims to provide health professionals with tools to make the clinical interview easier, when they suspect mistreatment and how to tackle a case once it is detected. The main measurement will be the mean variation between intervention and control groups in the number of cases of domestic violence detected during the study, through specific recording and mean variation between the initial and final variations in each group. A weighted student's t test or, if covariates need to be adjusted, a regression analysis will be used for comparison. All analyses will be based on intention to treat.

[Barriers and facilitators to health care coordination in two integrated health care organizations in Catalonia (Spain)].

PubMed

Vargas Lorenzo, Ingrid; Vázquez Navarrete, M Luisa

2007-01-01

To analyze 2 integrated delivery systems (IDS) in Catalonia and identify areas for future development to improve their effectiveness. An exploratory, descriptive, qualitative study was carried out based on case studies by means of document analysis and semi-structured individual interviews. A criterion sample of cases and, for each case, of documents and informants was selected. Study cases consisted of the Consorci Sanitari del Maresme (CSdM) and the Consorci Sanitari de Terrassa/Fundació Hospital Sant Llàtzer (FHSLL). A total of 127 documents were analyzed and 29 informants were interviewed: IDS managers (n = 10), technical staff (n = 5), operational unit managers (n = 5) and health professionals (n = 9). Content analysis was conducted, with mixed generation of categories and segmentation by cases and subjects. CSdM and CSdT/FHSLL are health care organizations with backward vertical integration, total services production, and real (CSdM) and virtual (CSdT/FHSLL) ownership. Funds are allocated by care level. The governing body is centralized in CSdM and decentralized in CSdT/FHSLL. In both organizations, the global objectives are oriented toward improving coordination and efficiency but are not in line with those of the operational units. Both organizations present a functional structure with integration of support functions and utilize mechanisms for collaboration between care levels based on work processes standardization. Both IDS present facilitators and barriers to health care coordination. To improve coordination, changes in external elements (payment mechanism) and in internal elements (governing body role, organizational structure and coordination mechanisms) are required.

Analysis of patient diaries in Danish ICUs: a narrative approach.

PubMed

Egerod, Ingrid; Christensen, Doris

2009-10-01

The objective was to describe the structure and content of patient diaries written for critically ill patients in Danish intensive care units (ICUs). Critical illness is associated with physical and psychological aftermath including cognitive impairment and post-traumatic stress. Patient diaries written in the intensive care unit are used to help ICU-survivors come to terms with their illness. The study had a qualitative, descriptive and explorative design, using a narrative approach of analysis. Data were analysed on several levels: extra-case level, case level, diary-entry level, and sub-entry level. The sample consisted of 25 patient diaries written by critical care nurses in 2007 for patients at a general ICU in Denmark. The base narrative describes three stages: crisis, turning point, and normalisation. Each case includes parallel plots of nurse, patient and family, which converge during normalisation. Each diary is structured by: summary, daily entries and end note. Each diary entry is structured by: greeting, narrator status, patient status, family status/contextual cues and sign-off note. Patient diaries acknowledge the patient experience and provide new insights into nursing performance. This study offers a framework for understanding ICU patient diaries, which may facilitate cross-unit comparisons and support future guideline development. The dual perspectives of patient diaries and the ambiguous ownership of the narratives may pave the way for insights to improve critical care nursing and ICU rehabilitation.

[The managment of serious pregnant disease in the intensive care unit].

PubMed

Ali, Elhusseini; Bechir, Khemiri; Badis, Chennoufi Mohamed; Nabil, Mathlouthi; Hanene, Ellouze; Mourad, Bouchnak; Salah, Hendaoui Mohamed; Hayen, Maghrebi; Ezzeddine, Sfar; Hela, Chelli

2005-02-01

We report a retrospective study over a period of 4 years and half and bearing on 59 patients that require an intensive care. The number of childbirth during this period was 22237 with 8.97% of Caesareans. The main obstetrical diseases was: gravidic toxaemia 75.5%, uterine inertia 7%, cardiopathy 5% of the cases. The reasons for the transfer were: eclamptic state in 27% of the cases, hémostasis disorder 22% of the cases, and acute pulmonary oedema 18.6% of the cases. Average duration of hospitalization was 3.18 days. Five cases of death were noted.

The Swine Flu Triage (SwiFT) study: development and ongoing refinement of a triage tool to provide regular information to guide immediate policy and practice for the use of critical care services during the H1N1 swine influenza pandemic.

PubMed

Rowan, K M; Harrison, D A; Walsh, T S; McAuley, D F; Perkins, G D; Taylor, B L; Menon, D K

2010-12-01

To use, existing critical care and early pandemic, data to inform care during the pandemic influenza A 2009 (H1N1) pandemic (with a possible use for triage - if the demand for critical care seriously exceeded supply). To monitor the impact of the H1N1 pandemic on critical care services, in real time, with regular feedback to critical care clinicians and other relevant jurisdictions to inform ongoing policy and practice. Modelling of data and cohort study. Modelling - 148 adult, general critical care units in England, Wales and Northern Ireland in the Intensive Care National Audit & Research Centre Case Mix Programme. Cohort study - 192 acute hospitals in England, Wales, Northern Ireland, Scotland and the Republic of Ireland. Modelling - 105,397 admissions to adult, general critical care units. Cohort study - 1728 H1N1 pandemic-related admissions referred and assessed as requiring critical care. Modelling - requirement for organ support and acute hospital mortality. Cohort study - survival to the end of critical care. Modelling - cancelled or postponed, elective or scheduled surgery resulted in savings in calendar days of critical, Level 3 and advanced respiratory care of 17, 11 and 10%, respectively. These savings varied across units. Using routine, physiological variables, the best triage models, for all and for acute respiratory admissions, achieved only satisfactory concordance of 0.79 and 0.75, respectively. Application of the best model on all admissions indicated that approximately 12.5% of calendar days of critical care could be saved. Cohort study - research governance approvals were achieved for 192 acute hospitals, for 91 within 1 day of central research and development approval across the five countries. A total of 1725 cases (562 confirmed) were reported. Confirmed cases were young (mean age of 40 years), had low severity of acute illness on presentation [61% CURB-65 (confusion, urea, respiratory rate, blood pressure, age over 65 years) 0-1], but had long stays in critical care (median 8.5 days) and were likely to be ventilated (77% for median 9 days). Risk factors for acute hospital death were similar to those for general critical care admissions. SwiFT was rapidly established. Models based on routine physiology suggested limited value for triage. More data and further modelling are warranted. The magnitude of the pandemic did not approach the worst-case scenario modelling, and UK-confirmed H1N1 cases appeared similar to those reported internationally. The National Institute for Health Research Health Technology Assessment programme.

HIV Infection and Linkage to HIV-Related Medical Care in Large Urban Areas in the United States, 2009.

PubMed

Laffoon, Benjamin T; Hall, H Irene; Surendera Babu, Aruna; Benbow, Nanette; Hsu, Ling C; Hu, Yunyin W

2015-08-01

Residents of urban areas have accounted for the majority of persons diagnosed with HIV disease in the United States. Linking persons recently diagnosed with HIV to primary medical care is an important indicator in the National HIV/AIDS Strategy. We analyzed data reported to the HIV Surveillance System in 18 urban areas in the United States. Standardized executable SAS programs were distributed to determine the number of HIV cases living through 2008, number of HIV cases diagnosed in 2009, and the percentage of those diagnosed in 2009 who had reported CD4 lymphocyte or HIV viral load test results within 3 months of HIV diagnosis. Data were presented by jurisdiction, age group at diagnosis, race/ethnicity, sex at birth, birth country, disease stage, and transmission category. By jurisdiction, the percentage of persons diagnosed in 2009 with at least 1 CD4 or HIV viral load test within 3 months of diagnosis ranged from 48.5% to 92.5% (median: 70.9). The percentage of persons linked to care varied by age group and by racial/ethnic groups. Fourteen of the 18 areas reported that the percentage of persons linked to care was greater than 65%, the baseline measure indicated in the National HIV/AIDS Strategy. A wide range in percent linked to HIV medical care was observed between residents of 18 urban areas in the United States with noted age and racial disparities. Routine testing and linkage efforts and intensified prevention efforts should be considered to increase access to primary HIV-related medical care.

[Detection of palliative care needs in an acute care hospital unit. Pilot study].

PubMed

Rodríguez-Calero, Miguel Ángel; Julià-Mora, Joana María; Prieto-Alomar, Araceli

2016-01-01

Previous to wider prevalence studies, we designed the present pilot study to assess concordance and time invested in patient evaluations using a palliative care needs assessment tool. We also sought to estimate the prevalence of palliative care needs in an acute care hospital unit. A cross-sectional study was carried out, 4 researchers (2 doctors and 2 nurses) independently assessed all inpatients in an acute care hospital unit in Manacor Hospital, Mallorca (Spain), using the validated tool NECPAL CCOMS-ICO©, measuring time invested in every case. Another researcher revised clinical recordings to analise the sample profile. Every researcher assessed 29 patients, 15 men and 14 women, mean age 74,03 ± 10.25 years. 4-observer concordance was moderate (Kappa 0,5043), tuning out to be higher between nurses. Mean time per patient evaluation was 1.9 to 7.72 minutes, depending on researcher. Prevalence of palliative care needs was 23,28%. Moderate concordance lean us towards multidisciplinary shared assessments as a method for future research. Avarage of time invested in evaluations was less than 8 minutes, no previous publications were identified regarding this variable. More than 20% of inpatients of the acute care unit were in need of palliative care. Copyright © 2015 Elsevier España, S.L.U. All rights reserved.

Ethical issues recognized by critical care nurses in the intensive care units of a tertiary hospital during two separate periods.

PubMed

Park, Dong Won; Moon, Jae Young; Ku, Eun Yong; Kim, Sun Jong; Koo, Young-Mo; Kim, Ock-Joo; Lee, Soon Haeng; Jo, Min-Woo; Lim, Chae-Man; Armstrong, John David; Koh, Younsuck

2015-04-01

This research aimed to investigate the changes in ethical issues in everyday clinical practice recognized by critical care nurses during two observation periods. We conducted a retrospective analysis of data obtained by prospective questionnaire surveys of nurses in the intensive care units (ICU) of a tertiary university-affiliated hospital in Seoul, Korea. Data were collected prospectively during two different periods, February 2002-January 2003 (Period 1) and August 2011-July 2012 (Period 2). Significantly fewer cases with ethical issues were reported in Period 2 than in Period 1 (89 cases [2.1%] of 4,291 ICU admissions vs. 51 [0.5%] of 9,302 ICU admissions, respectively; P < 0.001). The highest incidence of cases with identified ethical issues in both Periods occurred in MICU. The major source of ethical issues in Periods 1 and 2 was behavior-related. Among behaviorrelated issues, inappropriate healthcare professional behavior was predominant in both periods and mainly involved resident physicians. Ethical issue numbers regarding end-oflife (EOL) care significantly decreased in the proportion with respect to ethical issues during Period 2 (P = 0.044). In conclusion, the decreased incidence of cases with identified ethical issues in Period 2 might be associated with ethical enhancement related with EOL and improvements in the ICU care environment of the studied hospital. However, behaviorrelated issues involving resident physicians represent a considerable proportion of ethical issues encountered by critical care nurses. A systemic approach to solve behavior-related issues of resident physicians seems to be required to enhance an ethical environment in the studied ICU.

Quality of life in patients with advanced lung cancer treated at home and at a palliative care unit.

PubMed

Leppert, Wojciech; Turska, Anna; Majkowicz, Mikolaj; Dziegielewska, Sylwia; Pankiewicz, Piotr; Mess, Eleonora

2012-08-01

To assess quality of life (QOL) in patients with advanced lung cancer. A prospective study of 78 patients cared at home and at a palliative care unit (PCU) with 2 QOL assessments was conducted. Fifty patients completed the study. In the EORTC QLQ-C30 role, cognitive, social functioning, global QOL, fatigue, pain, dyspnea, and appetite deteriorated; nausea/vomiting improved; dyspnea was more intense in the case of in-home patients. In the EORTC QLQ-LC13 hemoptysis improved; pain in other parts was more intense in the PCU patients. Pain (Visual Analogue scale) was more intense in the PCU patients; the level of activity (Karnofsky) decreased in the case of patients treated at home. QOL deteriorated with few differences between home and the PCU patients.

Stressors in the relatives of patients admitted to an intensive care unit

PubMed Central

Barth, Angélica Adam; Weigel, Bruna Dorfey; Dummer, Claus Dieter; Machado, Kelly Campara; Tisott, Taís Montagner

2016-01-01

Objective To identify and stratify the main stressors for the relatives of patients admitted to the adult intensive care unit of a teaching hospital. Methods Cross-sectional descriptive study conducted with relatives of patients admitted to an intensive care unit from April to October 2014. The following materials were used: a questionnaire containing identification information and demographic data of the relatives, clinical data of the patients, and 25 stressors adapted from the Intensive Care Unit Environmental Stressor Scale. The degree of stress caused by each factor was determined on a scale of values from 1 to 4. The stressors were ranked based on the average score obtained. Results The main cause of admission to the intensive care unit was clinical in 36 (52.2%) cases. The main stressors were the patient being in a state of coma (3.15 ± 1.23), the patient being unable to speak (3.15 ± 1.20), and the reason for admission (3.00 ± 1.27). After removing the 27 (39.1%) coma patients from the analysis, the main stressors for the relatives were the reason for admission (2.75 ± 1.354), seeing the patient in the intensive care unit (2.51 ± 1.227), and the patient being unable to speak (2.50 ± 1.269). Conclusion Difficulties in communication and in the relationship with the patient admitted to the intensive care unit were identified as the main stressors by their relatives, with the state of coma being predominant. By contrast, the environment, work routines, and relationship between the relatives and intensive care unit team had the least impact as stressors. PMID:27737424

Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey.

PubMed

Cortegiani, Andrea; Russotto, Vincenzo; Raineri, Santi Maurizio; Gregoretti, Cesare; Giarratano, Antonino; Mercadante, Sebastiano

2018-06-01

The aim of this paper is to collect data on the practice of palliative care, withholding and withdrawal of life-sustaining therapies, and management of end of life (EOL) in Italian intensive care units (ICUs). Web-based survey among Italian anesthesiologists endorsed by the Italian Society of Anesthesiology Analgesia Reanimation and Intensive Care (SIAARTI). The survey consists of 27 close-ended and 2 open-ended questions. Eight hundred and five persons responded to the full list of questions. The highest proportion of respondents was of 36-45 years of age (34%) and catholic (66%). Almost 70% of responders declared that palliative/supportive care are applied in their ICU in case of futility of intensive treatments. Decision on withdrawing/withholding of life-sustaining treatments resulted from team consensus in most cases (58%). In more than 70% of responders' ICUs, there is no collaboration with palliative/supportive care experts. Systematic recording of most frequent symptoms experienced by critically ill patients (e.g., pain, dyspnea, thirst) was not common. Vasopressors, extracorporeal therapies, blood component transfusions and invasive monitoring were the most commonly modified/interrupted measures in case of futility. Almost 85% of respondents have not received training in palliative/supportive care. The proportion of respondents whose institution has a palliative care team and who had training in palliative care was not homogenous across the country. These data suggest that training in palliative care and its clinical application should be implemented in Italy. Efforts should be made to improve and homogenize the management of dying patients in ICU.

Perspective: united we stand, divided we fall: the case for a single primary care specialty in the United States.

PubMed

Halvorsen, John G

2008-05-01

Primary care as an academic discipline and key component of the U.S. health care system faces a threatened future, despite numerous studies in the United States and cross-nationally that substantiate its health-promoting benefits. The United States remains the only Western industrialized nation that delivers primary care through three major disciplines rather than as a single specialty. This fragmented model may contribute to the fact that the United States does not have a primary-care-based health care system and that the U.S. population demonstrates poorer health outcomes than do those countries whose health systems are based on primary care and managed by a single primary care specialty. Fragmentation also creates confusion about primary care's identity, diminishes its influence because it does not speak with a common voice, and creates competition for academic and professional status, resources, curricular priority, research and training program funding, patients, and reimbursement. A large, single-specialty body of primary physicians could eliminate much duplication and competition and demonstrate greater political influence with academia, government agencies, insurers, and corporate America. A single specialty that incorporates the strengths of the three primary care disciplines would expand the clinical scope of primary care and could serve as a potent enabling force to lead health system reform. It would also produce measurable benefits for medical student and graduate medical education, health system design and service delivery, and primary care research. The author outlines a plan of action, involving all stakeholders, to initiate and achieve the single-specialty goal.

Explaining Direct Care Resource Use of Nursing Home Residents: Findings from Time Studies in Four States

PubMed Central

Arling, Greg; Kane, Robert L; Mueller, Christine; Lewis, Teresa

2007-01-01

Objective To explain variation in direct care resource use (RU) of nursing home residents based on the Resource Utilization Groups III (RUG-III) classification system and other resident- and unit-level explanatory variables. Data Sources/Study Setting Primary data were collected on 5,314 nursing home residents in 156 nursing units in 105 facilities from four states (CO, IN, MN, MS) from 1998 to 2004. Study Design Nurses and other direct care staff recorded resident-specific and other time caring for all residents on sampled nursing units. Care time was linked to resident data from the Minimum Data Set assessment instrument. Major variables were: RUG-III group (34-group), other health and functional conditions, licensed and other professional minutes per day, unlicensed minutes per day, and direct care RU (wage-weighted minutes). Resident- and unit-level relationships were examined through hierarchical linear modeling. Data Collection/Extraction Methods Time study data were recorded with hand-held computers, verified for accuracy by project staff at the data collection sites and then merged into resident and unit-level data sets. Principal Findings Resident care time and RU varied between and within nursing units. RUG-III group was related to RU; variables such as length of stay and unit percentage of high acuity residents also were significantly related. Case-mix indices (CMIs) constructed from study data displayed much less variation across RUG-III groups than CMIs from earlier time studies. Conclusions Results from earlier time studies may not be representative of care patterns of Medicaid and private pay residents. New RUG-III CMIs should be developed to better reflect the relative costs of caring for these residents. PMID:17362220

The Medication Optimization Value Proposition: Aligning Teams and Education to Improve Care.

PubMed

Easter, Jon C; DeWalt, Darren A

2017-01-01

United States health care lags behind other countries in quality and cost. The present health care system is unsustainable, and there is now a quick movement toward value-based care. This article lays out essential care delivery elements, and makes the case for medication optimization to enable new value-based models. Success factors include enhancing team-based care and interdisciplinary education to achieve patient-centered care. ©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

Serratia marcescens Bacteremia: Nosocomial Cluster Following Narcotic Diversion.

PubMed

Schuppener, Leah M; Pop-Vicas, Aurora E; Brooks, Erin G; Duster, Megan N; Crnich, Christopher J; Sterkel, Alana K; Webb, Aaron P; Safdar, Nasia

2017-09-01

OBJECTIVE To describe the investigation and control of a cluster of Serratia marcescens bacteremia in a 505-bed tertiary-care center. METHODS Cluster cases were defined as all patients with S. marcescens bacteremia between March 2 and April 7, 2014, who were found to have identical or related blood isolates determined by molecular typing with pulsed-field gel electrophoresis. Cases were compared using bivariate analysis with controls admitted at the same time and to the same service as the cases, in a 4:1 ratio. RESULTS In total, 6 patients developed S. marcescens bacteremia within 48 hours after admission within the above period. Of these, 5 patients had identical Serratia isolates determined by molecular typing, and were included in a case-control study. Exposure to the post-anesthesia care unit was a risk factor identified in bivariate analysis. Evidence of tampered opioid-containing syringes on several hospital units was discovered soon after the initial cluster case presented, and a full narcotic diversion investigation was conducted. A nurse working in the post-anesthesia care unit was identified as the employee responsible for the drug diversion and was epidemiologically linked to all 5 patients in the cluster. No further cases were identified once the implicated employee's job was terminated. CONCLUSION Illicit drug use by healthcare workers remains an important mechanism for the development of bloodstream infections in hospitalized patients. Active mechanisms and systems should remain in place to prevent, detect, and control narcotic drug diversions and associated patient harm in the healthcare setting. Infect Control Hosp Epidemiol 2017;38:1027-1031.

Quality of Care in Creches for Disadvantaged Children: A Brazilian Case Study.

ERIC Educational Resources Information Center

Ferreira, M. C. Rossetti; And Others

A study was conducted to critically assess the developmental conditions of 187 children (ages 1 month to 6 years) in eight creches (day nurseries) located in and around Ribeirao Preto, Brazil. Data were collected through informal interviews of day care staff and from 20 hours of direct observations of day care units. Findings indicated inadequate…

Disease Management, Case Management, Care Management, and Care Coordination: A Framework and a Brief Manual for Care Programs and Staff.

PubMed

Ahmed, Osman I

2016-01-01

With the changing landscape of health care delivery in the United States since the passage of the Patient Protection and Affordable Care Act in 2010, health care organizations have struggled to keep pace with the evolving paradigm, particularly as it pertains to population health management. New nomenclature emerged to describe components of the new environment, and familiar words were put to use in an entirely different context. This article proposes a working framework for activities performed in case management, disease management, care management, and care coordination. The author offers standard working definitions for some of the most frequently used words in the health care industry with the goal of increasing consistency for their use, especially in the backdrop of the Centers for Medicaid & Medicare Services offering a "chronic case management fee" to primary care providers for managing the sickest, high-cost Medicare patients. Health care organizations performing case management, care management, disease management, and care coordination. Road map for consistency among users, in reporting, comparison, and for success of care management/coordination programs. This article offers a working framework for disease managers, case and care managers, and care coordinators. It suggests standard definitions to use for disease management, case management, care management, and care coordination. Moreover, the use of clear terminology will facilitate comparing, contrasting, and evaluating all care programs and increase consistency. The article can improve understanding of care program components and success factors, estimate program value and effectiveness, heighten awareness of consumer engagement tools, recognize current state and challenges for care programs, understand the role of health information technology solutions in care programs, and use information and knowledge gained to assess and improve care programs to design the "next generation" of programs.

Ebola virus disease cases among health care workers not working in Ebola treatment units--Liberia, June-August, 2014.

PubMed

Matanock, Almea; Arwady, M Allison; Ayscue, Patrick; Forrester, Joseph D; Gaddis, Bethany; Hunter, Jennifer C; Monroe, Benjamin; Pillai, Satish K; Reed, Christie; Schafer, Ilana J; Massaquoi, Moses; Dahn, Bernice; De Cock, Kevin M

2014-11-21

West Africa is experiencing the largest Ebola virus disease (Ebola) epidemic in recorded history. Health care workers (HCWs) are at increased risk for Ebola. In Liberia, as of August 14, 2014, a total of 810 cases of Ebola had been reported, including 10 clusters of Ebola cases among HCWs working in facilities that were not Ebola treatment units (non-ETUs). The Liberian Ministry of Health and Social Welfare and CDC investigated these clusters by reviewing surveillance data, interviewing county health officials, HCWs, and contact tracers, and visiting health care facilities. Ninety-seven cases of Ebola (12% of the estimated total) were identified among HCWs; 62 HCW cases (64%) were part of 10 distinct clusters in non-ETU health care facilities, primarily hospitals. Early recognition and diagnosis of Ebola in patients who were the likely source of introduction to the HCWs (i.e., source patients) was missed in four clusters. Inconsistent recognition and triage of cases of Ebola, overcrowding, limitations in layout of physical spaces, lack of training in the use of and adequate supply of personal protective equipment (PPE), and limited supervision to ensure consistent adherence to infection control practices all were observed. Improving infection control infrastructure in non-ETUs is essential for protecting HCWs. Since August, the Liberian Ministry of Health and Social Welfare with a consortium of partners have undertaken collaborative efforts to strengthen infection control infrastructure in non-ETU health facilities.

The relationship between nurse staffing and failure to rescue: where does it matter most?

PubMed

Talsma, AkkeNeel; Jones, Katherine; Guo, Ying; Wilson, Deleise; Campbell, Darrell A

2014-09-01

This study further expands on the relationship between nurse staffing levels and patient outcomes, in particular, failure to rescue. Many studies are based on single-site hospitals or single-year data, thus limiting the generalizations of the findings. The purpose was to evaluate in a multisite multiyear study the relationship between unit-level nurse staffing and FTR mortality, for ICU and non-ICU patients. Using administrative and actual unit level nurse staffing data, we used AHRQ 2003 Patient Safety Indicator (2003) software and matched those with the patient's discharge month. Fixed effects multilevel logistic analyses were used to take into account the hierarchical structure of the database and patient clustering within units. We controlled for patient demographics, clinical conditions, and CCS categories. The majority (94%) of cases were discharged from general care units, ICUs reported higher nurse staffing levels based on patient complexity. Expired cases were 3 years older, male, and nonwhite. For general care discharges, the relationship between RN level HPPD approached significance (P = 0.07), suggesting increased odds of higher FTR mortality with higher staffing levels. We did not observe any of the expected associations between the nurse staffing variables and FTR for either general care unit or ICU discharges. The comprehensive risk adjustments provided adequate "leveling of the playing field" to evaluate the impact of unit-based nurse staffing levels on FTR mortality. Future studies should evaluate the influence of unit environment and patient risk.

Incidence and Outcomes for Patients With Cirrhosis Admitted to the United Kingdom Critical Care Units.

PubMed

McPhail, Mark J W; Parrott, Francesca; Wendon, Julia A; Harrison, David A; Rowan, Kathy A; Bernal, William

2018-05-01

To assess the epidemiology and outcome of patients with cirrhosis following critical care unit admission. Retrospective cohort study. Critical care units in England, Wales, and Northern Ireland participating in the U.K. Intensive Care National Audit and Research Centre Case Mix Programme. Thirty-one thousand three hundred sixty-three patients with cirrhosis identified of 1,168,650 total critical care unit admissions (2.7%) admitted to U.K. critical care units between 1998 and 2012. None. Ten thousand nine hundred thirty-six patients had alcohol-related liver disease (35%). In total, 1.6% of critical care unit admissions in 1998 had cirrhosis rising to 3.1% in 2012. The crude critical care unit mortality of patients with cirrhosis was 41% in 1998 falling to 31% in 2012 (p < 0.001). Crude hospital mortality fell from 58% to 46% over the study period (p < 0.001). Mean(SD) Acute Physiology and Chronic Health Evaluation II score in 1998 was 20.3 (8.5) and 19.5 (7.1) in 2012. Mean Acute Physiology and Chronic Health Evaluation II score for patients with alcohol-related liver disease in 2012 was 20.6 (7.0) and 19.0 (7.2) for non-alcohol-related liver disease (p < 0.001). In adjusted analysis, alcohol-related liver disease was associated with increased risk of death (odds ratio, 1.51 [95% CI, 1.42-1.62; p < 0.001]) with a year-on-year reduction in hospital mortality (adjusted odds ratio, 0.95/yr, [0.94-0.96, p < 0.001]). More patients with cirrhosis are being admitted to critical care units but with increasing survival rates. Patients with alcohol-related liver disease have reduced survival rates partly explained by higher levels of organ failure at admission. Patients with cirrhosis and organ failure warrant a trial of organ support and universal prognostic pessimism is not justified.

End-of-life decisions in Dutch neonatal intensive care units.

PubMed

Verhagen, A A Eduard; Dorscheidt, Jozef H H M; Engels, Bernadette; Hubben, Joep H; Sauer, Pieter J

2009-10-01

To clarify the practice of end-of-life decision making in severely ill newborns. Retrospective descriptive study with face-to-face interviews. The 10 neonatal intensive care units in the Netherlands from October 2005 to September 2006. All 367 newborn infants who died in the first 2 months of life in Dutch neonatal intensive care units. Adequate documentation was available in 359 deaths. Presence of end-of-life decisions, classification of deaths in 3 groups, and physicians' considerations leading to end-of-life decisions. An end-of-life decision preceded death in 95% of cases, and in 5% treatment was continued until death. Of all of the deaths, 58% were classified as having no chance of survival and 42% were stabilized newborns with poor prognoses. Withdrawal of life-sustaining therapy was the main mode of death in both groups. One case of deliberate ending of life was found. In 92% of newborns with poor prognoses, end-of-life decisions were based on patients' future quality of life and mainly concerned future suffering. Considerations regarding the infant's present state were made in 44% of infants. Virtually all deaths in Dutch neonatal intensive care units are preceded by the decision to withdraw life-sustaining treatment and many decisions are based on future quality of life. The decision to deliberately end the life of a newborn may occur less frequently than was previously assumed.

Long-term care and dementia services: an impending crisis.

PubMed

Macdonald, Alastair; Cooper, Brian

2007-01-01

since the transfer of long-stay care to the independent sector, provision of places in care homes in the United Kingdom has varied in response to market trends, and has shown a consistent fall in the past 10 years. People with dementia constitute the largest diagnostic group affected by these changes, and are also likely to be the group that will determine future need. We therefore estimated the number and proportion of older residents in care homes who suffer from dementia relative to all those with dementia in the United Kingdom and projected future levels of demand on the basis of this data. the number of dementia cases in long-stay care was estimated from a random sample survey in south-east England and compared with data on age-specific prevalence. Projections of future demand were based on UK population projections for the next 40 years. over half of all people with dementia in the United Kingdom are in care homes. The number of available long-stay places in care homes has fallen by one-sixth over the past decade. Projection of future demand suggests that well over double the present total places in care homes would be required by 2043 to maintain the present ratio of institutional to community services for dementia. this finding suggests an impending crisis of availability. A more realistic scenario calls for investment in affordable domiciliary care of good quality, but it will also depend on the acceptance of the fact that the main function of long-stay care for old people is now to provide for advanced cases of dementia, with consequent requirement for improvement in staff ratios and training.

Nurses' knowledge and barriers regarding pain management in intensive care units.

PubMed

Wang, Hsiang-Ling; Tsai, Yun-Fang

2010-11-01

To explore nurses' knowledge and barriers regarding pain management in intensive care units. Pain is a common and treatable condition among intensive care patients. Quality care of these patients depends on the pain knowledge and pain management skills of critical care nurses. However, no single study has explored these nurses' knowledge of and perceived barriers to pain management in Taiwan. A cross-sectional study. Intensive care unit nurses (n = 370) were recruited from 16 hospitals chosen by stratified sampling across Taipei County in Taiwan. Data were collected on nurses' knowledge of pain management using the Nurses' Knowledge and Attitudes Survey-Taiwanese version, on perceived barriers to pain management using a researcher-developed scale and on background information. The overall average correct response rate for the knowledge scale was 53.4%, indicating poor knowledge of pain management. The top barrier to managing pain identified by these nurses was 'giving proper pain prescription needs doctor's approval; can't depend on me'. Knowledge of pain management was significantly and negatively related to perceived barriers to pain management. In addition, scores for knowledge and perceived barriers differed significantly by specific intensive care unit. Knowledge also differed significantly by nurses' education level, clinical competence level (nursing ladder) and hospital accreditation category. Our results indicate an urgent need to strengthen pain education by including case analysis for intensive care nurses in Taiwan. Pain education should target knowledge deficits and barriers to changing pain management approaches for Taiwanese nurses in intensive care units. © 2010 Blackwell Publishing Ltd.

Successful removal of endobronchial blood clots using bronchoscopic cryotherapy at bedside in the intensive care unit.

PubMed

Lee, Hongyeul; Leem, Cho Sun; Lee, Jae Ho; Lee, Choon-Taek; Cho, Young-Jae

2014-10-01

Acute airway obstruction after hemoptysis occurs due to the presence of blood clots. These conditions may result in life-threatening ventilation impairment. We report a case of obstruction of the large airway by endobronchial blood clots which were removed using bronchoscopic cryotherapy at the bedside of intensive care unit. A 66-year-old female with endometrial cancer who had undergone chemotherapy, was admitted to the intensive care unit due to neutropenic fever. During mechanical ventilation, the minute ventilation dropped to inadequately low levels and chest radiography showed complete opacification of the left hemithorax. Flexible bronchoscopy revealed large blood clots obstructing the proximal left main bronchus. After unsuccessful attempts to remove the clots with bronchial lavage and forceps extraction, blood clots were removed using bronchoscopic cryotherapy. This report shows that cryotherapy via flexible bronchoscopy at the bedside in the intensive of intensive care unit is a simple and effective alternative for the removal of endobronchial blood clots.

Body dirt or liquid gold? How the 'safety' of donated breastmilk is constructed for use in neonatal intensive care.

PubMed

Carroll, Katherine

2014-06-01

When mothers of preterm infants are unable to produce sufficient volumes of breastmilk, neonatologists in many Western countries prescribe pasteurized donor breastmilk. Breastmilk has a paradoxical presence in the neonatal intensive care unit while it has therapeutic properties, it also has the potential to transmit disease. National health authorities and local neonatal intensive care unit policies each delimit the safety of donor milk by focusing on the presence or absence of pathogens. It is in this light that breastmilk from the human milk bank is both sought and legitimated to minimize safety concerns. This research uses data arising from an ethnographic study of two human milk banks and two neonatal intensive care units in the United States, and 73 interviews with milk donors, neonatal intensive care unit parents and clinicians. The primary research question framing the study was 'What are the underlying processes and practices that have enabled donor milk to be endorsed as a safe and legitimate feeding option in neonatal intensive care units?' This study is framed using three key principles of Latour's 'new critique', namely, adding to reality rather than debunking it, getting closer to data rather than turning away from fact and creating arenas in which to assemble. As a result, conceptions of donor milk's safety are expanded. This case study of donor milk demonstrates how Latour's new critique can inform science and technology studies approaches to the study of safety in health care.

Pregnancy, Labor, and Delivery after Ebola Virus Disease and Implications for Infection Control in Obstetric Services, United States.

PubMed

Kamali, Amanda; Jamieson, Denise J; Kpaduwa, Julius; Schrier, Sarah; Kim, Moon; Green, Nicole M; Ströher, Ute; Muehlenbachs, Atis; Bell, Michael; Rollin, Pierre E; Mascola, Laurene

2016-07-01

Many of the survivors of the 2014-2015 epidemic of Ebola virus disease (EVD) in western Africa were women of childbearing age. Limited clinical and laboratory data exist that describe these women's pregnancies and outcomes. We report the case of an EVD survivor who became pregnant and delivered her child in the United States, and we discuss implications of this case for infection control practices in obstetric services. Hospitals in the United States must be prepared to care for EVD survivors.

Infection and acute respiratory distress syndrome during pregnancy: a case series of preventable maternal deaths from southern India.

PubMed

Vasudeva, Akhila; Bhat, Rajeshwari G; Ramachandran, Amar; Kumar, Pratap

2013-02-01

Acute respiratory distress syndrome (ARDS) is common among women admitted to obstetric intensive care units, and it contributes significantly, both directly and indirectly, to maternal deaths. We present a case series of ARDS in pregnant women caused by non-obstetric causes. The women were treated at a tertiary hospital in southern India. The striking features were delayed referral from the primary care unit and the lack of a primary diagnosis or treatment. Undiagnosed rheumatic heart disease, anemia, and malaria and H1N1 epidemics contributed to these cases of ARDS and maternal death. It is necessary to increase the awareness of evidence-based uniform protocols to tackle common medical complaints during pregnancy. Copyright © 2012 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved.

[Analysis of obstetric-pediatric care in the perinatal period. Are births before 31 weeks' gestation in level 2B maternity units avoidable?

PubMed

Martin, I; Roussel, A; Olieric, M-F; Feldmann, M; Wallerich, Y; Trabelsi, N; Miton, A; Zuily-Lamy, C; Valdès, V; Fresson, J

2017-12-01

Regionalization of perinatal care has been developed to improve the survival of preterm babies. The mortality rate is higher among very premature infants born outside level-3 maternity units. The objective of this study was to evaluate the preventability of these very premature births occurring outside recommendations within level-2B maternity units. The secondary objective was to describe the care of premature infants between 23 and 24 weeks. This is a single-center retrospective qualitative study of the care delivery pathways. Thirty-one deliveries in which the fetus was alive between 23 and 30 weeks+6 days occurred in a level-2B maternity unit in Thionville, France, between 1 January 2013 and 31 December 2015. After oral presentation of the cases, a level 2-3 multidisciplinary committee of experts in Lorraine evaluated the preventability criteria and reasons, and divided the deliveries into three groups: (i) birth in level-2B institutions avoidable, (ii) inevitable with factors related to the mother or the organization of care, (iii) with no inevitable factors. Out of the 31 deliveries included, the committee classified six deliveries as preventable, 14 as inevitable with factors, and 11 as inevitable with no factors. The criteria for preventability of birth in a level-2B unit were underestimation of maternal and fetal risk, an erroneous initial estimate of term or preterm labor, and two births in the upper limits of the French recommendations for in utero transfer. Nineteen of the 35 premature infants before 31 weeks' gestation died, 16 children were transferred to a level-3 maternity ward, and 16 children were allowed to go home. Analysis of the obstetrical-pediatric care course by an expert committee determined the preventability of the average birth and prematurity in level-2B maternity units in Lorraine for a small but significant number of cases. The local regionalization of neonatal care could be improved by the application of this method of analysis to other maternity wards in the Lorraine network. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Process Improvement to Enhance Quality in a Large Volume Labor and Birth Unit.

PubMed

Bell, Ashley M; Bohannon, Jessica; Porthouse, Lisa; Thompson, Heather; Vago, Tony

The goal of the perinatal team at Mercy Hospital St. Louis is to provide a quality patient experience during labor and birth. After the move to a new labor and birth unit in 2013, the team recognized many of the routines and practices needed to be modified based on different demands. The Lean process was used to plan and implement required changes. This technique was chosen because it is based on feedback from clinicians, teamwork, strategizing, and immediate evaluation and implementation of common sense solutions. Through rapid improvement events, presence of leaders in the work environment, and daily huddles, team member engagement and communication were enhanced. The process allowed for team members to offer ideas, test these ideas, and evaluate results, all within a rapid time frame. For 9 months, frontline clinicians met monthly for a weeklong rapid improvement event to create better experiences for childbearing women and those who provide their care, using Lean concepts. At the end of each week, an implementation plan and metrics were developed to help ensure sustainment. The issues that were the focus of these process improvements included on-time initiation of scheduled cases such as induction of labor and cesarean birth, timely and efficient assessment and triage disposition, postanesthesia care and immediate newborn care completed within approximately 2 hours, transfer from the labor unit to the mother baby unit, and emergency transfers to the main operating room and intensive care unit. On-time case initiation for labor induction and cesarean birth improved, length of stay in obstetric triage decreased, postanesthesia recovery care was reorganized to be completed within the expected 2-hour standard time frame, and emergency transfers to the main hospital operating room and intensive care units were standardized and enhanced for efficiency and safety. Participants were pleased with the process improvements and quality outcomes. Working together as a team using the Lean process, frontline clinicians identified areas that needed improvement, developed and implemented successful strategies that addressed each gap, and enhanced the quality and safety of care for a large volume perinatal service.

Reimbursement in hospital-based vascular surgery: Physician and practice perspective.

PubMed

Perri, Jennifer L; Zwolak, Robert M; Goodney, Philip P; Rutherford, Gretchen A; Powell, Richard J

2017-07-01

The purpose of this study was to determine change in value of a vascular surgery division to the health care system during 6 years at a hospital-based academic practice and to compare physician vs hospital revenue earned during this period. Total revenue generated by the vascular surgery service line at an academic medical center from 2010 through 2015 was evaluated. Total revenue was measured as the sum of physician (professional) and hospital (technical) net revenue for all vascular-related patient care. Adjustments were made for work performed, case complexity, and inflation. To reflect the effect of these variables, net revenue was indexed to work relative value units (wRVUs), case mix index, and consumer price index, which adjusted for work, case complexity, and inflation, respectively. Differences in physician and hospital net revenue were compared over time. Physician work, measured in RVUs per year, increased by 4%; case complexity, assessed with case mix index, increased by 10% for the 6-year measurement period. Despite stability in payer mix at 64% to 69% Medicare, both physician and hospital vascular-related revenue/wRVU decreased during this period. Unadjusted professional revenue/wRVU declined by 14.1% (P = .09); when considering case complexity, physician revenue/wRVU declined by 20.6% (P = .09). Taking into account both case complexity and inflation, physician revenue declined by 27.0% (P = .04). Comparatively, hospital revenue for vascular surgery services decreased by 13.8% (P = .07) when adjusting for unit work, complexity, and inflation. At medical centers where vascular surgeons are hospital based, vascular care reimbursement decreased substantially from 2010 to 2015 when case complexity and inflation were considered. Physician reimbursement (professional fees) decreased at a significantly greater rate than hospital reimbursement for vascular care. This trend has significant implications for salaried vascular surgeons in hospital-based settings, where the majority of revenue generated by vascular surgery care is the technical component received by the facility. Appropriate care for patients with vascular disease is increasingly resource intensive, and as a corollary, reimbursement levels must reflect this situation if high-quality care is to be maintained. Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

[Cases of acute poisoning admitted to a medical intensive care unit].

PubMed

Viertel, A; Weidmann, E; Brodt, H R

2001-10-19

Because of the paucity of information on the epidemiology of acute poisoning requiring intensive medical care, all such patients treated on the medical intensive care unit of the university hospital in Frankfurt am Main, Germany, between January 1993 and December 1999, were retrospectively evaluated. Of the total of 6211 patients, 147 (80 women, 67 men, mean age 41 years, 2,3 %) were treated for acute intoxication in the intensive care unit. Reasons for admission to the intensive care unit were the need for ventilator treatment or intensive monitoring of vital functions. 52 % of the patients (n = 76) had attempted suicide, most of them using anti-depressive drugs (n = 19), paracetamol (n = 16), or benzodiazepines (n = 9). Two patients (2,6 %) died. 48 % of the patients (n = 71) were admitted because of accidental poisoning. Leading toxic agents in this group were heroin (n = 19), alcohol (n = 18) and digitalis (n = 12). 11 patients had taken herbicides, animal poisons or chemicals used at work or for house cleaning. In this cohort, three i. v. drug abusers (4,2 %) had died. Depending on the agents used, a variety of treatments (charcoal, antidots, extracorporal therapy) were undertaken. Due to excellent care in the prehospital phase and in the emergency room the number of patients requiring treatment on the intensive care unit was rather low. The mortality was in the range of other reports.

Priority Queuing Models for Hospital Intensive Care Units and Impacts to Severe Case Patients

PubMed Central

Hagen, Matthew S.; Jopling, Jeffrey K; Buchman, Timothy G; Lee, Eva K.

2013-01-01

This paper examines several different queuing models for intensive care units (ICU) and the effects on wait times, utilization, return rates, mortalities, and number of patients served. Five separate intensive care units at an urban hospital are analyzed and distributions are fitted for arrivals and service durations. A system-based simulation model is built to capture all possible cases of patient flow after ICU admission. These include mortalities and returns before and after hospital exits. Patients are grouped into 9 different classes that are categorized by severity and length of stay (LOS). Each queuing model varies by the policies that are permitted and by the order the patients are admitted. The first set of models does not prioritize patients, but examines the advantages of smoothing the operating schedule for elective surgeries. The second set analyzes the differences between prioritizing admissions by expected LOS or patient severity. The last set permits early ICU discharges and conservative and aggressive bumping policies are contrasted. It was found that prioritizing patients by severity considerably reduced delays for critical cases, but also increased the average waiting time for all patients. Aggressive bumping significantly raised the return and mortality rates, but more conservative methods balance quality and efficiency with lowered wait times without serious consequences. PMID:24551379

Effectiveness of Ebola treatment units and community care centers - Liberia, September 23-October 31, 2014.

PubMed

Washington, Michael L; Meltzer, Martin L

2015-01-30

Previous reports have shown that an Ebola outbreak can be slowed, and eventually stopped, by placing Ebola patients into settings where there is reduced risk for onward Ebola transmission, such as Ebola treatment units (ETUs) and community care centers (CCCs) or equivalent community settings that encourage changes in human behaviors to reduce transmission risk, such as making burials safe and reducing contact with Ebola patients. Using cumulative case count data from Liberia up to August 28, 2014, the EbolaResponse model previously estimated that without any additional interventions or further changes in human behavior, there would have been approximately 23,000 reported Ebola cases by October 31, 2014. In actuality, there were 6,525 reported cases by that date. To estimate the effectiveness of ETUs and CCCs or equivalent community settings in preventing greater Ebola transmission, CDC applied the EbolaResponse model to the period September 23-October 31, 2014, in Liberia. The results showed that admitting Ebola patients to ETUs alone prevented an estimated 2,244 Ebola cases. Having patients receive care in CCCs or equivalent community settings with a reduced risk for Ebola transmission prevented an estimated 4,487 cases. Having patients receive care in either ETUs or CCCs or in equivalent community settings, prevented an estimated 9,100 cases, apparently as the result of a synergistic effect in which the impact of the combined interventions was greater than the sum of the two interventions. Caring for patients in ETUs, CCCs, or in equivalent community settings with reduced risk for transmission can be important components of a successful public health response to an Ebola epidemic.

D-Dimer Use and Pulmonary Embolism Diagnosis in Emergency Units: Why Is There Such a Difference in Pulmonary Embolism Prevalence between the United States of America and Countries Outside USA?

PubMed

Pernod, Gilles; Caterino, Jeffrey; Maignan, Maxime; Tissier, Cindy; Kassis, Jeannine; Lazarchick, John

2017-01-01

Although diagnostic guidelines are similar, there is a huge difference in pulmonary embolism (PE) prevalence between the United States of America (US) and countries outside the USA (OUS) in the emergency care setting. In this study, we prospectively analyze patients' characteristics and differences in clinical care that may influence PE prevalence in different countries. An international multicenter prospective diagnostic study was conducted in a standard-of-care setting. Consecutive outpatients presenting to the emergency unit and suspected for PE were managed using the Wells score, STA-Liatest® D-Dimers and imaging. The prevalence of PE in the study was 7.9% in low and moderate risk patients. Among the 1060 patients with low or moderate pre-test probability (PTP), PE prevalence was four times higher in OUS (10.7%) than in the US (2.5%) (P < 0.0001). The mean number of imaging procedures performed for one new PE diagnosis was 3.3 in OUS vs 17 in the US (P < 0.001). Stopping investigation in the case of negative D-dimers (DD combined) with low/moderate PTP was more frequent in OUS (92.7%) than in the US (75.7%) (P < 0.01). Moreover, the use of imaging was much higher in the US (44.4% vs 19.2% in OUS) in the case of moderate PTP combined with negative DD. Differences between US and OUS PE prevalence in emergency setting might be explained by differences in patients' characteristics and mostly in care patterns. US physicians performed computed tomographic pulmonary angiography more often than in Europe in cases of low/moderate PTP combined with negative DD. ClinicalTrials.gov NCT01221805.

Care of a Homebound Super Obese Patient: A Case Study.

PubMed

Pagels, Jamie Lynn

2016-03-01

Obesity is becoming more prevalent in the United States with almost 40% of the population being overweight or obese. A new category, defining super obesity as a body mass index of 50 or higher, has been added. The purpose of this article is to use a case study to develop a more thorough understanding of the complex care needs of the super obese patient and how home healthcare clinicians can use technology to advocate for super obese patients who are home and bedbound. A review of the literature and discussion will be provided. Potential technologies involved in provision of care will also be explored. Finally, a summary of the case along with proposed solutions will be offered.

A comparative study of patients' activities and interactions in a stroke unit before and after reconstruction-The significance of the built environment.

PubMed

Anåker, Anna; von Koch, Lena; Sjöstrand, Christina; Bernhardt, Julie; Elf, Marie

2017-01-01

Early mobilization and rehabilitation, multidisciplinary stroke expertise and comprehensive therapies are fundamental in a stroke unit. To achieve effective and safe stroke care, the physical environment in modern stroke units should facilitate the delivery of evidence-based care. Therefore, the purpose of this study was to explore patients' activities and interactions in a stroke unit before the reconstruction of the physical environment, while in a temporary location and after reconstruction. This case study examined a stroke unit as an integrated whole. The data were collected using a behavioral mapping technique at three different time points: in the original unit, in the temporary unit and in the new unit. A total of 59 patients were included. The analysis included field notes from observations of the physical environment and examples from planning and design documents. The findings indicated that in the new unit, the patients spent more time in their rooms, were less active, and had fewer interactions with staff and family than the patients in the original unit. The reconstruction involved a change from a primarily multi-bed room design to single-room accommodations. In the new unit, the patients' lounge was located in a far corner of the unit with a smaller entrance than the patients' lounge in the old unit, which was located at the end of a corridor with a noticeable entrance. Changes in the design of the stroke unit may have influenced the patients' activities and interactions. This study raises the question of how the physical environment should be designed in the future to facilitate the delivery of health care and improve outcomes for stroke patients. This research is based on a case study, and although the results should be interpreted with caution, we strongly recommend that environmental considerations be included in future stroke guidelines.

Improving Posthospital Discharge Telephone Reach Rates Through Prehospital Discharge Face-to-Face Meetings.

PubMed

Vergara, Franz H; Sheridan, Daniel J; Sullivan, Nancy J; Budhathoki, Chakra

The purpose of this study was to determine whether a face-to-face meeting with patients by a telephonic case manager prehospital discharge would result in increased telephone follow-up (TFU) reach rates posthospital discharge. Acute care adult medicine inpatient units. A quasiexperimental design was utilized. Two adult inpatient medicine units were selected as the intervention and comparison groups. The framework of the study is the transitions theory. A convenience sampling technique was used, whereby 88 eligible patients on the intervention unit received face-to-face meetings prehospital discharge whereas 123 patients on the comparison unit received standard care (no face-to-face meetings). Cross-tabulation and chi-square tests were employed to examine the association of face-to-face meeting intervention and TFU reach rates. Implementing brief (<10 min) face-to-face meetings by a telephonic case manager prehospital discharge resulted in a TFU reach rate of 87% on the intervention unit, whereas the comparison unit only had a 58% TFU reach rate (p < .001). Increasing reach rates by a telephonic case manager facilitates communication with more patients posthospital discharge. A brief prehospital discharge face-to-face meeting with patients assisted them to understand the reasons for a posthospital discharge telephone call, identified the best times to call using accurate telephone numbers, and taught patients how best to prepare for the call. In addition, by meeting patients face-to-face, the telephonic case manager was no longer an unknown person on the telephone asking them questions about their medical condition. These factors combined may have significantly helped to increase TFU reach rates.

Safety and Security Concerns of Nurses Working in the Intensive Care Unit: A Qualitative Study.

PubMed

Keys, Yolanda; Stichler, Jaynelle F

Intensive care units (ICUs) exist to serve as a safe place for critically ill patients to receive care from skilled practitioners. In this qualitative study, ICU nurses shared their perspectives on elements that promote safety and security on their units. After obtaining institutional review board approval, participants participated in telephone interviews with a nurse researcher who has experience as a bedside ICU nurse. Five categories and 14 themes were identified and then confirmed using member checking. Results indicate that participants prefer to provide care in ICUs with no more than 12 to 14 beds and provide the following: visibility of patients and coworkers; more than 1 way to exit; and can be locked in case of emergency or threat. Nearly all respondents mentioned adequate staffing as the most important attribute of a safe, secure care environment for patients and families. More research is needed to identify design features that make the most impact on providing a safe, secure ICU environment.

Economic Analysis of Delivering Primary Health Care Services through Community Health Workers in 3 North Indian States

PubMed Central

Prinja, Shankar; Jeet, Gursimer; Verma, Ramesh; Kumar, Dinesh; Bahuguna, Pankaj; Kaur, Manmeet; Kumar, Rajesh

2014-01-01

Background We assessed overall annual and unit cost of delivering package of services and specific services at sub-centre level by CHWs and cost effectiveness of Government of India’s policy of introducing a second auxiliary nurse midwife (ANM) at the sub-centre compared to scenario of single ANM sub-centre. Methods We undertook an economic costing of health services delivered by CHWs, from a health system perspective. Bottom-up costing method was used to collect data on resources spent in 50 randomly selected sub-centres selected from 4 districts. Mean unit cost along with its 95% confidence intervals were estimated using bootstrap method. Multiple linear regression model was used to standardize cost and assess its determinants. Results Annually it costs INR 1.03 million (USD 19,381), or INR 187 (USD 3.5) per capita per year, to provide a package of preventive, curative and promotive services through community health workers. Unit costs for antenatal care, postnatal care, DOTS treatment and immunization were INR 525 (USD 10) per full ANC care, INR 767 (USD 14) per PNC case registered, INR 974 (USD 18) per DOTS treatment completed and INR 97 (USD 1.8) per child immunized in routine immunization respectively. A 10% increase in human resource costs results in 6% rise in per capita cost. Similarly, 10% increment in the ANC case registered per provider through-put results in a decline in unit cost ranging from 2% in the event of current capacity utilization to 3% reduction in case of full capacity utilization. Incremental cost of introducing 2nd ANM at sub-centre level per unit percent increase ANC coverage was INR 23,058 (USD 432). Conclusion Our estimates would be useful in undertaking full economic evaluations or equity analysis of CHW programs. Government of India’s policy of hiring 2nd ANM at sub-centre level is very cost effective from Indian health system perspective. PMID:24626285

[Rationing, prioritisation, rationalizing: Significance in everyday intensive care].

PubMed

Gretenkort, P

2015-11-01

Rationing, even in the treatment of critically ill patients, is the reality on intensive care units. Severity of illnesses and urgency of care are posing high ethical barriers for explicit cost-saving orders. Nevertheless, implicit rationing decisions are a daily ethical minefield, which is not always appreciated by healthcare providers. In this article, typical decision-making situations are described, where limitation of resources plays a role. The idea of saving resources by rationalising rather than rationing results from the fact that not every patient benefits from the full scope of services available in the intensive care unit, and not every patient desires the full scope of care to be supplied to them. Thus, the irrational use of resources can sometimes be avoided to save them for cases where they are necessary.

Pseudomembranous aspergillar tracheobronchitis in a non-neutropenic critically ill patient in the intensive care unit

PubMed Central

Khalid, Sameen; -Rahman, FNU Asad-ur; Abbass, Aamer; Aldarondo, Sigfredo; Abusaada, Khalid

2017-01-01

ABSTRACT Invasive aspergillosis is an important cause of morbidity and mortality among immunocompromised patients. Prolonged neutropenia is the most common risk factor. It has rarely been reported to occur in non-neutropenic critically ill patients in the intensive care unit setting. Mortality rate in this group has been reported to be as high as 92%. We report a case of tracheobronchial aspergillosis in a non-neutropenic critically ill patient to highlight the fact that critically ill patients admitted in the intensive care unit can develop opportunistic infections such as invasive aspergillosis even in the absence of classic risk factors and prior history of immunosuppression. Early diagnosis and prompt initiation of antifungal therapy may improve the outcome and decrease mortality rate. PMID:28634525

[Visitation policy, design and comfort in Spanish intensive care units].

PubMed

Escudero, D; Martín, L; Viña, L; Quindós, B; Espina, M J; Forcelledo, L; López-Amor, L; García-Arias, B; del Busto, C; de Cima, S; Fernández-Rey, E

2015-01-01

To determine the design and comfort in the Intensive Care Units (ICUs), by analysing visiting hours, information, and family participation in patient care. Descriptive, multicentre study. Spanish ICUs. A questionnaire e-mailed to members of the Spanish Society of Intensive Care Medicine, Critical and Coronary Units (SEMICYUC), subscribers of the Electronic Journal Intensive Care Medicine, and disseminated through the blog Proyecto HU-CI. A total of 135 questionnaires from 131 hospitals were analysed. Visiting hours: 3.8% open 24h, 9.8% open daytime, and 67.7% have 2 visits a day. Information: given only by the doctor in 75.2% of the cases, doctor and nurse together in 4.5%, with a frequency of once a day in 79.7%. During weekends, information is given in 95.5% of the cases. Information given over the phone 74.4%. Family participation in patient care: hygiene 11%, feeding 80.5%, physiotherapy 17%. Personal objects allowed: mobile phone 41%, computer 55%, sound system 77%, and television 30%. Architecture and comfort: all individual cubicles 60.2%, natural light 54.9%, television 7.5%, ambient music 12%, clock in the cubicle 15.8%, environmental noise meter 3.8%, and a waiting room near the ICU 68.4%. Visiting policy is restrictive, with a closed ICU being the predominating culture. On average, technological communication devices are not allowed. Family participation in patient care is low. The ICU design does not guarantee privacy or provide a desirable level of comfort. Copyright © 2015 SECA. Published by Elsevier Espana. All rights reserved.

Pandemic influenza A(H1)pdm09 in hospitals and intensive care units - results from a new hospital surveillance, Germany 2009/2010.

PubMed

Adlhoch, Cornelia; Wadl, Maria; Behnke, Michael; Peña Diaz, Luis Alberto; Clausmeyer, Jörg; Eckmanns, Tim

2012-11-01

The pandemic influenza A(H1)pdm09 (PI) was introduced to Germany in April 2009. The Robert Koch Institute (RKI) implemented a nationwide voluntary hospital sentinel surveillance for to assess the burden and severity of PI. Three modules were offered: a hospital module collected aggregated data from all hospital units on admissions and fatalities with and without PI; an intensive care module data on admissions, patient-days, and ventilated patient-days with and without PI; and a case-based module retrieved clinical patient data of PI cases. A in-patient with a PCR confirmation was defined as a PI case. Descriptive, trend, uni-, and multivariable analysis were performed. Between week 49/2009 and 13/2010, the hospitals reported 103 (0.07%) PI cases among 159181 admissions and 59/16728 (0.35%) PI-related admissions in intensive care units (ICUs). The weekly average incidence decreased in hospitals by 21.5% and in ICUs by 19.2%. In ICUs, 1848/85559 (2.2%) patient-days were PI-related, 94.8% of those with mechanical ventilation. Case-based data on 43 recovered and 16 fatal PI cases were reported. Among recovered, 61% were admitted to ICUs, 51% were mechanically ventilated, and 16% received extracorporeal membrane oxygenation (ECMO). All fatal cases were admitted to ICUs and received mechanical ventilation, 75% ECMO. Fatal outcome was rather associated with complications than with underlying medical conditions. The surveillance started shortly after the PI peak, which explains the small number of PI cases. The burden of PI disease was low, but higher in ICUs with a high proportion of severe cases needing ventilation and ECMO treatment. A continuous hospital surveillance system could be helpful to measure the burden of severe community-acquired infections. © 2012 Blackwell Publishing Ltd.

Advantages of not using the intensive care unit after operations for oropharyngeal cancer: an audit at Worcester Royal Hospital.

PubMed

McVeigh, K P; Moore, R; James, G; Hall, T; Barnard, N

2007-12-01

We reviewed 68 cases of oral and oropharyngeal cancer that were managed without the routine use of intensive care units (ICU), to establish success rates for flaps, complications including nosocomial infections, cancellations, and length of stay. More than 98% of flaps survived and over half the patients had no complications. Low rates of perioperative infection were recorded with a median length of stay of 12 days (range 2-63), and there were no cancellations. We conclude that the routine use of a specialist head and neck ward is more appropriate than ICU for selected cases; it fulfils current guidelines for cancer services, and is an effective use of resources.

Investigation of the First Seven Reported Cases of Candida auris, a Globally Emerging Invasive, Multidrug-Resistant Fungus-United States, May 2013-August 2016.

PubMed

Vallabhaneni, S; Kallen, A; Tsay, S; Chow, N; Welsh, R; Kerins, J; Kemble, S K; Pacilli, M; Black, S R; Landon, E; Ridgway, J; Palmore, T N; Zelzany, A; Adams, E H; Quinn, M; Chaturvedi, S; Greenko, J; Fernandez, R; Southwick, K; Furuya, E Y; Calfee, D P; Hamula, C; Patel, G; Barrett, P; Lafaro, P; Berkow, E L; Moulton-Meissner, H; Noble-Wang, J; Fagan, R P; Jackson, B R; Lockhart, S R; Litvintseva, A P; Chiller, T M

2017-01-01

November 11, 2016/65(44);1234-1237. What is already known about this topic? Candida auris is an emerging pathogenic fungus that has been reported from at least a dozen countries on four continents during 2009-2015. The organism is difficult to identify using traditional biochemical methods, some isolates have been found to be resistant to all three major classes of antifungal medications, and C. auris has caused health care-associated outbreaks. What is added by this report? This is the first description of C. auris cases in the United States. C. auris appears to have emerged in the United States only in the last few years, and U.S. isolates are related to isolates from South America and South Asia. Evidence from U.S. case investigations suggests likely transmission of the organism occurred in health care settings. What are the implications for public health practice? It is important that U.S. laboratories accurately identify C. auris and for health care facilities to implement recommended infection control practices to prevent the spread of C. auris. Local and state health departments and CDC should be notified of possible cases of C. auris and of isolates of C. haemulonii and Candida spp. that cannot be identified after routine testing. No claim to original US government works © 2016 The American Society of Transplantation and the American Society of Transplant Surgeons.

Delivery room triage of large for gestational age infants of diabetic mothers.

PubMed

Cordero, Leandro; Rath, Krista; Zheng, Katherine; Landon, Mark B; Nankervis, Craig A

2014-01-01

To review our 4-year experience (2008-2011) with delivery room triage of large for gestational age infants of diabetic mothers. Retrospective cohort investigation of 311 large for gestational age infants of diabetic mothers (White's Class A1 (77), A2 (87), B (77), and C-R (70)). Of 311 women, 31% delivered at 34-36 weeks gestational age and 69% at term. While 70% were delivered by cesarean, 30% were vaginal deliveries. A total of 160 asymptomatic infants were triaged from the delivery room to the well baby nursery. Of these, 55 (34%) developed hypoglycemia. In 43 cases, the hypoglycemia was corrected by early feedings; in the remaining 12, intravenous dextrose treatment was required. A total of 151 infants were triaged from the delivery room to the neonatal intensive care unit. Admission diagnoses included respiratory distress (51%), prevention of hypoglycemia (27%), prematurity (21%), and asphyxia (1%). Hypoglycemia affected 66 (44%) of all neonatal intensive care unit infants. Safe triage of asymptomatic large for gestational age infants of diabetic mothers from the delivery room to well baby nursery can be accomplished in the majority of cases. Those infants in need of specialized care can be accurately identified and effectively treated in the neonatal intensive care unit setting.

Understanding safety culture in long-term care: a case study.

PubMed

Halligan, Michelle H; Zecevic, Aleksandra; Kothari, Anita R; Salmoni, Alan W; Orchard, Treena

2014-12-01

This case study aimed to understand safety culture in a high-risk secured unit for cognitively impaired residents in a long-term care (LTC) facility. Specific objectives included the following: diagnosing the present level of safety culture maturity using the Patient Safety Culture Improvement Tool (PSCIT), examining the barriers to a positive safety culture, and identifying actions for improvement. A mixed methods design was used within a secured unit for cognitively impaired residents in a Canadian nonprofit LTC facility. Semistructured interviews, a focus group, and the Modified Stanford Patient Safety Culture Survey Instrument were used to explore this topic. Data were synthesized to situate safety maturity of the unit within the PSCIT adapted for LTC. Results indicated a reactive culture, where safety systems were piecemeal and developed only in response to adverse events and/or regulatory requirements. A punitive regulatory environment, inadequate resources, heavy workloads, poor interdisciplinary collaboration, and resident safety training capacity were major barriers to improving safety. This study highlights the importance of understanding a unit's safety culture and identifies the PSCIT as a useful framework for planning future improvements to safety culture maturity. Incorporating mixed methods in the study of health care safety culture provided a good model that can be recommended for future use in research and LTC practice.

Paediatric cardiac intensive care unit: current setting and organization in 2010.

PubMed

Fraisse, Alain; Le Bel, Stéphane; Mas, Bertrand; Macrae, Duncan

2010-10-01

Over recent decades, specialized paediatric cardiac intensive care has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centres (dealing with over 300 surgical cases per year) have dedicated paediatric cardiac intensive care units, with the smallest programmes more likely to care for paediatric cardiac patients in mixed paediatric or adult intensive care units. Specialized nursing staff are also a crucial presence at the patient's bedside for quality of care. A paediatric cardiac intensive care programme should have patients (preoperative and postoperative) grouped together geographically, and should provide proximity to the operating theatre, catheterization laboratory and radiology department, as well as to the regular ward. Age-appropriate medical equipment must be provided. An optimal strategy for running a paediatric cardiac intensive care programme should include: multidisciplinary collaboration and involvement with paediatric cardiology, anaesthesia, cardiac surgery and many other subspecialties; a risk-stratification strategy for quantifying perioperative risk; a personalized patient approach; and anticipatory care. Finally, progressive withdrawal from heavy paediatric cardiac intensive care management should be institutionalized. Although the countries of the European Union do not share any common legislation on the structure and organization of paediatric intensive care or paediatric cardiac intensive care, any paediatric cardiac surgery programme in France that is agreed by the French Health Ministry must perform at least '150 major procedures per year in children' and must provide a 'specialized paediatric intensive care unit'. Copyright © 2010 Elsevier Masson SAS. All rights reserved.

Predictors of and Trends in High-Intensity End-of-Life Care Among Children With Cancer: A Population-Based Study Using Health Services Data.

PubMed

Kassam, Alisha; Sutradhar, Rinku; Widger, Kimberley; Rapoport, Adam; Pole, Jason D; Nelson, Katherine; Wolfe, Joanne; Earle, Craig C; Gupta, Sumit

2017-01-10

Purpose Children with cancer often receive high-intensity (HI) medical care at the end-of-life (EOL). Previous studies have been limited to single centers or lacked detailed clinical data. We determined predictors of and trends in HI-EOL care by linking population-based clinical and health-services databases. Methods A retrospective decedent cohort of patients with childhood cancer who died between 2000 and 2012 in Ontario, Canada, was assembled using a provincial cancer registry and linked to population-based health-care data. Based on previous studies, the primary composite measure of HI-EOL care comprised any of the following: intravenous chemotherapy < 14 days from death; more than one emergency department visit; and more than one hospitalization or intensive care unit admission < 30 days from death. Secondary measures included those same individual measures and measures of the most invasive (MI) EOL care (eg, mechanical ventilation < 14 days from death). We determined predictors of outcomes with appropriate regression models. Sensitivity analysis was restricted to cases of cancer-related mortality, excluding treatment-related mortality (TRM) cases. Results The study included 815 patients; of these, 331 (40.6%) experienced HI-EOL care. Those with hematologic malignancies were at highest risk (odds ratio, 2.5; 95% CI, 1.8 to 3.6; P < .001). Patients with hematologic cancers and those who died after 2004 were more likely to experience the MI-EOL care (eg, intensive care unit, mechanical ventilation, odds ratios from 2.0 to 5.1). Excluding cases of TRM did not substantively change the results. Conclusion Ontario children with cancer continue to experience HI-EOL care. Patients with hematologic malignancies are at highest risk even when excluding TRM. Of concern, rates of the MI-EOL care have increased over time despite increased palliative care access. Linking health services and clinical data allows monitoring of population trends in EOL care and identifies high-risk populations for future interventions.

Tension pneumocephalus secondary to non-invasive mechanical ventilation in a patient with severe traumatic brain injury.

PubMed

Andreu-Ruiz, Antonio; Ros-Argente Del Castillo, Tomas; Moya-Sánchez, José; Garcia-Ortega, Ana Azahara

The presence of air inside intracranial cavity is a rare entity known as pneumocephalus and in most cases doesńt present any clinical repercussion except in case of elevated intracranial pressure that can lead to a decreasing level of consciousness, coma and even death. We present a rare case of a young male, without medical precedents of interest, hospitalized in an intensive care unit for vigilance after a traffic accident with asymptomatic crane encephalic trauma and cranial computerized tomography without meaningful findings. During the intensive care unit stay positive pressure is applied in airway with non-invasive mechanical ventilation that produces air entrance in cranial cavity (pneumocephalus) causing neurological deterioration and necessity of urgent surgery. Copyright © 2017 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.

Safety cases for medical devices and health information technology: involving health-care organisations in the assurance of safety.

PubMed

Sujan, Mark A; Koornneef, Floor; Chozos, Nick; Pozzi, Simone; Kelly, Tim

2013-09-01

In the United Kingdom, there are more than 9000 reports of adverse events involving medical devices annually. The regulatory processes in Europe and in the United States have been challenged as to their ability to protect patients effectively from unreasonable risk and harm. Two of the major shortcomings of current practice include the lack of transparency in the safety certification process and the lack of involvement of service providers. We reviewed recent international standardisation activities in this area, and we reviewed regulatory practices in other safety-critical industries. The review showed that the use of safety cases is an accepted practice in UK safety-critical industries, but at present, there is little awareness of this concept in health care. Safety cases have the potential to provide greater transparency and confidence in safety certification and to act as a communication tool between manufacturers, service providers, regulators and patients.

Evolving paradigm of illnesses presented to medical Intensive Care Unit in body builders: Cases from tertiary care center.

PubMed

Garg, Sunil Kumar

2015-04-01

Bodybuilding is the use of progressive resistance exercise to control and develop one's musculature. With the rise in number of persons adopting this activity, there is evolving paradigm of illnesses presented to intensive care in this population subset. Strict adherence to details of bodybuilding and avoidance of unsupervised medications are essential to prevent untoward effects.

Evolving paradigm of illnesses presented to medical Intensive Care Unit in body builders: Cases from tertiary care center

PubMed Central

Garg, Sunil Kumar

2015-01-01

Bodybuilding is the use of progressive resistance exercise to control and develop one's musculature. With the rise in number of persons adopting this activity, there is evolving paradigm of illnesses presented to intensive care in this population subset. Strict adherence to details of bodybuilding and avoidance of unsupervised medications are essential to prevent untoward effects. PMID:25878431

[Indication for antimycotic therapy for tracheobronchial candidosis under artificial ventilation].

PubMed

Grossherr, M; Sedemund-Adib, Beate; Klotz, K-F

2005-01-01

Tracheobronchial candidosis is an impetuous complication in intensive care medicine. This article presents a concept to compare diagnostic procedure, Candida species and resistant species of different intensive care units with each other. This concept should encourage bench marking between similar intensive care units. The report and retrospective analysis of the intensive care course offer the opportunity to reflect own decisions and to adjust them to the current therapy strategies. Both procedures should improve the antimycotic therapy for intensive care units and should avoid the occurrence of resistant species. Candida species are often detected in the respiratory system of ventilated patients in intensive care, but this alone is no indication for antimycotic therapy. A strict retention is recommended, but this retention is diminished by an unclear infection, critical situation of the patient in the case of multiple organ failure, additional infection and long term ventilation. A therapy strategy for individual situations should be established and a close diagnostic procedure should be performed. A positive blood culture or detection of Candida species in two or more diagnostic materials indicate an early antimycotic therapy.

A case study evaluation of a Critical Care Information System adoption using the socio-technical and fit approach.

PubMed

Yusof, Maryati Mohd

2015-07-01

Clinical information systems have long been used in intensive care units but reports on their adoption and benefits are limited. This study evaluated a Critical Care Information System implementation. A case study summative evaluation was conducted, employing observation, interview, and document analysis in operating theatres and 16-bed adult intensive care units in a 400-bed Malaysian tertiary referral centre from the perspectives of users (nurses and physicians), management, and information technology staff. System implementation, factors influencing adoption, fit between these factors, and the impact of the Critical Care Information System were evaluated after eight months of operation. Positive influences on system adoption were associated with technical factors, including system ease of use, usefulness, and information relevancy; human factors, particularly user attitude; and organisational factors, namely clinical process-technology alignment and champions. Organisational factors such as planning, project management, training, technology support, turnover rate, clinical workload, and communication were barriers to system implementation and use. Recommendations to improve the current system problems were discussed. Most nursing staff positively perceived the system's reduction of documentation and data access time, giving them more time with patients. System acceptance varied among doctors. System use also had positive impacts on timesaving, data quality, and clinical workflow. Critical Care Information Systems is crucial and has great potentials in enhancing and delivering critical care. However, the case study findings showed that the system faced complex challenges and was underutilised despite its potential. The role of socio-technical factors and their fit in realizing the potential of Critical Care Information Systems requires continuous, in-depth evaluation and stakeholder understanding and acknowledgement. The comprehensive and specific evaluation measures of the Human-Organisation-Technology Fit framework can flexibly evaluate Critical Care Information Systems. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Prognosis of cocaine body-packers.

PubMed

de Prost, Nicolas; Lefebvre, Aurélie; Questel, Frank; Roche, Nicolas; Pourriat, Jean-Louis; Huchon, Gérard; Rabbat, Antoine

2005-07-01

To study the prognosis and complications of cocaine body-packing (concealment of cocaine in the body for transportation between countries). We retrospectively reviewed the files of all cocaine body-packers hospitalized during a 4-year period in a medico-judiciary emergency unit. Subjects included in the survey were identified from the hospital databases using ICD-10 codes. The Medico-Judiciary Emergency Unit of Hôtel-Dieu university hospital in Paris is a unique medical and surgical emergency unit receiving all patients in legal custody arrested at the two Paris international airports and suspected of body-packing. All the cases of cocaine body-packers (n=581) hospitalized between January 1999 and December 2002 were studied. They had been arrested at Paris airports while arriving from drug-producing countries. The mean number of carried packets was 70.0+/-20.4 (range 18-150). The mean duration of hospitalization was 5.0+/-1.6 days (range 1-18). No complication occurred in 573 body-packers cases. Eight subjects developed a complication requiring admission to an intensive care unit: six acute cocaine intoxications due to packet rupture and two intestinal occlusions. No one died. Surgical treatment was necessary in six cases. Good prognosis observed in these body-packers cases is due to the careful monitoring of asymptomatic patients, allowing early detection and treatment of complications. Surgical removal of the packets when complication occurs is warranted.

Family Satisfaction in Critical Care Units: Does an Open Visiting Hours Policy Have an Impact?

PubMed

Baharoon, Salim; Al Yafi, Walid; Al Qurashi, Ahmad; Al Jahdali, Hamdan; Tamim, Hani; Alsafi, Eiman; Al Sayyari, Abdullah A

2017-09-01

For critically ill patients, the interaction between health care providers and family members is essential in daily decision making. Improving this relationship has a positive impact on satisfaction with the overall care provided to patients and reduces family member symptoms of depression, anxiety, and posttraumatic stress disorder. In this study, we analyzed the impact of visitation policy (open versus restricted) on family satisfaction using the previously well-validated Critical Care Family Satisfaction Survey (CCFSS) questionnaire. This is a cross-sectional prospective observational study conducted between November 1, 2009, and January 31, 2010, in 2 critical care units with 2 different visiting policy systems, unit A (open visiting hours) and B (restricted visiting hours), comparing family satisfaction in both units using the CCFSS questionnaire. Responses were grouped in 5 satisfaction constructs, namely, the support construct, which assesses the degree of satisfaction with the support of the intensive care staff as perceived by relatives; the assurance construct, which assesses the degree of satisfaction regarding honest answers being given and the responder's confidence that the patient is receiving the best care possible; the proximity construct, which assesses the degree of satisfaction with the physical and emotional access to the patient; the information construct, which assesses the degree of satisfaction with the adequacy of information given to relatives; and the comfort construct, which assesses satisfaction with physical comfort and amenities. During the study period, 115 questionnaires were distributed in each of the 2 sites. The response rates in units A and B were 92% (106) and 100% (115), respectively. The mean stay time in the intensive care unit was 3.7 days. There were more trauma cases in unit A and more cardiac patients in unit B. There was no significant difference between the 2 units in any of the 5 satisfaction constructs, the support, assurance, proximity, information, and comfort constructs, although there was a nonsignificant trend favoring the unit with the more liberal visit policy regarding amenities (unit A). We concluded that family satisfaction to care provided in intensive care as measured by the CCFSS questionnaire was not influenced by frequency of visitation among Saudi families. Factors other than open visiting hours may be important to evaluate.

Case report: severe heat stroke with multiple organ dysfunction – a novel intravascular treatment approach

PubMed Central

Broessner, Gregor; Beer, Ronny; Franz, Gerhard; Lackner, Peter; Engelhardt, Klaus; Brenneis, Christian; Pfausler, Bettina; Schmutzhard, Erich

2005-01-01

Introduction We report the case of a patient who developed a severe post-exertional heat stroke with consecutive multiple organ dysfunction resistant to conventional antipyretic treatment, necessitating the use of a novel endovascular device to combat hyperthermia and maintain normothermia. Methods A 38-year-old male suffering from severe heat stroke with predominant signs and symptoms of encephalopathy requiring acute admission to an intensive care unit, was admitted to a ten-bed neurological intensive care unit of a tertiary care hospital. The patient developed consecutive multiple organ dysfunction with rhabdomyolysis, and hepatic and respiratory failure. Temperature elevation was resistant to conventional treatment measures. Aggressive intensive care treatment included forced diuresis and endovascular cooling to combat hyperthermia and maintain normothermia. Results Analyses of serum revealed elevation of proinflammatory cytokines (TNF alpha, IL-6), cytokines (IL-2R), anti-inflammatory cytokines (IL-4) and chemokines (IL-8) as well as signs of rhabdomyolysis and hepatic failure. Aggressive intensive care treatment as forced diuresis and endovascular cooling (CoolGard® and CoolLine®) to combat hyperthermia and maintain normothermia were used successfully to treat this severe heat stroke. Conclusion In this case of severe heat stroke, presenting with multiple organ dysfunction and elevation of cytokines and chemokines, which was resistant to conventional cooling therapies, endovascular cooling may have contributed significantly to the reduction of body temperature and, possibly, avoided a fatal result. PMID:16285034

Defining the cost of care for lobectomy and segmentectomy: a comparison of open, video-assisted thoracoscopic, and robotic approaches.

PubMed

Deen, Shaun A; Wilson, Jennifer L; Wilshire, Candice L; Vallières, Eric; Farivar, Alexander S; Aye, Ralph W; Ely, Robson E; Louie, Brian E

2014-03-01

Knowledge about the cost of open, video-assisted thoracoscopic (VATS), or robotic lung resection and drivers of cost is crucial as the cost of care comes under scrutiny. This study aims to define the cost of anatomic lung resection and evaluate potential cost-saving measures. A retrospective review of patients who had anatomic resection for early stage lung cancer, carcinoid, or metastatic foci between 2008 and 2012 was performed. Direct hospital cost data were collected from 10 categories. Capital depreciation was separated for the robotic and VATS cases. Key costs were varied in a sensitivity analysis. In all, 184 consecutive patients were included: 69 open, 57 robotic, and 58 VATS. Comorbidities and complication rates were similar. Operative time was statistically different among the three modalities, but length of stay was not. There was no statistically significant difference in overall cost between VATS and open cases (Δ = $1,207) or open and robotic cases (Δ = $1,975). Robotic cases cost $3,182 more than VATS (p < 0.001) owing to the cost of robotic-specific supplies and depreciation. The main opportunities to reduce cost in open cases were the intensive care unit, respiratory therapy, and laboratories. Lowering operating time and supply costs were targets for VATS and robotic cases. VATS is the least expensive surgical approach. Robotic cases must be shorter in operative time or reduce supply costs, or both, to be competitive. Lessening operating time, eradicating unnecessary laboratory work, and minimizing intensive care unit stays will help decrease direct hospital costs. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Use of National Syphilis Surveillance Data to Develop a Congenital Syphilis Prevention Cascade and Estimate the Number of Potential Congenital Syphilis Cases Averted.

PubMed

Kidd, Sarah; Bowen, Virginia B; Torrone, Elizabeth A; Bolan, Gail

2018-03-14

Recent increases in reported congenital syphilis have led to an urgent need to identify interventions that will have the greatest impact on congenital syphilis prevention. We sought to create a congenital syphilis prevention cascade using national syphilis surveillance data to (1) estimate the proportion of potential congenital syphilis cases averted with current prevention efforts, and (2) develop a classification framework to better describe why reported cases were not averted. We reviewed national syphilis and congenital syphilis case report data from 2016, including pregnancy status of all reported female syphilis cases and data on prenatal care, testing, and treatment status of mothers of reported congenital syphilis cases to derive estimates of the proportion of pregnant women with syphilis who received prenatal care, syphilis testing, and adequate syphilis treatment at least 30 days prior to delivery, as well as the proportion of potential congenital syphilis cases averted. Among the 2,508 pregnant women who were reported to have syphilis, an estimated 88.0% received prenatal care at least 30 days prior to delivery, 89.4% were tested for syphilis at least 30 days prior to delivery, and 76.9% received an adequate treatment regimen that began at least 30 days prior to delivery. Overall, an estimated 1,928 (75.0%) potential congenital syphilis cases in the United States were successfully averted. Among states that reported at least 10 syphilis cases among pregnant women, the estimated proportion of potential congenital syphilis cases averted ranged from 55.0% to 92.3%. While the majority of potential congenital syphilis cases in the United States were averted in 2016, there was substantial geographic variation, and significant gaps in delivering timely prenatal care, syphilis testing, and adequate treatment to pregnant women with syphilis were identified. The congenital syphilis prevention cascade is a useful tool to quantify programmatic successes and identify where improvements are needed.

Case Management for Patients with Complex Multimorbidity: Development and Validation of a Coordinated Intervention between Primary and Hospital Care

PubMed Central

Giménez-Campos, María Soledad; Villar-López, Julia; Faubel-Cava, Raquel; Donat-Castelló, Lucas; Valdivieso-Martínez, Bernardo; Soriano-Melchor, Elisa; Bahamontes-Mulió, Amparo; García-Gómez, Juan M.

2017-01-01

In the past few years, healthcare systems have been facing a growing demand related to the high prevalence of chronic diseases. Case management programs have emerged as an integrated care approach for the management of chronic disease. Nevertheless, there is little scientific evidence on the impact of using a case management program for patients with complex multimorbidity regarding hospital resource utilisation. We evaluated an integrated case management intervention set up by community-based care at outpatient clinics with nurse case managers from a telemedicine unit. The hypothesis to be tested was whether improved continuity of care resulting from the integration of community-based and hospital services reduced the use of hospital resources amongst patients with complex multimorbidity. A retrospective cohort study was performed using a sample of 714 adult patients admitted to the program between January 2012 and January 2015. We found a significant decrease in the number of emergency room visits, unplanned hospitalizations, and length of stay, and an expected increase in the home care hospital-based episodes. These results support the hypothesis that case management interventions can reduce the use of unplanned hospital admissions when applied to patients with complex multimorbidity. PMID:28970745

Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice

PubMed Central

Coughlin, Mary; Gibbins, Sharyn; Hoath, Steven

2009-01-01

Title Core measures for developmentally supportive care in neonatal intensive care units: theory, precedence and practice. Aim This paper is a discussion of evidence-based core measures for developmental care in neonatal intensive care units. Background Inconsistent definition, application and evaluation of developmental care have resulted in criticism of its scientific merit. The key concept guiding data organization in this paper is the United States of America’s Joint Commission’s concept of ‘core measures’ for evaluating and accrediting healthcare organizations. This concept is applied to five disease- and procedure-independent measures based on the Universe of Developmental Care model. Data sources Electronically accessible, peer reviewed studies on developmental care published in English were culled for data supporting the selected objective core measures between 1978 and 2008. The quality of evidence was based on a structured predetermined format that included three independent reviewers. Systematic reviews and randomized control trials were considered the strongest level of evidence. When unavailable, cohort, case control, consensus statements and qualitative methods were considered the strongest level of evidence for a particular clinical issue. Discussion Five core measure sets for evidence-based developmental care were evaluated: (1) protected sleep, (2) pain and stress assessment and management, (3) developmental activities of daily living, (4) family-centred care, and (5) the healing environment. These five categories reflect recurring themes that emerged from the literature review regarding developmentally supportive care and quality caring practices in neonatal populations. This practice model provides clear metrics for nursing actions having an impact on the hospital experience of infant-family dyads. Conclusion Standardized disease-independent core measures for developmental care establish minimum evidence-based practice expectations and offer an objective basis for cross-institutional comparison of developmental care programmes. PMID:19686402

Which medical device and/or which local treatment for prevention in patients with risk factors for pressure sores in 2012? Developing French guidelines for clinical practice.

PubMed

Nicolas, B; Moiziard, A S; Barrois, B; Colin, D; Michel, J M; Passadori, Y; Ribinik, P

2012-10-01

Implementation of a prevention strategy after the identification of risk factors is essential at the entrance in a care unit or in a medical-social unit. Determine which medical devices and which treatments may be used in order to prevent pressure sore in 2012. Systematic review of the literature using databases: Pascal, Biomed, PubMed, and Cochrane library between 2000 and 2010. Nursing care including use of soft product, non-irritating for the cleaning, hydration of the skin with emollients, protection of fragile skin in case of incontinence by applying a skin protector and application of dressings in front of bony prominences to reduce shear forces, remain valid (level C). Nursing cares and use of dressing in patients with high risks of pressure sores are the responsibility of the nurses. The engagement of health care teams involves screening of risk factors and the knowledge of treatments and local devices. Local preventive treatment in a patient with risk factors of pressure sore is of great interest at entrance in a care unit or in a medical-social unit. Copyright © 2012. Published by Elsevier Masson SAS.

Candidemia in neonatal intensive care units: Barcelona, Spain.

PubMed

Rodriguez, Dolors; Almirante, Benito; Park, Benjamin J; Cuenca-Estrella, Manuel; Planes, Ana M; Sanchez, Ferran; Gene, Amadeu; Xercavins, Mariona; Fontanals, Dionisia; Rodriguez-Tudela, Juan L; Warnock, David W; Pahissa, Albert

2006-03-01

Candida spp. are increasingly important hospital-acquired pathogens in neonatal intensive care units (NICU) and cause considerable mortality in preterm infants. Most studies have been limited to a single institution. The aim of this study was to determine the epidemiology of candidemia in all Barcelona NICUs. We conducted prospective population-based surveillance for candidemia in Barcelona, Spain, during 2002-2003. This report focuses on the results from 5 participating hospitals with NICUs. We detected 24 cases, resulting in an annual incidence of 32.6 cases per 100,000 live births and 1.1 cases per 100 NICU discharges. Median gestational age was 27.5 weeks (range, 24-40.5), and there were 21 cases among very low birth weight infants. Among the 20 (83%) cases evaluated for the presence of end organ infection, endophthalmitis occurred in 2 cases, and endocarditis, meningitis and peritonitis occurred in 1 case each. Candida parapsilosis was the most frequent species isolated (67%). All isolates were fluconazole-susceptible. Crude mortality was 21%. The preponderance of C. parapsilosis candidemias observed in Barcelona NICUs is similar to reports from the literature. Morbidity and mortality associated with neonatal candidemia remain high.

Using vignettes to assess contributions to the work of addressing child mental health problems in primary care.

PubMed

Wissow, Lawrence S; Zafar, Waleed; Fothergill, Kate; Ruble, Anne; Slade, Eric

2016-01-22

To further efforts to integrate mental health and primary care, this study develops a novel approach to quantifying the amount and sources of work involved in shifting care for common mental health problems to pediatric primary care providers. Email/web-based survey of a convenience sample (n = 58) of Maryland pediatricians (77% female, 58% at their site 10 or more years; 44% in private practice, 52 % urban, 48 % practicing with a co-located mental health provider). Participants were asked to review 11 vignettes, which described primary care management of child/youth mental health problems, and rate them on an integer-based ordinal scale for the overall amount of work involved compared to a 12th reference vignette describing an uncomplicated case of ADHD. Respondents were also asked to indicate factors (time, effort, stress) accounting for their ratings. Vignettes presented combinations of three diagnoses (ADHD, anxiety, and depression) and three factors (medical co-morbidity, psychiatric co-morbidity, and difficult families) reported to complicate mental health care. The reference case was pre-assigned a work value of 2. Estimates of the relationship of diagnosis and complicating factors with workload were obtained using linear regression, with random effects at the respondent level. The 58 pediatricians gave 593 vignette responses. Depression was associated with a 1.09 unit (about 50%) increase in work (95% CL .94, 1.25), while anxiety did not differ significantly from the reference case of uncomplicated ADHD (p = .28). Although all three complicating factors increased work ratings compared with the reference case, family complexity and psychiatric co-morbidity did so the most (.87 and 1.07 units, respectively, P < .001) while medical co-morbidity increased it the least (.44 units, p < .001). Factors most strongly associated with increased overall work were physician time, physician mental effort, and stress; those least strongly associated were staff time, physician physical effort, and malpractice risk. Pediatricians working with co-located mental health providers gave higher work ratings than did those without co-located staff. Both diagnosis and cross-diagnosis complicating factors contribute to the work involved in providing mental health services in primary care. Vignette studies may facilitate understanding which mental health services can be most readily incorporated into primary care as it is presently structured and help guide the design of training programs and other implementation strategies.

Moral distress in end-of-life care in the intensive care unit.

PubMed

St Ledger, Una; Begley, Ann; Reid, Joanne; Prior, Lindsay; McAuley, Danny; Blackwood, Bronagh

2013-08-01

To explore moral distress in relatives doctors and nurses, in end-of-life care decision-making, in the adult intensive care unit. Many deaths in intensive care involve decisions about withholding and withdrawing therapy, potentially triggering moral distress. Moral distress occurs when individuals feel constrained from acting in accordance with moral choice, or act against moral judgement, generating painful, unresolved emotions, and problems that continue long after an event. Prior research has focused mainly on nurses; less is known about doctors' experiences and occurrence and impact on relatives is unknown. A narrative inquiry case study approach, funded by a Northern Ireland Health and Social Care Doctorate Fellowship Award (April 2011). In-depth digitally recorded interviews will be conducted with relatives, doctors, and nurses involved in end-of-life cases comprising: (1) withdrawal of therapy, including circulatory death organ donation; (2) non-escalation of therapy; and (3) brain stem death with a request for organ donation. Relatives will be offered the opportunity to share their experiences on 'Healthtalkonline' by copyrighting audio-visual interviews to the Health Experiences Research Group, Oxford University. Research Ethics Committee approval was obtained (April 2012). This is the first time that moral distress is explored, in a case approach, among relatives, doctors, and nurses intimately involved in end-of-life decisions in intensive care. Dissemination of findings will make a large contribution to international knowledge and understanding in this area and alert healthcare professionals and relatives to an otherwise under-recognized, but potentially detrimental, experience. Findings will inform education, practice, and policy. © 2012 Blackwell Publishing Ltd.

Healthcare associated infections in Paediatric Intensive Care Unit of a tertiary care hospital in India: Hospital stay & extra costs.

PubMed

Sodhi, Jitender; Satpathy, Sidhartha; Sharma, D K; Lodha, Rakesh; Kapil, Arti; Wadhwa, Nitya; Gupta, Shakti Kumar

2016-04-01

Healthcare associated infections (HAIs) increase the length of stay in the hospital and consequently costs as reported from studies done in developed countries. The current study was undertaken to evaluate the impact of HAIs on length of stay and costs of health care in children admitted to Paediatric Intensive Care Unit (PICU) of a tertiary care hospital in north India. This prospective study was done in the seven bedded PICU of a large multi-specialty tertiary care hospital in New Delhi, India. A total of 20 children with HAI (cases) and 35 children without HAI (controls), admitted to the PICU during the study period (January 2012 to June 2012), were matched for gender, age, and average severity of illness score. Each patient's length of stay was obtained prospectively. Costs of healthcare were estimated according to traditional and time driven activity based costing methods approach. The median extra length of PICU stay for children with HAI (cases), compared with children with no HAI (controls), was seven days (IQR 3-16). The mean total costs of patients with and without HAI were ' 2,04,787 (US$ 3,413) and ' 56,587 (US$ 943), respectively and the mean difference in the total cost between cases and controls was ' 1,48,200 (95% CI 55,716 to 2,40,685, p<0.01). This study highlights the effect of HAI on costs for PICU patients, especially costs due to prolongation of hospital stay, and suggests the need to develop effective strategies for prevention of HAI to reduce costs of health care.

Physical Therapist Practice in the Intensive Care Unit: Results of a National Survey

PubMed Central

Ridgeway, Kyle; Nordon-Craft, Amy; Moss, Parker; Schenkman, Margaret; Moss, Marc

2015-01-01

Background Early rehabilitation improves outcomes, and increased use of physical therapist services in the intensive care unit (ICU) has been recommended. Little is known about the implementation of early rehabilitation programs or physical therapists' preparation and perceptions of care in the United States. Objective A national survey was conducted to determine the current status of physical therapist practice in the ICU. Design This study used a cross-sectional, observational design. Methods Self-report surveys were mailed to members of the Acute Care Section of the American Physical Therapy Association. Questions addressed staffing, training, barriers, and protocols, and case scenarios were used to determine perceptions about providing rehabilitation. Results The response rate was 29% (667/2,320). Staffing, defined as the number of physical therapists per 100 ICU beds, was highest in community hospitals (academic: median=5.4 [range=3.6–9.2]; community: median=6.7 [range=4.4–10.0]) and in the western United States (median=7.5 [range=4.2–12.9]). Twelve percent of physical therapists reported no training. Barriers to providing ICU rehabilitation included insufficient staffing and training, departmental prioritization policies, and inadequate consultation criteria. Responses to case scenarios demonstrated differences in the likelihood of consultation and physical therapists' prescribed frequency and intensity of care based on medical interventions rather than characteristics of patients. Physical therapists in academic hospitals were more likely to be involved in the care of patients in each scenario and were more likely to perform higher-intensity mobilization. Limitations Members of the Acute Care Section of the American Physical Therapy Association may not represent most practicing physical therapists, and the 29% return rate may have contributed to response bias. Conclusions Although staffing was higher in community hospitals, therapists in academic and community hospitals cited insufficient staffing as the most common barrier to providing rehabilitation in the ICU. Implementing strategies to overcome barriers identified in this study may improve the delivery of ICU rehabilitation services. PMID:26045604

[Severe cases of Salmonella non typhi infections on sickle cell patients in Réunion Island].

PubMed

Vandroux, D; Jabot, J; Angue, M; Belcour, D; Galliot, R; Allyn, J; Gaüzère, B-A

2014-12-01

We report two cases of septic shocks due to Salmonella non typhi infection on sickle cell patients admitted to an intensive care unit. Such patients should enforce food hygiene measures, especially under tropical settings, to avoid potentially deadly severe infections.

Assessment of Clinical Practices for Crushing Medication in Geriatric Units.

PubMed

Fodil, M; Nghiem, D; Colas, M; Bourry, S; Poisson-Salomon, A-S; Rezigue, H; Trivalle, C

2017-01-01

To assess the modification of the form of medication and evaluate staff observance of good clinical practices. One-day assessment of clinical practices. 17 geriatrics units in the 3 Teaching Hospitals of Paris-Sud (APHP), France. Elderly in-patients with difficulties swallowing capsules and tablets. Assessment of target-patient prescriptions and direct observation of nurses' medical rounds. 155/526 in-patients (29.5%) were unable to swallow tablets or capsules: 98 (40.3%) in long-term care, 46 patients (23.8%) in the rehabilitation unit and 11 (12.2%) in the acute care unit (p = .005). In thirty-nine (27.3%) of the 143 prescriptions studied all tablets were safe to crush and all capsules were safe to open. In 104 cases, at least one medication could not be safely modified, including 26 cases (18.2%) in which none of the prescribed drugs were safe to crush or open. In 48.2% of the 110 medications that were crushed, crushing was forbidden, and presented a potential threat in 12.7% of cases or a reduced efficacy in 8.2% of cases. Crushing methods were rarely appropriate: no specific protective equipment was used (81.8%), crushing equipment was shared between patients without cleaning (95.1%), medications were spilled or lost (69.9%). The method of administration was appropriate (water, jellified water) in 25% of the cases, questionable (soup, coffee, compote, juice, cream) in 55% of the cases and unacceptable (laxative) in 21% of the cases. Management of drug prescriptions in patients with swallowing difficulties is not optimal, and may even have iatrogenic effects. In this study, 12.7% of the modifications of the drug form could have been harmful. Doctors, pharmacists and nurses need to reevaluate their practices.

Use of palivizumab with other infection control measures to control respiratory syncytial virus outbreaks in neonatal care units.

PubMed

Hammoud, Majeda S; Al-Taiar, Abdullah; Raina, Aditiya; Elsori, Dalal; Al-Qabandi, Sarah; Al-Essa, Mazen

2016-10-01

No guidelines exist on the use of palivizumab during outbreaks of Respiratory Syncytial Virus (RSV) in Neonatal Intensive Care Units (NICUs). We aimed to describe an outbreak of RSV in NICU settings and the role of palivizumab in controlling the outbreak. The index case was a 30-day-old premature infant. During the outbreak, 13 cases of RSV were confirmed by RT-PCR. All infants in the NICU received palivizumab after RSV diagnosis. Of the 13 cases, seven were male; and the median (interquartile) of birth weight was 1585 (IQR: 1480-1705) g. All cases were premature under 34-weeks-gestation. Age at onset of disease varies between 10 and 160 days. Only four cases occurred after administering palivizumab and applying other infection control measures. During nosocomial outbreaks of RSV, administration of palivizumab to all infants in NICU appears to be rational and may help contain outbreaks. © The Author [2016]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Lesions requiring wound management in a central tertiary neonatal intensive care unit.

PubMed

Meszes, Angéla; Tálosi, Gyula; Máder, Krisztina; Orvos, Hajnalka; Kemény, Lajos; Csoma, Zsanett Renáta

2017-04-01

Most of the skin disorders that occur in neonatal intensive care units are due in part to the immaturity and vulnerability of the neonatal skin. Various iatrogenic diagnostic and therapeutic procedures are also conducive to iatrogenic damage. This study was to review the neonates admitted to our neonatal intensive care unit who needed wound management, and to assess the most common skin injuries and wounds, and their aetiology. Data were extracted from medical records of neonates who needed wound management in our Neonatal Intensive Care Unit between January 31, 2012 and January 31, 2013. Information about gestational age, sex, birth weight, area of involvement, wound aetiology, and therapy were collected. Among the 211 neonates observed, wound management was required in 10 cases of diaper dermatitis, 7 epidermal stripping, 6 extravasation injuries, 5 pressure ulcers, 1 surgical wound and infection, 1 thermal burn, and 5 other lesions. International guidelines in neonatal wound care practice are not available, and further research concerns are clearly needed. Dressings and antiseptic agents should be chosen with great care for application to neonates, with particular attention to the prevention of adverse events in this sensitive population. Team work among dermatologists, neonatologists and nurses is crucial for the successful treatment of neonates.

User embracement with risk classification in an emergency care unit: an evaluative study.

PubMed

Hermida, Patrícia Madalena Vieira; Nascimento, Eliane Regina Pereira do; Echevarría-Guanilo, Maria Elena; Brüggemann, Odaléa Maria; Malfussi, Luciana Bihain Hagemann de

2018-01-01

Objective Describing the evaluation of the Structure, Process and Outcome of User Embracement with Risk Classification of an Emergency Care Unit from the perspective of physicians and nurses. Method An evaluative, descriptive, quantitative study developed in Santa Catarina. Data were collected using a validated and adapted instrument consisting of 21 items distributed in the dimensions of Structure (facilities), Process (activities and relationships in providing care) and Outcome (care effects). In the analysis, descriptive statistics and the Mean Ranking and Mean Score calculations were applied. Results The sample consisted of 37 participants. From the 21 evaluated items, 11 (52.4%) had a Mean Ranking between 3 and 4, and none of them reached the maximum ranking (5 points). "Prioritization of severe cases" and "Primary care according to the severity of the case" reached a higher Mean Ranking (4.5), while "Flowchart discussion" had the lowest Ranking (2.1). The dimensions of Structure, Process and Outcome reached mean scores of 23.9, 21.9 and 25.5, respectively, indicating a Precarious evaluation (17.5 to 26.1 points). Conclusion User Embracement with Risk Classification is precarious, especially regarding the Process which obtained a lower satisfaction level from the participants.

A case report of dexmedetomidine used to treat intractable pain and delirium in a tertiary palliative care unit.

PubMed

Hilliard, Neil; Brown, Stuart; Mitchinson, Steve

2015-03-01

This case report describes an end-stage cancer patient with intractable neuropathic pain and delirium who was successfully managed during the last 3 weeks of her life with a continuous subcutaneous infusion of dexmedetomidine. A 55-year-old woman with locally advanced cervical cancer and uncontrolled pelvic pain was admitted to a tertiary palliative care unit for pain management. As her disease progressed, the patient's pelvic pain intensified despite treatment with methadone, gabapentin, ketamine, and hydromorphone administered by continuous subcutaneous infusion plus frequent breakthrough doses of hydromorphone and sufentanil. A continuous subcutaneous infusion of dexmedetomidine was started and titrated to achieve pain relief. The patient's pain and delirium cleared. The treatment was successful in fulfilling the patient's goal of care: not to be deeply and continuously sedated, but to be rousable and of clear mind while still having good pain control. Dexmedetomidine is a potentially useful medication for the targeted treatment of intractable pain and delirium in the tertiary palliative care environment. Future research is required to compare dexmedetomidine infusion to standard treatment with midazolam infusion for treatment of intractable symptoms in the palliative care environment. © The Author(s) 2014.

The effect of statutory limitations on the authority of substitute decision makers on the care of patients in the intensive care unit: case examples and review of state laws affecting withdrawing or withholding life-sustaining treatment.

PubMed

Venkat, Arvind; Becker, Julianna

2014-01-01

While the ethics and critical care literature is replete with discussion of medical futility and the ethics of end-of-life care decisions in the intensive care unit, little attention is paid to the effect of statutory limitations on the authority of substitute decision makers during the course of treatment of patients in the critical care setting. In many jurisdictions, a clear distinction is made between the authority of a health care power of attorney, who is legally designated by a competent adult to make decisions regarding withholding or withdrawing life-sustaining treatment, and of next-of-kin, who are limited in this regard. However, next-of-kin are often relied upon to consent to necessary procedures to advance a patient's medical care. When conflicts arise between critical care physicians and family members regarding projected patient outcome and functional status, these statutory limitations on decision-making authority by next of kin can cause paralysis in the medical care of severely ill patients, leading to practical and ethical impasses. In this article, we will provide case examples of how statutory limitations on substitute decision making authority for next of kin can impede the care of patients. We will also review the varying jurisdictional limitations on the authority of substitute decision makers and explore their implications for patient care in the critical care setting. Finally, we will review possible ethical and legal solutions to resolve these impasses.

Utilization of Observation Units for the Care of Poisoned Patients: Trends from the Toxicology Investigators Consortium Case Registry.

PubMed

Judge, Bryan S; Ouellette, Lindsey M; VandenBerg, Melissa; Riley, Brad D; Wax, Paul M

2016-03-01

Many poisoned patients may only require a period of observation after their exposure. There are limited data describing the use of observation units for managing poisoned adult and pediatric patients. We performed a retrospective review of all patients reported to the ToxIC Case Registry between January 1, 2012 and December 31, 2013. Eligible patients included those who received a bedside consultation by a medical toxicologist and whose care was provided in an observation unit, or those who were admitted under the care of a medical toxicologist in an observation unit. A total of 15,562 poisonings were reported to the registry during the study period, of which 340 (2.2 %) involved patients who were cared for in an observation unit. Of these patients, 22.1 % were 18 years of age or younger, and the remaining 77.9 % were greater than 18 years of age. The most common reason for exposure was the intentional ingestion of a pharmaceutical agent in both adult (30.2 %) and pediatric patients (36.0 %). Alcohols (ethanol) (24.9 %), opioids (20.0 %), and sedative-hypnotics (17.7 %) were the most common agent classes involved in adult patient exposures. The most common agent classes involved in pediatric exposures were antidepressants (12.0 %), anticonvulsants (10.7 %), and envenomations (10.7 %). In adult patients, the most common signs and symptoms involved the nervous system (52.0 %), a toxidrome (17.0 %), or a major vital sign abnormality (14.7 %). In pediatric patients, the most common signs and symptoms involved the nervous system (53.3 %), a toxidrome (21.3 %), or a major vital sign abnormality (17.3 %). The results of this study demonstrate that a wide variety of poisoned patients have been cared for in an observation unit in consultation with a board-certified medical toxicologist. Patterns for the reasons for exposure, agents responsible for the exposure, and toxicological treatments will continue to evolve. Further study is needed to identify better those poisoned patients who can be appropriately managed in an observation unit.

Psychosocial factors and prevalence of burnout syndrome among nursing workers in intensive care units.

PubMed

da Silva, Jorge Luiz Lima; Soares, Rafael da Silva; Costa, Felipe dos Santos; Ramos, Danusa de Souza; Lima, Fabiano Bittencourt; Teixeira, Liliane Reis

2015-01-01

To evaluate the prevalence of burnout syndrome among nursing workers in intensive care units and establish associations with psychosocial factors. This descriptive study evaluated 130 professionals, including nurses, nursing technicians, and nursing assistants, who performed their activities in intensive care and coronary care units in 2 large hospitals in the city of Rio de Janeiro, Brazil. Data were collected in 2011 using a self-reported questionnaire. The Maslach Burnout Inventory was used to evaluate the burnout syndrome dimensions, and the Self Reporting Questionnaire was used to evaluate common mental disorders. The prevalence of burnout syndrome was 55.3% (n = 72). In the quadrants of the demand-control model, low-strain workers exhibited a prevalence of 64.5% of suspected cases of burnout, whereas high-strain workers exhibited a prevalence of 72.5% of suspected cases (p = 0.006). The prevalence of suspected cases of common mental disorders was 27.7%; of these, 80.6% were associated with burnout syndrome (< 0.0001). The multivariate analysis adjusted for gender, age, educational level, weekly work duration, income, and thoughts about work during free time indicated that the categories associated with intermediate stress levels - active work (OR = 0.26; 95%CI = 0.09 - 0.69) and passive work (OR = 0.22; 95%CI = 0.07 - 0.63) - were protective factors for burnout syndrome. Psychosocial factors were associated with the development of burnout syndrome in this group. These results underscore the need for the development of further studies aimed at intervention and the prevention of the syndrome.

Psychosocial factors and prevalence of burnout syndrome among nursing workers in intensive care units

PubMed Central

da Silva, Jorge Luiz Lima; Soares, Rafael da Silva; Costa, Felipe dos Santos; Ramos, Danusa de Souza; Lima, Fabiano Bittencourt; Teixeira, Liliane Reis

2015-01-01

Objective To evaluate the prevalence of burnout syndrome among nursing workers in intensive care units and establish associations with psychosocial factors. Methods This descriptive study evaluated 130 professionals, including nurses, nursing technicians, and nursing assistants, who performed their activities in intensive care and coronary care units in 2 large hospitals in the city of Rio de Janeiro, Brazil. Data were collected in 2011 using a self-reported questionnaire. The Maslach Burnout Inventory was used to evaluate the burnout syndrome dimensions, and the Self Reporting Questionnaire was used to evaluate common mental disorders. Results The prevalence of burnout syndrome was 55.3% (n = 72). In the quadrants of the demand-control model, low-strain workers exhibited a prevalence of 64.5% of suspected cases of burnout, whereas high-strain workers exhibited a prevalence of 72.5% of suspected cases (p = 0.006). The prevalence of suspected cases of common mental disorders was 27.7%; of these, 80.6% were associated with burnout syndrome (< 0.0001). The multivariate analysis adjusted for gender, age, educational level, weekly work duration, income, and thoughts about work during free time indicated that the categories associated with intermediate stress levels - active work (OR = 0.26; 95%CI = 0.09 - 0.69) and passive work (OR = 0.22; 95%CI = 0.07 - 0.63) - were protective factors for burnout syndrome. Conclusion Psychosocial factors were associated with the development of burnout syndrome in this group. These results underscore the need for the development of further studies aimed at intervention and the prevention of the syndrome. PMID:26340152

Outcomes of exertional rhabdomyolysis following high-intensity resistance training.

PubMed

Huynh, A; Leong, K; Jones, N; Crump, N; Russell, D; Anderson, M; Steinfort, D; Johnson, D F

2016-05-01

High-intensity resistance training (HIRT) programmes are increasingly popular amongst personal trainers and those attending gymnasiums. We report the experience of exertional rhabdomyolysis (ER) at two tertiary hospitals in Melbourne, Australia. To compare the clinical outcomes of ER with other causes of rhabdomyolysis. Retrospective cross-sectional study of patients presenting with a serum creatine kinase (CK) of greater than 25 000 units/L from 1 September 2013 to 31 August 2014 at two tertiary referral hospitals in Melbourne, Australia. Records were examined to identify care measures implemented during hospital stay, clinical outcomes during admission and on subsequent follow up. Thirty four cases of rhabdomyolysis with a CK of greater than 25 000 units/L (normal range: 20-180 units/L) were identified during the 12-month study period. Twelve of the 34 cases (35%) had ER with 10 of 12 related to HIRT. No acute kidney injury, intensive care admission or death were seen among those with ER. All cases were managed conservatively, with 11 admitted and 9 receiving intravenous fluids only. In contrast, patients with rhabdomyolysis from other causes experienced significantly higher rates of intensive care admission (64%, P = 0.0002), acute kidney injury (82%, P = 0.0001) and death (27%, P = 0.069). ER resulting from HIRT appears to have a benign course compared with rhabdomyolysis of other aetiologies in patients with a serum CK greater than 25 000 units/L. Conservative management of ER appears to be adequate, although this requires confirmation in future prospective studies. © 2016 Royal Australasian College of Physicians.

Communication between family carers and health professionals about end-of-life care for older people in the acute hospital setting: a qualitative study.

PubMed

Caswell, Glenys; Pollock, Kristian; Harwood, Rowan; Porock, Davina

2015-08-01

This paper focuses on communication between hospital staff and family carers of patients dying on acute hospital wards, with an emphasis on the family carers' perspective. The age at which people in the UK die is increasing and many continue to die in the acute hospital setting. Concerns have been expressed about poor quality end of life care in hospitals, in particular regarding communication between staff and relatives. This research aimed to understand the factors and processes which affect the quality of care provided to frail older people who are dying in hospital and their family carers. The study used mixed qualitative methods, involving non-participant observation, semi-structured interviews and a review of case notes. Four acute wards in an English University teaching hospital formed the setting: an admissions unit, two health care of older people wards and a specialist medical and mental health unit for older people. Thirty-two members of staff took part in interviews, five members of the palliative care team participated in a focus group and 13 bereaved family carers were interviewed. In all, 245 hours of observation were carried out including all days of the week and all hours of the day. Forty-two individual patient cases were constructed where the patient had died on the wards during the course of the study. Thirty three cases included direct observations of patient care. Interviews were completed with 12 bereaved family carers of ten patient cases. Carers' experience of the end of life care of their relative was enhanced when mutual understanding was achieved with healthcare professionals. However, some carers reported communication to be ineffective. They felt unsure about what was happening with their relative and were distressed by the experience of their relative's end of life care. Establishing a concordant relationship, based on negotiated understanding of shared perspectives, can help to improve communication between healthcare professionals and family carers of their patients.

The impact of the introduction of critical care outreach services in England: a multicentre interrupted time-series analysis

PubMed Central

Gao, Haiyan; Harrison, David A; Parry, Gareth J; Daly, Kathleen; Subbe, Christian P; Rowan, Kathy

2007-01-01

Introduction Critical care outreach services (CCOS) have been widely introduced in England with little rigorous evaluation. We undertook a multicentre interrupted time-series analysis of the impact of CCOS, as characterised by the case mix, outcome and activity of admissions to adult, general critical care units in England. Methods Data from the Case Mix Programme Database (CMPD) were linked with the results of a survey on the evolution of CCOS in England. Over 350,000 admissions to 172 units between 1996 and 2004 were extracted from the CMPD. The start date of CCOS, activities performed, coverage and staffing were identified from survey data and other sources. Individual patient-level data in the CMPD were collapsed into a monthly time series for each unit (panel data). Population-averaged panel-data models were fitted using a generalised estimating equation approach. Various potential outcomes reflecting possible objectives of the CCOS were investigated in three subgroups of admissions: all admissions to the unit, admissions from the ward, and unit survivors discharged to the ward. The primary comparison was between periods when a formal CCOS was and was not present. Secondary analyses considered specific CCOS activities, coverage and staffing. Results In all, 108 units were included in the analysis, of which 79 had formal CCOS starting between 1996 and 2004. For admissions from the ward, CCOS were associated with significant decreases in the proportion of admissions receiving cardiopulmonary resuscitation before admission (odds ratio 0.84, 95% confidence interval 0.73 to 0.96), admission out of hours (odds ratio 0.91, 0.84 to 0.97) and mean Intensive Care National Audit & Research Centre physiology score (decrease in mean 1.22, 0.31 to 2.12). There was no significant change in unit mortality (odds ratio 0.97, 0.87 to 1.08) and no significant, sustained effects on outcomes for unit survivors discharged alive to the ward. Conclusion The observational nature of the study limits its ability to infer causality. Although associations were observed with characteristics of patients admitted to critical care units, there was no clear evidence that CCOS have a big impact on the outcomes of these patients, or for characteristics of what should form the optimal CCOS. PMID:17949497

The Impact of Critical Care Nursing Certification on Pediatric Patient Outcomes.

PubMed

Hickey, Patricia A; Gauvreau, Kimberlee; Porter, Courtney; Connor, Jean A

2018-06-14

To examine the relationship of nursing and unit characteristics including Critical Care Registered Nurse certification on patient complications for children undergoing congenital heart surgery in free-standing children's hospitals in the United States. A cross-sectional descriptive survey of nursing and organizational characteristics was sent electronically. Free-standing children's hospitals in the United States. Children undergoing congenital heart surgery (congenital cardiac cases). Nursing and unit characteristics from children's hospitals were obtained via electronic survey during years 2010 and 2014. Survey data from 2014 were linked with patient-level data age less than 18 years old using the Pediatric Health Information System for years 2013-2014. The Complication Screening Method of Congenital Heart Surgery was used to adjust for baseline patient differences. Among 23 of 43 free-standing children's hospitals (53%) in 2014, the median proportion of nurses with Bachelor of Science in Nursing preparation or higher at each site was 77% and with Critical Care Registered Nurse certification was 24%. Among 12,324 eligible congenital cardiac cases, the rate of complication was 34.4%. The odds of complications significantly decreased as the institutional percentage of nurses with a Bachelor of Science in Nursing increased (odds ratio, 0.83; p = 0.04). The odds of complications also significantly decreased as the institutional percentage of nurses with Critical Care Registered Nurse certification increased (odds ratio, 0.86; p = 0.02). Bachelor of Science in Nursing education and Critical Care Registered Nurse certification significantly impact pediatric patient outcomes. Recognition of nursing and organizational characteristics that are associated with improved pediatric patient outcomes is important to patients, their families, and society. Clinical leaders must commit to facilitating pathways for hiring candidates with Bachelor of Science in Nursing as a minimum to practice in PICUs and supporting a culture of professional certification.

Price competition and hospital cost growth in the United States (1989-1994).

PubMed

Bamezai, A; Zwanziger, J; Melnick, G A; Mann, J M

1999-05-01

In recent years, most health care markets in the United States (US) have experienced rapid penetration by health maintenance organizations (HMOs) and preferred provider organizations (PPOs). During this same period, the US has also experienced slowing health care costs. Using a national database, we demonstrate that HMOs and PPOs have significantly restrained cost growth among hospitals located in competitive hospital markets, but not so in the case of hospitals located in relatively concentrated markets. In relative terms, we estimate that HMOs have contained cost growth more effectively than PPOs.

Implementation of Advanced Warehouses in a Hospital Environment - Case study

NASA Astrophysics Data System (ADS)

Costa, J.; Sameiro Carvalho, M.; Nobre, A.

2015-05-01

In Portugal, there is an increase of costs in the healthcare sector due to several factors such as the aging of the population, the increased demand for health care services and the increasing investment in new technologies. Thus, there is a need to reduce costs, by presenting the effective and efficient management of logistics supply systems with enormous potential to achieve savings in health care organizations without compromising the quality of the provided service, which is a critical factor, in this type of sector. In this research project the implementation of Advanced Warehouses has been studied, in the Hospital de Braga patient care units, based in a mix of replenishment systems approaches: the par level system, the two bin system and the consignment model. The logistics supply process is supported by information technology (IT), allowing a proactive replacement of products, based on the hospital services consumption records. The case study was developed in two patient care units, in order to study the impact of the operation of the three replenishment systems. Results showed that an important inventory holding costs reduction can be achieved in the patient care unit warehouses while increasing the service level and increasing control of incoming and stored materials with less human resources. The main conclusion of this work illustrates the possibility of operating multiple replenishment models, according to the types of materials that healthcare organizations deal with, so that they are able to provide quality health care services at a reduced cost and economically sustainable. The adoption of adequate IT has been shown critical for the success of the project.

Care delivery and compensation system changes: a case study of organizational readiness within a large dental care practice organization in the United States.

PubMed

Cunha-Cruz, Joana; Milgrom, Peter; Huebner, Colleen E; Scott, JoAnna; Ludwig, Sharity; Dysert, Jeanne; Mitchell, Melissa; Allen, Gary; Shirtcliff, R Mike

2017-12-20

Dental care delivery systems in the United States are consolidating and large practice organizations are becoming more common. At the same time, greater accountability for addressing disparities in access to care is being demanded when public funds are used to pay for care. As change occurs within these new practice structures, attempts to implement change in the delivery system may be hampered by failure to understand the organizational climate or fail to prepare employees to accommodate new goals or processes. Studies of organizational behavior within oral health care are sparse and have not addressed consolidation of current delivery systems. The objective of this case study was to assess organizational readiness for implementing change in a large dental care organization consisting of staff model clinics and affiliated dental practices and test associations of readiness with workforce characteristics and work environment. A dental care organization implemented a multifaceted quality improvement program, called PREDICT, in which community-based mobile and clinic-based dental services were integrated and the team compensated based in part on meeting performance targets. Dental care providers and supporting staff members (N = 181) were surveyed before program implementation and organizational readiness for implementing change (ORIC) was assessed by two 5-point scales: change commitment and efficacy. Providers and staff demonstrated high organizational readiness for change. Median change commitment was 3.8 (Interquartile range [IQR]: 3.3-4.3) and change efficacy was 3.8 (IQR: 3.0-4.2). In the adjusted regression model, change commitment was associated with organizational climate, support for methods to arrest tooth decay and was inversely related to office chaos. Change efficacy was associated with organizational climate, support for the company's mission and was inversely related to burnout. Each unit increase in the organizational climate scale predicted 0.45 and 0.8-unit increases in change commitment and change efficacy. The survey identified positive readiness for change and highlighted weaknesses that are important cautions for this organization and others initiating change. Future studies will examine how organizational readiness to change, workforce characteristics and work environment influenced successful implementation within this organization.

Health Insurance

MedlinePlus

Health insurance helps protect you from high medical care costs. It is a contract between you and ... Many people in the United States get a health insurance policy through their employers. In most cases, ...

Barriers and facilitators to care for the terminally ill: a cross-country case comparison study of Canada, England, Germany, and the United States.

PubMed

Klinger, Christopher A; Howell, Doris; Zakus, David; Deber, Raisa B

2014-02-01

Why do many patients not die at their preferred location? Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ill adults (barriers and facilitators). Cross-country comparison study from a "most similar-most different" perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews. Case study of Canada, England, Germany, and the United States. While similar with regard to leading causes of death, patient needs, and potential avenues to care, different models of service provision were employed in the four countries studied. Although hospice and palliative care services were generally offered with standard care along the disease continuum and in various settings, and featured common elements such as physical, psycho-social, and spiritual care, outcomes (access, utilization, etc.) varied across jurisdictions. Barriers to best practice service provision included legislative (including jurisdictional), regulatory (e.g. education and training), and financial issues as well as public knowledge and perception ("giving up hope") challenges. Advance care planning, dedicated and stable funding toward hospice and palliative care, including caregiver benefits, population aging, and standards of practice and guidelines to hospice and palliative care, were identified as facilitators. Successful implementation of effective and efficient best practice approaches to care for the terminally ill, such as shared care, requires concerted action to align these system-level characteristics; many factors were identified as being essential but not sufficient. Policy implementation needs to be tailored to the respective health-care system(s), monitored, and fine-tuned.

Acute Respiratory Failure Induced by Magnesium Replacement in a 62-Year-Old Woman with Myasthenia Gravis.

PubMed

Singh, Paramveer; Idowu, Olakunle; Malik, Imrana; Nates, Joseph L

2015-10-01

Magnesium is known to act at the neuromuscular junction by inhibiting the presynaptic release of acetylcholine and desensitizing the postsynaptic membrane. Because of these effects, magnesium has been postulated to potentiate neuromuscular weakness. We describe the case of a 62-year-old woman with myasthenia gravis and a metastatic thymoma who was admitted to our intensive care unit for management of a myasthenic crisis. The patient's neuromuscular weakness worsened in association with standard intravenous magnesium replacement, and the exacerbated respiratory failure necessitated intubation, mechanical ventilation, and an extended stay in the intensive care unit. The effect of magnesium replacement on myasthenia gravis patients has not been well documented, and we present this case to increase awareness and stimulate research. In addition, we discuss the relevant medical literature.

[Cancer incidence in a Cancer Care Unit of the Mexican Social Security Institute (IMSS) in Toluca, Mexico].

PubMed

Gómez-Villanueva, Angel; Chacón Sánchez, Jesús; Santillán Arreygue, Leopoldo; Sánchez González, Yolanda; Romero-Figueroa, María del Socorro

2014-01-01

In 2000, malignant tumors were responsible for 12% of nearly 56 million deaths that occurred in the world from all causes. To determine the incidence of cancer in a Cancer Care Unit of IMSS in Toluca, Mexico. Prospective cross-sectional study; we identified the primary tumor, age, family history of cancer, comorbidities, risk factors, and ECOG in patients with newly diagnosed cancer. We identified 446 cases, 66.1% were women. The age group of age 50 to 59 had the highest number of cases (98). The most common cancers in women are breast, cervical, and ovarian cancer, and in men, testicular, prostate, and colorectal cancer. The most common cancers in both sexes were breast cancer, cervical cancer, colorectal cancer, ovarian cancer, and testicular cancer.

Advance care planning: challenges and approaches for pediatricians.

PubMed

Heckford, Emma; Beringer, Antonia Jane

2014-09-01

There is increasing recognition of the value of advance care planning for children with life-limiting conditions. It is important that we acknowledge and reflect on the challenges that this work presents in order to optimize practice. Our aim was to review advance care planning for children with life-threatening or life-limiting conditions (LTLLCs) in our local area. We conducted a retrospective case note review. Study subjects were from two National Health Service (NHS) Trusts in Bristol in the United Kingdom. Cases were identified from Child Death Overview Panel data. Forty-two sets of case notes were reviewed in relation to 20 children. Measurements included quantitative and qualitative review of advance care planning in relation to standards set by The Association for Children's Palliative Care (ACT). In 25% of cases there was no documented discussion with families about the approach to end of life (EOL). In 25% of cases there was no evidence of an advance care plan, and the content and accessibility of those that did exist was variable. Forty-five percent of families were not offered a choice with regard to location of care (LOC) in the last months of life and 50% were not offered a choice about location of death (LOD). We hope that acknowledgement of some of the challenges, alongside recognition of the clear benefits, of planning will help pediatricians to deliver this important area of care.

[Development, implementation, and analysis of a "collaborative decision-making for reasonable care" document in pediatric palliative care].

PubMed

Paoletti, M; Litnhouvongs, M-N; Tandonnet, J

2015-05-01

In France, a legal framework and guidelines state that decisions to limit treatments (DLT) require a collaborative decision meeting and a transcription of decisions in the patient's file. The do-not-attempt-resuscitation order involves the same decision-making process for children in palliative care. To fulfill the law's requirements and encourage communication within the teams, the Resource Team in Pediatric Palliative Care in Aquitaine created a document shared by all children's hospital units, tracing the decision-making process. This study analyzed the decision-making process, quality of information transmission, and most particularly the relevance of this new "collaborative decision-making for reasonable care" card. Retrospective study evaluating the implementation of a traceable document relating the DLT process. All the data sheets collected between January and December 2013 were analyzed. A total of 58 data sheets were completed between January and December 2013. We chose to collect the most relevant data to evaluate the relevance of the items to be completed and the transmission of the document, to draw up the patients' profile, and the contents of discussions with families. Of the 58 children for whom DLT was discussed, 41 data sheets were drawn up in the pediatric intensive care unit, seven in the oncology and hematology unit, five in the neonatology unit, four in the neurology unit, and one in the pneumology unit. For 30 children, one sheet was created, for 11 children, two sheets and for two children, three sheets were filled out. Thirty-nine decisions were made for withholding lifesaving treatment, 11 withdrawing treatment, and for five children, no limitation was set. Nine children survived after DLT. Of the 58 data sheets, only 31 discussions with families were related to the content of the data sheet. Of the 14 children transferred out of the unit with a completed data sheet, it was transmitted to the new unit for 11 children (79%). The number of data sheets collected in 1 year shows the value of this document. The participation of several pediatric specialities' referents in its creation, then its progressive presentation in the children's hospital units, were essential steps in introducing and establishing its use. Items describing the situation, management proposals, and adaptation of the children's supportive care were completed in the majority of cases. They correspond to a clinical description, the object of the discussion, and the daily caregiver's practices, respectively. On the other hand, discussions with families were related to the card's contents in only 53% of the cases. This can be explained by the time required to complete the DLT process. It is difficult for referring doctors to systematically, faithfully, and objectively transcribe discussions with parents. Although this process has been used for a long time in intensive care units, this document made possible an indispensable formalisation in the decision-making process. In other pediatric specialities, the sheet allowed introducing the palliative approach and was a starter and a tool for reflection on the do-not-attempt-resuscitation order, thus suggesting the need for anticipation in these situations. With the implementation of this new document, the DLT, data transmission, and continuity of care conditions were improved in the children's hospital units. Sharing this sheet with all professionals in charge of these children would support homogeneity and quality of management and care for children and their parents. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Technology that achieves the Triple Aim: an economic analysis of the BrainPath™ approach in neurosurgery.

PubMed

Norton, Sidney P; Dickerson, Evan M; Kulwin, Charles G; Shah, Mitesh V

2017-01-01

The Triple Aim is defined as: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. The purpose of this analysis was to evaluate the economic value of a new neurosurgical technique, the BrainPath™ approach, for use in patients with subcortical tumors and intracerebral hemorrhage (ICH). Inpatient length of stay (LOS) data were collected for ICH and brain tumor surgical patient cases between August 2013 and November 2015. Patient cases were separated into two groups; BrainPath approach (n = 28) and conventional techniques, such as craniotomy, (n = 208). The average intensive care unit (ICU) LOS was calculated for each group by diagnosis-related group and compared between groups. The new surgical technology resulted in surgical intervention in 14 ICH cases which otherwise would have been medically managed due to the hemorrhage location or size of the ICH. A reduction in ICU LOS was seen in this group. Based on the variable direct cost per day in the neuro critical care unit at this academic medical center, 14 patient cases incurred ~ US$210,000 less in direct ICU costs. Surgical resection was possible in two tumor patient cases which would have been biopsied, rather than surgically resected, also due to location of the abnormalities. A total net value of > US$329,000 is attributable to the analyzed approach over a 28-month period. This analysis shows positive economic value for the new technology group when ICU LOS and reimbursement are considered against equipment costs, thus achieving Triple Aim objectives.

Obstetric near-miss and maternal mortality in maternity university hospital, Damascus, Syria: a retrospective study

PubMed Central

2010-01-01

Background Investigating severe maternal morbidity (near-miss) is a newly recognised tool that identifies women at highest risk of maternal death and helps allocate resources especially in low income countries. This study aims to i. document the frequency and nature of maternal near-miss at hospital level in Damascus, Capital of Syria, ii. evaluate the level of care at maternal life-saving emergency services by comparatively analysing near-misses and maternal mortalities. Methods Retrospective facility-based review of cases of near-miss and maternal mortality that took place in the years 2006-2007 at Damascus Maternity University Hospital, Syria. Near-miss cases were defined based on disease-specific criteria (Filippi 2005) including: haemorrhage, hypertensive disorders in pregnancy, dystocia, infection and anaemia. Main outcomes included maternal mortality ratio (MMR), maternal near miss ratio (MNMR), mortality indices and proportion of near-miss cases and mortality cases to hospital admissions. Results There were 28 025 deliveries, 15 maternal deaths and 901 near-miss cases. The study showed a MNMR of 32.9/1000 live births, a MMR of 54.8/100 000 live births and a relatively low mortality index of 1.7%. Hypertensive disorders (52%) and haemorrhage (34%) were the top causes of near-misses. Late pregnancy haemorrhage was the leading cause of maternal mortality (60%) while sepsis had the highest mortality index (7.4%). Most cases (93%) were referred in critical conditions from other facilities; namely traditional birth attendants homes (67%), primary (5%) and secondary (10%) healthcare unites and private practices (11%). 26% of near-miss cases were admitted to Intensive Care Unit (ICU). Conclusion Near-miss analyses provide valuable information on obstetric care. The study highlights the need to improve antenatal care which would help early identification of high risk pregnancies. It also emphasises the importance of both: developing protocols to prevent/manage post-partum haemorrhage and training health care professionals to manage infrequent but fatal conditions like sepsis. An urgent review of the referral system and the emergency obstetric care in Syria is highly recommended. PMID:20959012

Diagnosis of retinal detachments by a tele-ophthalmology screening program.

PubMed

McCord, Sarah A; Lynch, Mary G; Maa, April Y

2018-01-01

In 2015, a tele-ophthalmology program was undertaken at the Atlanta Veterans Affairs Medical Center to provide screening eye care for veterans in their primary care clinics. Though this program was developed as a screening tool, the availability of these services in primary care clinics has enabled triage of certain acute eye complaints. These case reports describe two patients who were diagnosed with retinal detachments through this program, although their primary care providers had triaged them as requiring non-urgent referrals to the eye clinic. Although many patients are seen for acute ocular complaints in primary care clinics and emergency departments, providers in such settings may lack the ability to adequately examine eyes and thus triage ocular complaints. These cases demonstrate the ability of tele-ophthalmology to assist in diagnosing urgent ocular conditions in primary care clinics. Though tele-ophthalmology has been accepted in some parts of the world, in the United States of America it remains widely underutilized. These cases highlight the ability of tele-ophthalmology to close the gap in acute eye care coverage that exists in the USA, most prominently in rural regions.

Causes and Characteristics of Death in Intensive Care Units: A Prospective Multicenter Study.

PubMed

Orban, Jean-Christophe; Walrave, Yannick; Mongardon, Nicolas; Allaouchiche, Bernard; Argaud, Laurent; Aubrun, Frédéric; Barjon, Geneviève; Constantin, Jean-Michel; Dhonneur, Gilles; Durand-Gasselin, Jacques; Dupont, Hervé; Genestal, Michèle; Goguey, Chloé; Goutorbe, Philippe; Guidet, Bertrand; Hyvernat, Hervé; Jaber, Samir; Lefrant, Jean-Yves; Mallédant, Yannick; Morel, Jerôme; Ouattara, Alexandre; Pichon, Nicolas; Guérin Robardey, Anne-Marie; Sirodot, Michel; Theissen, Alexandre; Wiramus, Sandrine; Zieleskiewicz, Laurent; Leone, Marc; Ichai, Carole

2017-05-01

Different modes of death are described in selected populations, but few data report the characteristics of death in a general intensive care unit population. This study analyzed the causes and characteristics of death of critically ill patients and compared anticipated death patients to unexpected death counterparts. An observational multicenter cohort study was performed in 96 intensive care units. During 1 yr, each intensive care unit was randomized to participate during a 1-month period. Demographic data, characteristics of organ failures (Sequential Organ Failure Assessment subscore greater than or equal to 3), and organ supports were collected on all patients who died in the intensive care unit. Modes of death were defined as anticipated (after withdrawal or withholding of treatment or brain death) or unexpected (despite engagement of full-level care or sudden refractory cardiac arrest). A total of 698 patients were included during the study period. At the time of death, 84% had one or more organ failures (mainly hemodynamic) and 89% required at least one organ support (mainly mechanical ventilation). Deaths were considered unexpected and anticipated in 225 and 473 cases, respectively. Compared to its anticipated counterpart, unexpected death occurred earlier (1 day vs. 5 days; P< 0.001) and had fewer organ failures (1 [1 to 2] vs. 1 [1 to 3]; P< 0.01) and more organ supports (2 [2 to 3] vs. 1 [1 to 2]; P< 0.01). Withdrawal or withholding of treatments accounted for half of the deaths. In a general intensive care unit population, the majority of patients present with at least one organ failure at the time of death. Anticipated and unexpected deaths represent two different modes of dying and exhibit profiles reflecting the different pathophysiologic underlying mechanisms.

Changes in NHS organization of care and management of hospital admissions with COPD exacerbations between the national COPD audits of 2003 and 2008.

PubMed

George, P M; Stone, R A; Buckingham, R J; Pursey, N A; Lowe, D; Roberts, C M

2011-10-01

The 2003 UK Chronic Obstructive Pulmonary Disease (COPD) audit revealed wide variability between hospital units in care delivered. To assess whether processes of care, patient outcomes and organization of care have improved since 2003. A UK national audit was performed in 2008 to survey the organization and delivery of clinical care provided to patients admitted to hospital with COPD. All UK acute hospital Trusts (units) were invited to participate. Each unit completed cross-sectional resource and organization questionnaires and a prospective clinical audit comprising up to 60 consecutively admitted cases of COPD exacerbation. Comparison between 2003 and 2008 includes aggregated statistics for units participating in both audit rounds. A total of 192 units participated in both audit rounds (6197 admissions in 2003 and 8170 in 2008). In 2008, patients were older and of a poorer functional class. Overall mortality was unchanged but adjusting for age and performance status, inpatient mortality (P = 0.05) and 90-day mortality (P = 0.001) were both reduced in 2008. More patients were discharged under a respiratory specialist (P < 0.01), treated with non-invasive ventilation if acidotic (P < 0.001) and accepted onto early discharge schemes (P < 0.01) while median length of stay fell from 6 to 5 days (P < 0.001). Within these mean data, however, there remains considerable inter-unit variation in organization, resources and outcomes. Overall improvements in resources and organization are accompanied by reduced mortality, shorter admissions and greater access to specialist services. There remains, however, considerable variation in the quality of secondary care provided between units.

Creating the Web-based Intensive Care Unit Safety Reporting System

PubMed Central

Holzmueller, Christine G.; Pronovost, Peter J.; Dickman, Fern; Thompson, David A.; Wu, Albert W.; Lubomski, Lisa H.; Fahey, Maureen; Steinwachs, Donald M.; Engineer, Lilly; Jaffrey, Ali; Morlock, Laura L.; Dorman, Todd

2005-01-01

In an effort to improve patient safety, researchers at the Johns Hopkins University designed and implemented a comprehensive Web-based Intensive Care Unit Safety Reporting System (ICUSRS). The ICUSRS collects data about adverse events and near misses from all staff in the ICU. This report reflects data on 854 reports from 18 diverse ICUs across the United States. Reporting is voluntary, and data collected is confidential, with patient, provider, and reporter information deidentified. Preliminary data include system factors reported, degree of patient harm, reporting times, and evaluations of the system. Qualitative and quantitative data are reported back to the ICU site study teams and frontline staff through monthly reports, case discussions, and a quarterly newsletter. PMID:15561794

Safety interventions on the labor and delivery unit.

PubMed

Kacmar, Rachel M

2017-06-01

The present review highlights recent advances in efforts to improve patient safety on labor and delivery units and well tolerated care for pregnant patients in general. Recent studies in obstetric patient safety have a broad focus but repetitive themes for interdisciplinary training include: simulating critical events, having open multidisciplinary communication, frequent reviews of cases of maternal morbidity, and implementing maternal early warning systems. The National Partnership for Maternal Safety is also active in promoting care bundles across many topics on maternal safety. A culture of safety is the goal for all obstetric units. Achieving that ideal requires multidisciplinary collaboration, frequent reassessment for areas of improvement, and a culture of openness to change when improvement opportunities arise.

Palliative care for patients with HIV/AIDS admitted to intensive care units

PubMed Central

Souza, Paola Nóbrega; de Miranda, Erique José Peixoto; Cruz, Ronaldo; Forte, Daniel Neves

2016-01-01

Objective To describe the characteristics of patients with HIV/AIDS and to compare the therapeutic interventions and end-of-life care before and after evaluation by the palliative care team. Methods This retrospective cohort study included all patients with HIV/AIDS admitted to the intensive care unit of the Instituto de Infectologia Emílio Ribas who were evaluated by a palliative care team between January 2006 and December 2012. Results Of the 109 patients evaluated, 89% acquired opportunistic infections, 70% had CD4 counts lower than 100 cells/mm3, and only 19% adhered to treatment. The overall mortality rate was 88%. Among patients predicted with a terminally ill (68%), the use of highly active antiretroviral therapy decreased from 50.0% to 23.1% (p = 0.02), the use of antibiotics decreased from 100% to 63.6% (p < 0.001), the use of vasoactive drugs decreased from 62.1% to 37.8% (p = 0.009), the use of renal replacement therapy decreased from 34.8% to 23.0% (p < 0.0001), and the number of blood product transfusions decreased from 74.2% to 19.7% (p < 0.0001). Meetings with the family were held in 48 cases, and 23% of the terminally ill patients were discharged from the intensive care unit. Conclusion Palliative care was required in patients with severe illnesses and high mortality. The number of potentially inappropriate interventions in terminally ill patients monitored by the palliative care team significantly decreased, and 26% of the patients were discharged from the intensive care unit. PMID:27737420

Review of noise in neonatal intensive care units regional analysis

NASA Astrophysics Data System (ADS)

Alvarez Abril, A.; Terrón, A.; Boschi, C.; Gómez, M.

2007-11-01

This work is about the problem of noise in neonatal incubators and in the environment in the neonatal intensive care units. Its main objective is to analyse the impact of noise in hospitals of Mendoza and La Rioja. Methodology: The measures were taken in different moments in front of higher or lower severity level in the working environment. It is shown that noise produces severe damages and changes in the behaviour and the psychological status of the new born babies. Results: The noise recorded inside the incubators and the neonatal intensive care units together have many components but the noise of motors, opening and closing of access gates have been considered the most important ones. Values above 60 db and and up to 120 db in some cases were recorded, so the need to train the health staff in order to manage the new born babies, the equipment and the instruments associated with them very carefully is revealed.

A Business Case for Tele-Intensive Care Units

PubMed Central

Coustasse, Alberto; Deslich, Stacie; Bailey, Deanna; Hairston, Alesia; Paul, David

2014-01-01

Objectives: A tele-intensive care unit (tele-ICU) uses telemedicine in an intensive care unit (ICU) setting, applying technology to provide care to critically ill patients by off-site clinical resources. The purpose of this review was to examine the implementation, adoption, and utilization of tele-ICU systems by hospitals to determine their efficiency and efficacy as identified by cost savings and patient outcomes. Methods: This literature review examined a large number of studies of implementation of tele-ICU systems in hospitals. Results: The evidence supporting cost savings was mixed. Implementation of a tele-ICU system was associated with cost savings, shorter lengths of stay, and decreased mortality. However, two studies suggested increased hospital cost after implementation of tele-ICUs is initially expensive but eventually results in cost savings and better clinical outcomes. Conclusions: Intensivists working these systems are able to more effectively treat ICU patients, providing better clinical outcomes for patients at lower costs compared with hospitals without a tele-ICU. PMID:25662529

Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer: a pilot feasibility study.

PubMed

Barnato, Amber E; Hsu, Heather E; Bryce, Cindy L; Lave, Judith R; Emlet, Lillian L; Angus, Derek C; Arnold, Robert M

2008-12-01

To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer. Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview. Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh. Twenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists. Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient's code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043). Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.

An analysis of whether higher health care spending in the United States versus Europe is 'worth it' in the case of cancer.

PubMed

Philipson, Tomas; Eber, Michael; Lakdawalla, Darius N; Corral, Mitra; Conti, Rena; Goldman, Dana P

2012-04-01

The United States spends more on health care than other developed countries, but some argue that US patients do not derive sufficient benefit from this extra spending. We studied whether higher US cancer care costs, compared with those of ten European countries, were "worth it" by looking at the survival differences for cancer patients in these countries compared to the relative costs of cancer care. We found that US cancer patients experienced greater survival gains than their European counterparts; even after considering higher US costs, this investment generated $598 billion of additional value for US patients who were diagnosed with cancer between 1983 and 1999. The value of that additional survival gain was highest for prostate cancer patients ($627 billion) and breast cancer patients ($173 billion). These findings do not appear to have been driven solely by earlier diagnosis. Our study suggests that the higher-cost US system of cancer care delivery may be worth it, although further research is required to determine what specific tools or treatments are driving improved cancer survival in the United States.

Exploring the Influence of Environment on the Spatial Behavior of Older Adults in a Purpose-Built Acute Care Dementia Unit.

PubMed

Mazzei, Francesco; Gillan, Roslyn; Cloutier, Denise

2014-06-01

Limited research explores the experience of individuals with dementia in acute care geriatric psychiatry units. This observational case study examines the influence of the physical environment on behavior (wandering, pacing, door testing, congregation and seclusions) among residents in a traditional geriatric psychiatry unit who were then relocated to a purpose-built acute care unit. Purpose-built environments should be well suited to the needs of residents with dementia. Observed trends revealed differences in spatial behaviors in the pre- and post- environments attributable to the physical environment. Person-centred modifications to the current environment including concerted efforts to know residents are meaningful in fostering quality of life. Color coded environments (rooms vs dining areas etc.) to improve wayfinding and opportunities to personalize rooms that address the `hominess' of the setting also have potential. Future research could also seek the opinions of staff about the impact of the environment on them as well as residents. © The Author(s) 2013.

[Emergency eye care in French university hospitals].

PubMed

Bourges, J-L

2018-03-01

The patient's request for urgent care in ophthalmology (PRUCO) at health care centers is constantly growing. In France, university hospitals are managing 75% of these cases. We sought to quantify PRUCO referred to French university hospital emergency units as well as to approach the structure and the territorial distribution of emergency eye care provided by French university hospitals. We conducted a quick cross-sectional survey sent to the 32 metropolitan and overseas French university hospitals. It inquired for each hospital whether emergency eye care units were available, whether ophthalmologists were on duty or on call overnight and how many PRUCO were managed in 2016. The 32 university hospitals completed the survey. A total of 398650 PRUCO were managed in French university hospitals in 2016. The emergency unit was exclusively dedicated to eye care for 70% of the hospitals, with 47% (15/32) of them employing an ophthalmologist on duty overnight. Every hospital but one had at least one ophthalmologist on call. The city of Paris set aside, university hospitals took care of an annual mean of 9000 PRUCO (min=500; max=32,250). The 32 French university hospitals are actively responding to patient's requests for urgent care in ophthalmology with very heterogeneous patient volumes and organizational systems. Half of them employ ophthalmologists on duty. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

Potentially preventable dental care in operating rooms for children enrolled in Medicaid.

PubMed

Bruen, Brian K; Steinmetz, Erika; Bysshe, Tyler; Glassman, Paul; Ku, Leighton

2016-09-01

In this study, the authors examined the prevalence and cost of care for children enrolled in Medicaid for potentially preventable dental conditions who receive surgical care in hospital operating rooms (ORs) or ambulatory surgery centers (ASCs). The authors analyzed Medicaid data from 8 states to find cases in which children aged 1 to 20 years received surgical care in ORs or ASCs in 2010 and 2011 for potentially preventable diagnoses, as defined with diagnostic codes. For 6 states with complete data, there were 26,373 cases in 2011 in which children received OR or ASC surgical care for potentially preventable conditions. These cases represent approximately 0.5% of all children enrolled in Medicaid in these states and approximately 1% of children enrolled in Medicaid who received any dental care. There were $68 million in total Medicaid payments for these cases, with an average of $2,581 per case. Diagnostic codes indicated that 98% of cases were related to treatment of dental caries. More than two-thirds of the cases (71%) were children aged 1 to 5 years. Extrapolation to the United States suggests that approximately $450 million in additional expenditures occurred in 2011 because of OR or ASC surgical care for potentially preventable pediatric dental conditions, primarily related to early childhood caries. Strategies to improve prevention of early childhood caries, including community- and family-based education, and to increase access to timely and early dental care for low-income children could reduce the burdens and costs of these dental problems. Copyright © 2016 American Dental Association. Published by Elsevier Inc. All rights reserved.

Safety of milrinone use in neonatal intensive care units

PubMed Central

Samiee-Zafarghandy, Samira; Raman, Sudha R.; van den Anker, John N.; McHutchison, Kerstin; Hornik, Christoph P.; Clark, Reese H.; Smith, P. Brian

2014-01-01

Background Milrinone use in the neonatal intensive care unit has increased over the last 10 years despite a paucity of published safety data in infants. We sought to determine the safety of milrinone therapy among infants in the neonatal intensive care unit. Methods We conducted a retrospective data analysis, identifying all infants exposed to milrinone discharged from 322 neonatal intensive care units managed by the Pediatrix Medical Group from 1997–2010. We identified adverse events (AEs) during milrinone exposure. The unit of observation for clinical AEs was the first course of milrinone and for laboratory AEs was an infant-day of exposure to milrinone. Results Overall, 1446 of 716,821 (0.2%) infants received milrinone for a total of 6894 infant-days. The proportion of infants exposed to milrinone increased from 0 in 1997 to 4/1000 infant cases in 2010. Persistent pulmonary hypertension (40%) was the most commonly reported diagnosis at the start of milrinone administration. Overall, 606/1446 (42%) of infants had at least 1 clinical AE recorded during milrinone therapy. Hypotension requiring pressors and thrombocytopenia (<100,000/mm3) were the most commonly reported clinical and laboratory AEs, respectively. Death was reported in 8% of infants during the first course of milrinone therapy. Conclusion Among infants hospitalized in the neonatal intensive care unit, there was an increase in the use of milrinone over the past 13 years. The safety, dosing, and efficacy of milrinone in infants should be determined in prospective clinical trials. PMID:25460254

Safety of milrinone use in neonatal intensive care units.

PubMed

Samiee-Zafarghandy, Samira; Raman, Sudha R; van den Anker, John N; McHutchison, Kerstin; Hornik, Christoph P; Clark, Reese H; Brian Smith, P

2015-01-01

Milrinone use in the neonatal intensive care unit has increased over the last 10 years despite a paucity of published safety data in infants. We sought to determine the safety of milrinone therapy among infants in the neonatal intensive care unit. We conducted a retrospective data analysis, identifying all infants who were exposed to milrinone and discharged from 322 neonatal intensive care units managed by the Pediatrix Medical Group from 1997-2010. We identified adverse events (AEs) during milrinone exposure. The unit of observation for clinical AEs was the first course of milrinone and for laboratory AEs it was an infant-day of exposure to milrinone. Overall, 1446 of 716,821 (0.2%) infants received milrinone for a total of 6894 infant-days. The proportion of infants exposed to milrinone increased from 0 in 1997 to 4/1000 infant cases in 2010. Persistent pulmonary hypertension (40%) was the most commonly reported diagnosis at the start of milrinone administration. Overall, 606/1446 (42%) of infants had at least 1 clinical AE recorded during milrinone therapy. Hypotension requiring pressors and thrombocytopenia (<100,000/mm(3)) were the most commonly reported clinical and laboratory AEs, respectively. Death was reported in 8% of infants during the first course of milrinone therapy. Among infants hospitalized in the neonatal intensive care unit, there was an increase in the use of milrinone over the past 13 years. The safety, dosing, and efficacy of milrinone in infants should be determined in prospective clinical trials. Copyright © 2014 Elsevier Ltd. All rights reserved.

Caring for the caregiver.

PubMed

Levy, Mitchell M

2004-07-01

There are certainly many coping behaviors that may assist ICU caregivers in the process of caring for themselves. Staff support groups,regular interdisciplinary meetings to discuss difficult cases,and bringing trained personnel into the intensive care unit (ICU)environment to offer staff training in communication and conflict resolution skills have been suggested as methods for alleviating caregiver stress. Combining these as well as other tools with a deeper look at the caregiver-patient relationship are important building blocks for creating a sane, healthy environment in the ICU. Over the next years, as the population ages, and as technologic advances continue, the critical care units will play an even more prominent role in health care. Given the threat posed by the severe nursing shortage, it becomes apparent that, to prepare for this increased need for critical care services, efforts must be directed to identify the sources of distress for ICU caregivers and develop focused training programs that alleviate the inevitably strains and pressures that arise in the process of compassionate caring for the critically ill.

Perceptions of diagnosis and management of patients with acute respiratory distress syndrome: a survey of United Kingdom intensive care physicians.

PubMed

Dushianthan, Ahilanandan; Cusack, Rebecca; Chee, Nigel; Dunn, John-Oliver; Grocott, Michael P W

2014-01-01

Acute respiratory distress syndrome (ARDS) is a potentially devastating refractory hypoxemic illness with multi-organ involvement. Although several randomised controlled trials into ventilator and fluid management strategies have provided level 1 evidence to guide supportive therapy, there are few, established guidelines on how to manage patients with ARDS. In addition, and despite their continued use, pharmacotherapies for ARDS disease modulation have no proven benefit in improving mortality. Little is known however about the variability in diagnostic and treatment practices across the United Kingdom (UK). The aim of this survey, therefore, was to assess the use of diagnostic criteria and treatment strategies for ARDS in critical care units across the UK. The survey questionnaire was developed and internally piloted at University Hospital Southampton NHS Foundation Trust. Following ethical approval from University of Southampton Ethics and Research Committee, a link to an online survey engine (Survey Monkey) was then placed on the Intensive Care Society (UK) website. Fellows of The Intensive Care Society were subsequently personally approached via e-mail to encourage participation. The survey was conducted over a period of 3 months. The survey received 191 responses from 125 critical care units, accounting for 11% of all registered intensive care physicians at The Intensive Care Society. The majority of the responses were from physicians managing general intensive care units (82%) and 34% of respondents preferred the American European Consensus Criteria for ARDS. There was a perceived decline in both incidence and mortality in ARDS. Primary ventilation strategies were based on ARDSnet protocols, though frequent deviations from ARDSnet positive end expiratory pressure (PEEP) recommendations (51%) were described. The majority of respondents set permissive blood gas targets (hypoxia (92%), hypercapnia (58%) and pH (90%)). The routine use of pharmacological agents is rare. Neuromuscular blockers and corticosteroids are considered occasionally and on a case-by-case basis. Routine (58%) or late (64%) tracheostomy was preferred to early tracheostomy insertion. Few centres offered routine follow-up or dedicated rehabilitation programmes following hospital discharge. There is substantial variation in the diagnostic and management strategies employed for patients with ARDS across the UK. National and/or international guidelines may help to improve standardisation in the management of ARDS.

Designing a complex intervention for dementia case management in primary care

PubMed Central

2013-01-01

Background Community-based support will become increasingly important for people with dementia, but currently services are fragmented and the quality of care is variable. Case management is a popular approach to care co-ordination, but evidence to date on its effectiveness in dementia has been equivocal. Case management interventions need to be designed to overcome obstacles to care co-ordination and maximise benefit. A successful case management methodology was adapted from the United States (US) version for use in English primary care, with a view to a definitive trial. Medical Research Council guidance on the development of complex interventions was implemented in the adaptation process, to capture the skill sets, person characteristics and learning needs of primary care based case managers. Methods Co-design of the case manager role in a single NHS provider organisation, with external peer review by professionals and carers, in an iterative technology development process. Results The generic skills and personal attributes were described for practice nurses taking up the case manager role in their workplaces, and for social workers seconded to general practice teams, together with a method of assessing their learning needs. A manual of information material for people with dementia and their family carers was also created using the US intervention as its source. Conclusions Co-design produces rich products that have face validity and map onto the complexities of dementia and of health and care services. The feasibility of the case manager role, as described and defined by this process, needs evaluation in ‘real life’ settings. PMID:23865537

Forward Aeromedical Evacuation: A Brief History, Lessons Learned from the Global War on Terror, and the Way Forward for US Policy

DTIC Science & Technology

2013-01-01

DUSTOFF and PEDRO units increased throughout the conflict and were con - sidered an unqualified success during the war; the DUSTOFF units alone would...direction was provided in most cases by general medical officers ( GMO ) serving with aviation units. These GMOs generally completed internships and were...awaiting placement into residency pro - grams. Their primary job was to provide routine medical care to the aviators in that unit. No standardized

Metformin-induced lactic acidosis: a case series.

PubMed

Silvestre, Joana; Carvalho, Susana; Mendes, Vitor; Coelho, Luis; Tapadinhas, Camila; Ferreira, Pedro; Povoa, Pedro; Ceia, Fatima

2007-10-31

Unlike other agents used in the treatment of type 2 diabetes mellitus, metformin has been shown to reduce mortality in obese patients. It is therefore being increasingly used in higher doses. The major concern of many physicians is a possible risk of lactic acidosis. The reported frequency of metformin related lactic acidosis is 0.05 per 1000 patient-years; some authors advocate that this rate is equal in those patients not taking metformin. We present two case reports of metformin-associated lactic acidosis. The first case is a 77 year old female with a past medical history of hypertension and type 2 diabetes mellitus who had recently been prescribed metformin (3 g/day), perindopril and acetylsalicylic acid. She was admitted to the emergency department two weeks later with abdominal pain and psychomotor agitation. Physical examination revealed only signs of poor perfusion. Laboratory evaluation revealed hyperkalemia, elevated creatinine and blood urea nitrogen and mild leukocytosis. Arterial blood gases showed severe lactic acidemia. She was admitted to the intensive care unit. Vasopressor and ventilatory support was initiated and continuous venovenous hemodiafiltration was instituted. Twenty-four hours later, full clinical recovery was observed, with return to a normal serum lactate level. The patient was discharged from the intensive care unit on the sixth day. The second patient is a 69 year old male with a past medical history of hypertension, type 2 diabetes mellitus and ischemic heart disease who was on metformin (4 g/day), glycazide, acetylsalicylic acid and isosorbide dinitrate. He was admitted to the emergency department in shock with extreme bradycardia. Initial evaluation revealed severe lactic acidosis and elevated creatinine and urea. The patient was admitted to the Intensive Care Unit and commenced on continuous venovenous hemodiafiltration in addition to other supportive measures. A progressive recovery was observed and he was discharged from the intensive care unit on the seventh day. We present two case reports of severe lactic acidosis most probably associated with high doses of metformin in patients with no known contraindications for metformin prescription. In both patients no other condition was identified to cause such severe lactic acidosis. Although controversial, lactic acidosis should be considered in patients taking metformin.

[Severe Plasmodium falciparum malaria. Description of 5 cases].

PubMed

Espinosa, G; Tortajada, C; Gascón, J; Miquel, R; Nicolás, J M; Nadal, P; Corachán, M

1997-09-01

In the last few years a considerable number of imported malaria has been reported in Spain, probably due the increased tourism to areas with endemic malaria, particularly with P. falciparum. This is the species more frequently associated with severe complications and the only one capable of causing cerebral malaria. In this report we review five cases of malaria which required intensive care because of their severity. None of the patients had received chemoprophylaxis. In all cases the admission criterion to the intensive care unit was the organic failure of one or more systems (renal failure and disseminated intravascular coagulation [DIC] mainly) or the presence of changes in the central nervous system. Parasitemia at admission was higher than 5% in all patients. One patient died on account of cerebral malaria. Only one patient had severe complications not directly associated with malaria. In patients who already have severity criteria, a negative parasitemia test during the clinical course does not necessarily implies a clinical improvement nor does it exclude the emergence of complications. On the other hand, a low parasitemic degree is never a contraindication for admission to the intensive care unit when severity criteria are present.

[Hematemesis in Togo: findings of a 12-month study in an intensive care unit].

PubMed

Djibril, A M; Tomta, K; Balaka, K; Bagny, A; M'ba, K B; Kaaga, L; Redah, D; Agbetra, A

2010-06-01

This prospective study was conducted over a 12-month period on patients who underwent upper digestive endoscopy for hematemesis in the medical intensive care unit (ICU) of the Tokoin University Hospital Center in Lomé, Togo. A total of 44 patients with a mean age of 44 years were included. The sex-ratio was 2.61. Risk factors included use of non-steroid anti-inflammatory (NSAI) in 16 patients (36.4%) and alcohol abuse in 13 (29.6%). At the time of admission to the ICU, 21 patients (47.7%) were in hemodynamic shock and 11 (25%) presented signs of portal hypertension. The underlying etiology was peptic ulcer in 18 cases (40.9%) including 13 cases of duodenal ulcer and 5 cases of stomach ulcer, rupture of esophageal varicosities in 8 (18.2%), gastric tumor in 6 (13.6%), Mallory Weiss syndrome in 5 (11.4%), gastritis in 4 (9,1%), and esophagitis in 3 (6.8%) due to peptic inflammation in 2 and mycotic infection in 1. The mortality rate was 45.5%. The main causes of hematemesis were peptic ulcer and rupture of esophageal varicosities. The death rate was high due to inadequate care facilities.

Shattered, Suffering, and Silenced: Sharon's Story.

PubMed

Shafer, Michaela R

2016-01-01

This chapter presents a case study of a 30-year-old female news reporter in Albuquerque, New Mexico, named Sharon Fullilove. The case is presented as a personal narrative by her mother, who is a critical care nurse, former chief nurse, Level I trauma unit commander, and colonel in the U.S. Air Force. The narrative is followed by excerpts from Sharon's chart that confirm a series of decisions made by both the hospital and the providers. The subsequent narrative is meant to give the reader an opportunity to reflect on the variety of clinical ethics questions that emerge when a patient enters into a contract with a physician and hospital for care. The goal is not to perform a thorough ethical analysis of the case but to let the reader experience what it is like when best practice standards, attention to patient care, and compassionate concern for family members are set aside. The case concludes with a set of broad questions that can be used for further discussion. Hopefully, this case will bring to the forefront the centrality of ethics in professional decision-making within the context of medical care.

Lessons from a national audit of acute pancreatitis: A summary of the NCEPOD report 'Treat the Cause'.

PubMed

O'Reilly, D A; McPherson, S J; Sinclair, M T; Smith, N

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an independent organisation whose remit is to review the quality of medical and surgical care provided in the United Kingdom. We undertook a review into the care provided to patients treated for acute pancreatitis during a 6 month study period between 1st January and 30th June 2014. This included assessment of care at an organisational level, clinical level within hospitals and external peer review. From a random sample, 712 patients underwent hospital clinician review and 418 patients had external peer review. Overall, we found that there was room for improvement in care in over 50% of patients with acute pancreatitis. Case reviewers felt that efforts to prevent recurrent episodes due to gallstones and alcohol were inadequate as 21% of patients in the study had one or more previous episodes of acute pancreatitis. Aspects of general care where improvements could be made include better antibiotic stewardship; as 1/5 of patients were considered to have been given antibiotics unnecessarily. Overall management of the patients' nutrition was considered adequate by the case reviewers in only 85% of cases. The use of an early warning score was omitted in 31% of emergency department admissions. Recommendations include standardised early warning scoring systems to be used throughout the hospital and commenced in the emergency department. The development of better networking arrangements and regional pancreatitis units, with shared management guidelines, is also essential to improve the coordination of care. Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Economic Evaluation of a General Hospital Unit for Older People with Delirium and Dementia (TEAM Randomised Controlled Trial).

PubMed

Tanajewski, Lukasz; Franklin, Matthew; Gkountouras, Georgios; Berdunov, Vladislav; Harwood, Rowan H; Goldberg, Sarah E; Bradshaw, Lucy E; Gladman, John R F; Elliott, Rachel A

2015-01-01

One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months. To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care. Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%). The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded. The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation. ClinicalTrials.gov NCT01136148.

Decrease in Staphylococcus aureus colonization and hospital-acquired infection in a medical intensive care unit after institution of an active surveillance and decolonization program.

PubMed

Fraser, Thomas G; Fatica, Cynthia; Scarpelli, Michele; Arroliga, Alejandro C; Guzman, Jorge; Shrestha, Nabin K; Hixson, Eric; Rosenblatt, Miriam; Gordon, Steven M; Procop, Gary W

2010-08-01

To evaluate the effects of an active surveillance program for Staphylococcus aureus linked to a decolonization protocol on the incidence of healthcare-associated infection and new nasal colonization due to S. aureus. Retrospective quasi-experimental study. An 18-bed medical intensive care unit at a tertiary care center in Cleveland, Ohio. From January 1, 2006, through December 31, 2007, all patients in the medical intensive care unit were screened for S. aureus nasal carriage at admission and weekly thereafter. During the preintervention period, January 1 through September 30, 2006, only surveillance occurred. During the intervention period, January 1 through December 31, 2007, S. aureus carriers received mupirocin intranasally. Beginning in February 2007, carriers also received chlorhexidine gluconate baths. During the preintervention period, 604 (73.7%) of 819 patients were screened for S. aureus nasal carriage, yielding 248 prevalent carriers (30.3%). During the intervention period, 752 (78.3%) of 960 patients were screened, yielding 276 carriers (28.8%). The incidence of S. aureus carriage decreased from 25 cases in 3,982 patient-days (6.28 cases per 1,000 patient-days) before intervention to 18 cases in 5,415 patient-days (3.32 cases per 1,000 patient-days) (P=.04; relative risk [RR], 0.53 [95% confidence interval {CI}, 0.28-0.97]) and from 9.57 to 4.77 cases per 1,000 at-risk patient-days (P=.02; RR, 0.50 [95% CI, 0.27-0.91]). The incidence of S. aureus hospital-acquired bloodstream infection during the 2 periods was 2.01 and 1.11 cases per 1,000 patient-days, respectively (P=.28). The incidence of S. aureus ventilator-associated pneumonia decreased from 1.51 to 0.18 cases per 1,000 patient-days (P=.03; RR, 0.12 [95% CI, 0.01-0.83]). The total incidence of S. aureus hospital-acquired infection decreased from 3.52 to 1.29 cases per 1,000 patient-days (P=.03; RR, 0.37 [95% CI, 0.14-0.90]). Active surveillance for S. aureus nasal carriage combined with decolonization was associated with a decreased incidence of S. aureus colonization and hospital-acquired infection.

The buck stops here: midwives and maternity care in rural Scotland.

PubMed

Harris, Fiona M; van Teijlingen, Edwin; Hundley, Vanora; Farmer, Jane; Bryers, Helen; Caldow, Jan; Ireland, Jillian; Kiger, Alice; Tucker, Janet

2011-06-01

To explore and understand what it means to provide midwifery care in remote and rural Scotland. Qualitative interviews with 72 staff from 10 maternity units, analysed via a case study approach. Remote and rural areas of Scotland. Predominantly midwives, with some additional interviews with paramedics, general surgeons, anaesthetists and GPs. Remote and rural maternity care includes a range of settings and models of care. However, the impact of rural geographies on decision-making and risk assessment is common to all settings. Making decisions and dealing with the implications of these decisions is, in many cases, done without onsite specialist support. This has implications for the skills and competencies that are needed to practice midwifery in remote and rural settings. Whereas most rural midwives reported that their skills in risk assessment and decisions to transfer were well developed and appropriate to practising in their particular settings, they perceived these decisions to be under scrutiny by urban-based colleagues and felt the need to stress their competence in the face of what they imagined to be stereotypes of rural incompetence. This study shows that skills in risk assessment and decision-making are central to high quality remote and rural midwifery care. However, linked to different perspectives on care, there is a risk that these skills can be undermined by contact with colleagues in large urban units, particularly when staff do not know each other well. There is a need to develop a professional understanding between midwives in different locations. It is important for the good working relationships between urban and rural maternity units that all midwives understand the importance of contextual knowledge in both decisions to transfer from rural locations and the position of midwives in receiving units. Multiprofessional CPD courses have been effective in bringing together teams around obstetric emergencies; we suggest that a similar format may be required in considering issues of transfer. Copyright © 2010 Elsevier Ltd. All rights reserved.

Prescription Pattern of Analgesic Drugs for Patients Receiving Palliative Care in a Teaching Hospital in India

PubMed Central

Menezes, Vishma Hydie; Nair, Shoba N; Soumya, MS; Tarey, SD

2016-01-01

Background: Drugs used in the palliative care unit for managing symptoms are major contributors toward the expenditure occurring in palliative care. This study was conducted to understand the prescription pattern of analgesic drugs in the patients who are receiving palliative care in a teaching hospital in India by a retrospective study of case records. Methods: Case record based, retrospective, descriptive study was conducted at the Pain and Palliative Care Department of St. John's Medical College Hospital, Bengaluru. Case record files of all patients referred to Pain and Palliative Care Department for the treatment of pain in the year of 2012 were studied. Patients’ age, gender, diagnoses, numerical pain rating scale (0–10), drugs prescribed, dosage, frequency, route of administration were recorded. The difference in drug utilization between the genders was done using Chi-square test. Data were collected from 502 patients of which 280 (56%) were males and 222 (44%) were females. Twelve percent of patients had mild pain (1–3), 34% had moderate pain (4–6), and 54% had severe pain (7–10). The most commonly used analgesic drugs were opioids (47%), followed by nonsteroidal anti-inflammatory drugs (36%). The opioids used were tramadol (56%), and morphine (38%). Ninety percent of patients with numerical pain scale more than 6 received morphine. There was no difference in analgesic drug utilization with regards to gender. Prescription pattern differed depending on the severity of pain. Opioids were the most commonly used drugs for pain management. Conclusion: The study shows that prescription pattern in palliative care unit of this hospital was in accordance with WHO pain management guidelines. The study showed the current trend in prescription of analgesic drugs in the teaching hospital where the study was conducted. PMID:26962282

[Seronin syndrome and cardiac arrest caused by high-dose moclobemide (case report)].

PubMed

Cekmen, N; Badalov, P; Erdemli, O

2008-01-01

Serotonin syndrome is the syndrome resulting from brain tissue serotonin accumulation and accompanying by central nervous system dysfunction and circulatory collapse, which leads to a serious mortal danger to life. A female patient aged 31 years, diagnosed as having chronic psychosis in the history, was admitted to an intensive care unit in a critical state for having taking an increased moclobemide dose. The patient developed cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated. A 15-minute CPR recovered sinus rhythm and pulse on the peripheral arteries of the limbs. When consciousness and respiration improved, the patient was weaned from resuscitation and extubated on the second day. On day 4, the patient was transferred from the intensive care unit to the department of psychiatry. The authors consider that patients with overdosage of antipsychotic agents at a risk for such serious complications, such as cardiac arrest, should be necessarily monitored in the intensive care unit.

ISO 9001 in a neonatal intensive care unit (NICU).

PubMed

Vitner, Gad; Nadir, Erez; Feldman, Michael; Yurman, Shmuel

2011-01-01

The aim of this paper is to present the process for approving and certifying a neonatal intensive care unit to ISO 9001 standards. The process started with the department head's decision to improve services quality before deciding to achieve ISO 9001 certification. Department processes were mapped and quality management mechanisms were developed. Process control and performance measurements were defined and implemented to monitor the daily work. A service satisfaction review was conducted to get feedback from families. In total, 28 processes and related work instructions were defined. Process yields showed service improvements. Family satisfaction improved. The paper is based on preparing only one neonatal intensive care unit to the ISO 9001 standard. The case study should act as an incentive for hospital managers aiming to improve service quality based on the ISO 9001 standard. ISO 9001 is becoming a recommended tool to improve clinical service quality.

Language Discordance and Patient-Centered Care in Occupational Therapy: A Case Study

PubMed Central

Martinez, Jenny; Leland, Natalie

2017-01-01

The accumulative burden of a growing non-English speaking minority population and health disparities in the United States demonstrate the urgency of examining occupational therapy practices and defining care that is timely, effective, safe, and patient-centered. In this context, we investigate an occupational therapy episode of care from the perspectives of patient, caregiver, and primary occupational therapy care provider. Treatment sessions were observed and one-on-one semi-structured interviews were conducted with the participants. Several themes describing areas of concern in communication and care delivery emerged, including expectations for care, the therapy relationship, professional identity, and pragmatic constraints. The use of untrained interpreters compromised treatment effectiveness and safety. This case highlights potential areas of concern in therapy when working with a diverse patient population. Abundant opportunities exist for occupational therapy to situate itself as an equitable, responsive, valuable, and essential service. PMID:26460475

Linkage to HIV, TB and Non-Communicable Disease Care from a Mobile Testing Unit in Cape Town, South Africa

PubMed Central

Govindasamy, Darshini; Kranzer, Katharina; van Schaik, Nienke; Noubary, Farzad; Wood, Robin; Walensky, Rochelle P.; Freedberg, Kenneth A.; Bassett, Ingrid V.; Bekker, Linda-Gail

2013-01-01

Background HIV counseling and testing may serve as an entry point for non-communicable disease screening. Objectives To determine the yield of newly-diagnosed HIV, tuberculosis (TB) symptoms, diabetes and hypertension, and to assess CD4 count testing, linkage to care as well as correlates of linkage and barriers to care from a mobile testing unit. Methods A mobile unit provided screening for HIV, TB symptoms, diabetes and hypertension in Cape Town, South Africa between March 2010 and September 2011. The yield of newly-diagnosed cases of these conditions was measured and clients were followed-up between January and November 2011 to assess linkage. Linkage to care was defined as accessing care within one, three or six months post-HIV diagnosis (dependent on CD4 count) and one month post-diagnosis for other conditions. Clinical and socio-demographic correlates of linkage to care were evaluated using Poisson regression and barriers to care were determined. Results Of 9,806 clients screened, the yield of new diagnoses was: HIV (5.5%), TB suspects (10.1%), diabetes (0.8%) and hypertension (58.1%). Linkage to care for HIV-infected clients, TB suspects, diabetics and hypertensives was: 51.3%, 56.7%, 74.1% and 50.0%. Only disclosure of HIV-positive status to family members or partners (RR=2.6, 95% CI: 1.04-6.3, p=0.04) was independently associated with linkage to HIV care. The main barrier to care reported by all groups was lack of time to access a clinic. Conclusion Screening for HIV, TB symptoms and hypertension at mobile units in South Africa has a high yield but inadequate linkage. After-hours and weekend clinics may overcome a major barrier to accessing care. PMID:24236170

The state of primary care in the United States of America and lessons for primary care groups in the United Kingdom.

PubMed

Koperski, M

2000-04-01

The health care system of the United States of America (USA) is lavishly funded and those with adequate insurance usually receive excellent attention. However, the system is fragmented and inequitable. Health workers often find it difficult to separate vocational roles from business roles. Care tends to focus on the acute rather than the chronic, on 'episodes of illness' rather than 'person-centred' care, on short-term fixes rather than long-term approaches, on scientific/technical solutions rather than discourse or the 'art of healing', and on individual health rather than population health. The majority of US doctors are trained in the 'hightech' hospital paradigm and there is no equivalent of the United Kingdom (UK) general practitioner (GP), who lies at the hub of a primary health care team (PHCT) and who is charged with taking a long-term view, co-ordinating health care for individual patients, and acting as patient advocate without major conflicting financial incentives. However, primary care groups/trusts (PCGs) could learn from US management and training techniques, case management, NHS Direct equivalents, and the effects of poorly developed PHCTs. PCGs could develop the UK's own version of utilisation management. A cash-limited, unified budget within an underfunded National Health Service poses threats to general practice. In both the USA and the UK, primary care is a prominent tool in new attempts at cost control. PCGs offer the opportunity of better integration with public health and social services, but threaten GPs' role as independent advocates by giving them a rationing role. Managed care has forced a similar role onto our US counterparts with consequent public displeasure and professional disillusion. UK GPs will have to steer a careful course if they are to avoid a similar fate.

Fetal laceration during caesarean section and its medico-legal sequelae.

PubMed

Esposito, Ciro; Escolino, Maria; Paternoster, Mariano; Buccelli, Claudio; Graziano, Vincenzo; Falco, Marianna; Alicchio, Francesca; Cerulo, Mariapina; Settimi, Alessandro; Savanelli, Antonio

2015-04-01

Fetal laceration is a recognized complication of caesarean delivery. The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal incised wounds during caesarean delivery. During a five-year period, we observed 25 cases of fetal lacerations caused by the scalpel during hysterotomy. In 20 of these cases, we observed these lesions as consultants for the Neonatologic Care Unit; the other five cases came under our care after an insurance claim for damages against the gynaecologist. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary, and only 16 of the 25 mothers had signed an informed consent before surgery. With regard to the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using single stitches in nine cases, and with biological glue in 11 cases. Concerning the five cases that underwent legal proceedings against the gynaecologist, a clinical examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon to evaluate the degree of biological damage. In all five cases, the result of the legal challenge was monetary compensation for the physical and moral damage caused by the gynaecologists to the patients and their parents. Accidental fetal lesions may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be informed about the risk of the occurrence of fetal lacerations during caesarean delivery in order to avoid legal complications. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Survey of Oxygen Delivery Practices in UK Paediatric Intensive Care Units

PubMed Central

Peters, Mark J.

2016-01-01

Purpose. Administration of supplemental oxygen is common in paediatric intensive care. We explored the current practice of oxygen administration using a case vignette in paediatric intensive care units (PICU) in the united kingdom. Methods. We conducted an online survey of Paediatric Intensive Care Society members in the UK. The survey outlined a clinical scenario followed by questions on oxygenation targets for 5 common diagnoses seen in critically ill children. Results. Fifty-three paediatric intensive care unit members from 10 institutions completed the survey. In a child with moderate ventilatory requirements, 21 respondents (42%) did not follow arterial partial pressure of oxygen (PaO2) targets. In acute respiratory distress syndrome, cardiac arrest, and sepsis, there was a trend to aim for lower PaO2 as the fraction of inspired oxygen (FiO2) increased. Conversely, in traumatic brain injury and pulmonary hypertension, respondents aimed for normal PaO2 even as the FiO2 increased. Conclusions. In this sample of clinicians PaO2 targets were not commonly used. Clinicians target lower PaO2 as FiO2 increases in acute respiratory distress syndrome, cardiac arrest, and sepsis whilst targeting normal range irrespective of FiO2 in traumatic brain injury and pulmonary hypertension. PMID:27516901

Transition from Clinical Manager to University Lecturer: A Self-Reflective Case Study

ERIC Educational Resources Information Center

Oldland, Elizabeth

2011-01-01

This paper is a case study exploring the author's use of reflective practice to facilitate the transition in role from a clinical manager with teaching responsibilities in a critical care unit to university lecturer. The similarities and differences in the roles with respect to learner characteristics, teaching contexts and effective teaching…

Actual and Potential Effects of Medical Resident Coverage on Reimbursement for Inpatient Visits by Attending Physicians

PubMed Central

Shine, Daniel; Jessen, Laurie; Bajaj, Jasmeet; Pencak, Dorothy; Panush, Richard

2002-01-01

CONTEXT The impact of residents on hospital finance has been studied; there are no data describing the economic effect of residents on attending physicians. OBJECTIVE In a community teaching hospital, we compared allowable inpatient visit codes and payments (based on documentation in the daily progress notes) between a general medicine teaching unit and nonteaching general medicine units. DESIGN Retrospective chart review, matched cohort study. SETTING Six hundred fifty–bed community teaching hospital. PATIENTS Patients were discharged July 1998 through February 1999 from Saint Barnabas Medical Center. We randomly selected 200 patients in quartets. Each quartet consisted of a pair of patients cared for by residents and a pair cared for only by an attending physician. In each pair, 1 of the patients was under the care of an attending physician who usually admitted to the teaching service, and 1 was under the care of a usually nonteaching attending. Within each quartet, patients were matched for diagnosis-related group, length of stay, and discharge date. MAIN OUTCOME MEASURES We assigned the highest daily visit code justifiable by resident and attending chart documentation, determining relative value units (RVUs) and reimbursements allowed by each patient's insurance company. RESULTS Although more seriously ill, teaching-unit patients generated a mean 1.75 RVUs daily, compared with 1.84 among patients discharged from nonteaching units (P = .3). Median reimbursement, daily and per hospitalization, was similar on teaching and nonteaching units. Nonteaching attendings documented higher mean daily RVUs than teaching attendings (1.83 vs 1.76, P = .2). Median allowable reimbursements were $267 per case ($53 daily) among teaching attendings compared with $294 per case ($58 daily) among nonteaching attendings (Z = 1.54, P = .1). When only the resident note was considered, mean daily RVUs increased 39% and median allowable dollars per day 27% (Z = 4.21, P < .001). CONCLUSIONS Nonteaching attendings appear to document their visits more carefully from a billing perspective than do teaching attendings. Properly counter-documented, resident notes could substantially increase payments to attending physicians. PMID:12133156

The impact of stroke unit care on outcome in a Scottish stroke population, taking into account case mix and selection bias.

PubMed

Turner, Melanie; Barber, Mark; Dodds, Hazel; Dennis, Martin; Langhorne, Peter; Macleod, Mary Joan

2015-03-01

Randomised trials indicate that stroke unit care reduces morbidity and mortality after stroke. Similar results have been seen in observational studies but many have not corrected for selection bias or independent predictors of outcome. We evaluated the effect of stroke unit compared with general ward care on outcomes after stroke in Scotland, adjusting for case mix by incorporating the six simple variables (SSV) model, also taking into account selection bias and stroke subtype. We used routine data from National Scottish datasets for acute stroke patients admitted between 2005 and 2011. Patients who died within 3 days of admission were excluded from analysis. The main outcome measures were survival and discharge home. Multivariable logistic regression was used to estimate the OR for survival, and adjustment was made for the effect of the SSV model and for early mortality. Cox proportional hazards model was used to estimate the hazard of death within 365 days. There were 41 692 index stroke events; 79% were admitted to a stroke unit at some point during their hospital stay and 21% were cared for in a general ward. Using the SSV model, we obtained a receiver operated curve of 0.82 (SE 0.002) for mortality at 6 months. The adjusted OR for survival at 7 days was 3.11 (95% CI 2.71 to 3.56) and at 1 year 1.43 (95% CI 1.34 to 1.54) while the adjusted OR for being discharged home was 1.19 (95% CI 1.11 to 1.28) for stroke unit care. In routine practice, stroke unit admission is associated with a greater likelihood of discharge home and with lower mortality up to 1 year, after correcting for known independent predictors of outcome, and excluding early non-modifiable mortality. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Kenya Hospices and Palliative Care Association: integrating palliative care in public hospitals in Kenya.

PubMed

Ali, Zipporah

2016-01-01

In Kenya, cancers as a disease group rank third as a cause of death after infectious and cardiovascular diseases. It is estimated that the annual incidence of cancer is about 37,000 new cases with an annual mortality of 28,000 cases (Kenya National Cancer Control Strategy 2010). The incidence of non-communicable diseases accounts for more than 50% of total hospital admissions and over 55% of hospital deaths (Kenya National Strategy for the Prevention and Control of Non Communicable Diseases 2015-2020). The prevalence of HIV is 6.8 (KIAS 2014). Most of these patients will benefit from palliative care services, hence the need to integrate palliative care services in the public healthcare system. The process of integrating palliative care in public hospitals involved advocacy both at the national level and at the institutional level, training of healthcare professionals, and setting up services within the hospitals that we worked with. Technical support was provided to each individual institution as needed. Eleven provincial hospitals across the country have now integrated palliative care services (Palliative Care Units) and are now centres of excellence. Over 220 healthcare providers have been trained, and approximately, over 30,000 patients have benefited from these services. Oral morphine is now available in the hospital palliative care units. As a success of the pilot project, Kenya Hospices and Palliative Care Association (KEHPCA) is now working with the Ministry of Health Kenya to integrate palliative care services in 30 other county hospitals across the country, thus ensuring more availability and access to more patients. Other developing countries can learn from Kenya's successful experience.

[Two cases of "scombroid syndrome" with severe cardiovascular compromise].

PubMed

Ascione, A; Barresi, L S; Sarullo, F M; De Silvestre, G

1997-12-01

Two cases of severe intoxication after ingestion of cooked tuna fish were observed. Symptoms and clinical signs were consistent with the scombroid syndrome. Cardiovascular shock was observed in both patients and was associated with subendocardial myocardial infarction in 1 case and acute pulmonary edema with myocardial ischemia in the other. The importance of ECG monitoring in the Intensive Coronary Care Unit is stressed.

[Description of patients with confirmed influenza A(H1N1)pdm09 admitted to an intensive care unit and identification of severity risk factors].

PubMed

Payet, C; Lutringer-Magnin, D; Cassier, P; Lina, B; Argaud, L; Allaouchiche, B; Vanhems, P

2013-02-01

The authors had for objective to describe patients with confirmed influenza A(H1N1)pdm09 admitted to an intensive care unit (ICU) in a university hospital and to identify risk factors correlated with the severity of the disease. A prospective study was conducted in an university hospital during the A(H1N1)pdm09 influenza pandemic. Severe laboratory confirmed cases (admitted to an ICU) were described and compared with non-severe confirmed cases (not admitted to an ICU). Sixty-nine patients were included; 36 (52%) were 15 to 44 years of age. Sixteen (23%) cases were defined as severe, ten of these (63%) concerned patients 45 to 64 years of age. The independent factors associated with severity were: a history of heart disease, obesity, and tobacco abuse. This work reinforces the need to identify and protect groups at risk of severe outcomes. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

[Legionella pneumonia--a case report].

PubMed

Marques, A S; Estrada, M H

2005-01-01

Legionella, as a cause of community-acquired pneumonia, is probably under-recognized because the diagnosis relies on the use of specific tests as well the existence of an in-numerous species and serogroups not easily identify by the tests available. In studies from Europe and North America, it ranged from 2 to 15 percent of all community-acquired pneumonias that required hospitalisation, in the first four causes when culture methods were done and the second cause of those admitted in the intensive care units. We do a case report of 43 year-old man with history of cigarette smoking and corticosteroid therapy for a ocular disease, that presents with a pneumonia complicated with a Acute Respiratory Distress Syndrome (ARDS), that leaded to his admission to an intensive care unit were he was mechanical ventilated. The epidemiological investigation identified Legionella pneumophila serogroup 1. The authors present this case doing a brief review of this disease and discussing the epidemiology, clinical features, laboratory diagnosis as well as therapeutic options.

Effects of reflection on clinical decision-making of intensive care unit nurses.

PubMed

Razieh, Shahrokhi; Somayeh, Ghafari; Fariba, Haghani

2018-07-01

Nurses are one of the most influential factors in overcoming the main challenges faced by health systems throughout the world. Every health system should, hence, empower nurses in clinical judgment and decision-making skills. This study evaluated the effects of implementing Tanner's reflection method on clinical decision-making of nurses working in an intensive care unit (ICU). This study used an experimental, pretest, posttest design. The setting was the intensive care unit of Amin Hospital Isfahan, Iran. The convenience sample included 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). This clinical trial was performed on 60 nurses working in the ICU of Amin Hospital (Isfahan, Iran). The nurses were selected by census sampling and randomly allocated to either the case or the control group. Data were collected using a questionnaire containing demographic characteristics and the clinical decision-making scale developed by Laurie and Salantera (NDMI-14). The questionnaire was completed before and one week after the intervention. The data were analyzed using SPSS 21.0. The two groups were not significantly different in terms of the level and mean scores of clinical decision-making before the intervention (P = 0.786). Based on the results of independent t-test, the mean score of clinical decision-making one week after the intervention was significantly higher in the case group than in the control group (P = 0.009; t = -2.69). The results of Mann Whitney test showed that one week after the intervention, the nurses' level of clinical decision-making in the case group rose to the next level (P = 0.001). Reflection could improve the clinical decision-making of ICU nurses. It is, thus, recommended to incorporate this method into the nursing curriculum and care practices. Copyright © 2018. Published by Elsevier Ltd.

Instituting Parent Education Practices in the Neonatal Intensive Care Unit: An Administrative Case Report of Practice Evaluation and Statewide Action

PubMed Central

Van Drew, Catherine M.; Brown, Shaaron E.

2012-01-01

Background and Purpose Infants born preterm are at high risk of developmental disabilities and benefit from early developmental intervention programs. Physical therapists with neonatal expertise are ideally suited to educate parents about ways to support their infant's development in the first months of life. However, administrative policies are needed to support the therapist in providing adequate parent education in the neonatal intensive care unit (NICU). This administrative case report describes the process used by a team of neonatal therapists to evaluate clinical practice, determine the need for change, and develop and implement a new parent education program in the NICU. Case Description Physical therapy parent education practices were evaluated in an academic medical center with a 36-bed, level-3 NICU. Physical therapists with neonatal expertise covered multiple units within the hospital each day. A series of focus groups, a small descriptive study, and staff discussion were used to evaluate parent education practices in this academic medical center. A new parent education program was developed based on data collected and literature to improve clinical care. Outcomes The new parent education model was implemented over the course of several months using overlapping initiatives. Administrative support for the change was developed through collaboration, open communication, and presentation of clinical data. In addition, this hospital-based program contributed to the development of a statewide initiative to educate parents of preterm infants about the importance of supporting development in the first months of life. Discussion A collaborative and data-driven approach to evaluating parent education practices supported the development of a new parent education practice while acknowledging the need to meet staff productivity standards and provide excellent care throughout the hospital. PMID:22466024

[Applying the Modified Delphi Technique to Develop the Role of HIV Case Managers and Essential Nursing Competencies in HIV Care].

PubMed

Ko, Nai-Ying; Hsieh, Chia-Yin; Chen, Yen-Chin; Tsai, Chen-Hsi; Liu, Hsiao-Ying; Liu, Li-Fang

2015-08-01

Since 2005, the Taiwan Centers for Disease Control (Taiwan CDC) initiated an HIV case management program in AIDS-designated hospitals to provide integrative services and risk-reduction counseling for HIV-infected individuals. In light of the increasingly complex and highly specialized nature of clinical care, expanding and improving competency-based professional education is important to enhance the quality of HIV/AIDS care. The aim of this study was to develop the essential competency framework for HIV care for HIV case managers in Taiwan. We reviewed essential competencies of HIV care from Canada, the United Kingdom, and several African countries and devised descriptions of the roles of case managers and of the associated core competencies for HIV care in Taiwan. The modified Delphi technique was used to evaluate the draft framework of these roles and core competencies. A total of 15 HIV care experts were invited to join the expert panel to review and rank the draft framework. The final framework consisted of 7 roles and 27 competencies for HIV case managers. In Round 1, only 3 items did not receive consensus approval from the experts. After modification based on opinions of the experts, 7 roles and 27 competencies received 97.06% consensus approval in Round 2 and were organized into the final framework for HIV case managers. These roles and associated core competencies were: HIV Care Expert (9 competencies), Communicator (1 competency), Collaborator (4 competencies), Navigator (2 competencies), Manager (4 competencies), Advocate (2 competencies), and Professional (5 competencies). The authors developed an essential competency framework for HIV care using the consensus of a multidisciplinary expert panel. Curriculum developers and advanced nurses and practitioners may use this framework to support developments and to ensure a high quality of HIV care.

[Evacuation plan of an intensive care unit: a new quality indicator?].

PubMed

Sánchez-Palacios, M; Lorenzo Torrent, R; Santana-Cabrera, L; Martín García, J A; Campos, S G; Carrasco de Miguel, V

2010-04-01

The intensive care units must be prepared for a possible disaster, whether internal or external, in case it becomes necessary to evacuate the in-patients. They must have an Emergency and Self-protection Plan that includes the patient evacuation criteria and this must be known by all the personnel who work in the service. For that reason, the patients must be triaged, based on their attention priorities, according to their survival possibilities. Having an evacuation, known by all the personnel and updated by means of the performance of periodic drills, should be included as a quality indicator that must be met, since this would achieve better attention to the patient in case of a disaster situation requiring the evacuation of the ICU. Copyright 2009 Elsevier España, S.L. y SEMICYUC. All rights reserved.

Impact of case volume on survival of septic shock in patients with malignancies.

PubMed

Zuber, Benjamin; Tran, Thi-Chien; Aegerter, Philippe; Grimaldi, David; Charpentier, Julien; Guidet, Bertrand; Mira, Jean-Paul; Pène, Frédéric

2012-01-01

Septic shock is a frequent and severe complication in the course of malignancies. In a large multicenter cohort of septic shock patients with hematologic malignancies and solid tumors, we assessed the temporal trend in survival and the prognostic factors, with particular emphasis on case volume. A 12-yr multicenter retrospective cohort study of prospectively collected data. Cancer patients with septic shock were selected over a 12-yr period (1997-2008) from a French regional database (CUB-Réa). The following variables were extracted: demographic characteristics, type of malignancy, characteristics of infection, severity-of-illness score (Simplified Acute Physiology Score II), organ failure supports, and vital status. For each unit, a running mean annual volume of admissions was calculated for the purpose of categorization into volume tertiles. Prognostic factors were analyzed by a conditional multivariate logistic model after matching on a propensity score of being admitted to a high-volume unit and on the year of admission. None. A total of 3,437 patients were included in the study. The intensive care unit mortality rate dramatically dropped over time (from 70.4% in 1997 to 52.5% in 2008, relative decrease 25.4%, p < .001). Participating units were distributed into low-volume (< five patients per year), medium-volume (five to 12 patients per year), and high-volume (≥ 13 patients per year) tertiles. A medical cause for intensive care unit admission, Simplified Acute Physiology Score II, invasive mechanical ventilation, renal replacement therapy, fungal infections, and unknown microorganism were identified as poor prognostic factors. Case volume demonstrated a strong influence on survival, admission in a high-volume unit being associated with a marked decrease in mortality as compared to low-volume units (adjusted odds ratio 0.63; 95% confidence interval [0.46-0.87], p = .002). Survival of septic shock patients with malignancies markedly increased over the recent years. Furthermore, we identified case volume as a major prognostic factor in this setting.

A Case Study of the Environmental Experience of a Hospitalized Newborn Infant With Complex Congenital Heart Disease.

PubMed

Daniels, Jacki M; Harrison, Tondi M

2016-01-01

Infants with complex congenital heart disease are at high risk for developmental delays. Although the etiology of these delays is multifactorial, the physical environment may be a contributory factor. Extensive studies have been conducted in neonatal intensive care units measuring environmental influences on development, resulting in policy and practice changes. Cardiothoracic intensive care units and cardiac step-down units are new environments in which newborns with heart disease receive care. No environmental studies have been conducted in units caring for newborn infants recovering from cardiac surgery. The aim of this study is to examine the environmental experience of a newborn infant with heart disease after surgical intervention within the first month of life. Measurements of illumination, sound levels, and sleep were recorded on 1 infant for 2 consecutive postoperative days in the cardiothoracic intensive care unit and 2 consecutive days in the step-down unit. Although average daily noise exposure remained below recommended guidelines on 3 of 4 days, the infant experienced intermittent periods of excessive noise (≥55 dBA) during 59 of 87 hours and 110 episodes of acute noise events greater than 70 dBA. Average daily light exposure was below the recommended guidelines. However, light levels were more than twice the recommended levels at multiple points daily. For each of the 4 observation days, the infant experienced 66 to 102 awakenings during sleep, and sleep durations were less than 30 minutes 90% of the time. This study provides the first report of potential environmental stressors in newborn infants cared for in cardiac specialty units. Excessive levels of light and noise as well as frequent interruptions for medical and nursing care may contribute to disorganized sleep and increased patient distress and may impact subsequent neurodevelopment. Studies are needed to identify potentially adverse aspects of the intensive caregiving environment for newborn infants who have undergone cardiac surgery.

Accuracy of a continuous noninvasive hemoglobin monitor in intensive care unit patients.

PubMed

Frasca, Denis; Dahyot-Fizelier, Claire; Catherine, Karen; Levrat, Quentin; Debaene, Bertrand; Mimoz, Olivier

2011-10-01

To determine whether noninvasive hemoglobin measurement by Pulse CO-Oximetry could provide clinically acceptable absolute and trend accuracy in critically ill patients, compared to other invasive methods of hemoglobin assessment available at bedside and the gold standard, the laboratory analyzer. Prospective study. Surgical intensive care unit of a university teaching hospital. Sixty-two patients continuously monitored with Pulse CO-Oximetry (Masimo Radical-7). None. Four hundred seventy-one blood samples were analyzed by a point-of-care device (HemoCue 301), a satellite lab CO-Oximeter (Siemens RapidPoint 405), and a laboratory hematology analyzer (Sysmex XT-2000i), which was considered the reference device. Hemoglobin values reported from the invasive methods were compared to the values reported by the Pulse CO-Oximeter at the time of blood draw. When the case-to-case variation was assessed, the bias and limits of agreement were 0.0±1.0 g/dL for the Pulse CO-Oximeter, 0.3±1.3g/dL for the point-of-care device, and 0.9±0.6 g/dL for the satellite lab CO-Oximeter compared to the reference method. Pulse CO-Oximetry showed similar trend accuracy as satellite lab CO-Oximetry, whereas the point-of-care device did not appear to follow the trend of the laboratory analyzer as well as the other test devices. When compared to laboratory reference values, hemoglobin measurement with Pulse CO-Oximetry has absolute accuracy and trending accuracy similar to widely used, invasive methods of hemoglobin measurement at bedside. Hemoglobin measurement with pulse CO-Oximetry has the additional advantages of providing continuous measurements, noninvasively, which may facilitate hemoglobin monitoring in the intensive care unit.

Deaths associated with insertion of nasogastric tubes for enteral nutrition in the medical intensive care unit: Clinical and autopsy findings

PubMed Central

Smith, Avery L.; Santa Ana, Carol A.; Fordtran, John S.; Guileyardo, Joseph M.

2018-01-01

ABSTRACT It is generally assumed that blind insertion of nasogastric tubes for enteral nutrition in patients admitted to medical intensive care units is safe; that is, does not result in life-threatening injury. If death occurs in temporal association with insertion of a nasogastric tube, caregivers typically attribute it to underlying diseases, with little or no consideration of iatrogenic death due to tube insertion. The clinical and autopsy results in three recent cases at Baylor University Medical Center challenge the validity of these notions. PMID:29904295

A blueprint for transforming stroke rehabilitation care in Canada: the case for change.

PubMed

Teasell, Robert W; Foley, Norine C; Salter, Katherine L; Jutai, Jeffrey W

2008-03-01

Stroke is a major source of disability in Canada and other developed countries, which carries with it a high toll in terms of personal suffering for the stroke survivor and their family in addition to the associated economic costs. Despite the impressive body of evidence describing effective and feasible stroke rehabilitation practices, stroke survivors, their families, and health professionals currently do not benefit from a rehabilitation system that is well organized and evidence based. Using the principles of best evidence, we make the case for needed changes to the current system based on 5 processes of care known to be important in the pursuit of optimal outcomes: (1) admission to specialized stroke rehabilitation units, (2) early admission to stroke rehabilitation units, (3) intensive stroke rehabilitation therapies, (4) task-specific rehabilitation therapies, and (5) well-resourced outpatient programs. Implementation of these strategies will be expected to result in improved functional gain, fewer complications, decreased mortality, and reduced need for institutionalization. In addition to providing improved care for both the stroke survivor and their family, evidence-based stroke rehabilitation care is more efficient and may reduce costs. Our experience in Canada suggests that instituting these 5 measures alone will result in significant improvements to the health care system.

Complex clinical reasoning in the critical care unit - difficulties, pitfalls and adaptive strategies.

PubMed

Shaw, M; Singh, S

2015-04-01

Diagnostic error has implications for both clinical outcome and resource utilisation, and may often be traced to impaired data gathering, processing or synthesis because of the influence of cognitive bias. Factors inherent to the intensive/acute care environment afford multiple additional opportunities for such errors to occur. This article illustrates many of these with reference to a case encountered on our intensive care unit. Strategies to improve completeness of data gathering, processing and synthesis in the acute care environment are critically appraised in the context of early detection and amelioration of cognitive bias. These include reflection, targeted simulation training and the integration of social media and IT based aids in complex diagnostic processes. A framework which can be quickly and easily employed in a variety of clinical environments is then presented. © 2015 John Wiley & Sons Ltd.

Core guidelines for the discharge home of the child on long term assisted ventilation in the United Kingdom

PubMed Central

Jardine, E.; Wallis, C.

1998-01-01

Paediatric home ventilation is a feasible option and can be successful in a wide range of conditions and ages. Advances in ventilator technology and an ethos of optimism for home care has increased the possibilities for discharging chronically ventilated children from intensive care units and acute medical beds. With careful planning the process can succeed, but difficulties often thwart the responsible team, especially when attempting discharge for the first time. These core guidelines aim to assist a smooth, swift and successful transfer. They were developed by a working party of interested professionals spanning a wide range of health care disciplines and represent a synthesis of views accumulated from the experiences of individual teams throughout the UK. Three case scenarios provide further illustrative detail and guidance.

 PMID:10319058

Two decades (1993-2012) of adult intensive care unit design: a comparative study of the physical design features of the best practice examples.

PubMed

Rashid, Mahbub

2014-01-01

In 2006, Critical Care Nursing Quarterly published a study of the physical design features of a set of best practice example adult intensive care units (ICUs). These adult ICUs were awarded between 1993 and 2003 by the Society of Critical Care Medicine (SCCM), the American Association of Critical-Care Nurses, and the American Institute of Architects/Academy of Architecture for Health for their efforts to promote the critical care unit environment through design. Since 2003, several more adult ICUs were awarded by the same organizations for similar efforts. This study includes these newer ICUs along with those of the previous study to cover a period of 2 decades from 1993 to 2012. Like the 2006 study, this study conducts a systematic content analysis of the materials submitted by the award-winning adult ICUs. On the basis of the analysis, the study compares the 1993-2002 and 2003-2012 adult ICUs in relation to construction type, unit specialty, unit layout, unit size, patient room size and design, support and service area layout, and family space design. The study also compares its findings with the 2010 Guidelines for Design and Construction of Health Care Facilities of the Facility Guidelines Institute and the 2012 Guidelines for Intensive Care Unit Design of the SCCM. The study indicates that the award-winning ICUs of both decades used several design features that were associated with positive outcomes in research studies. The study also indicates that the award-winning ICUs of the second decade used more evidence-based design features than those of the first decades. In most cases, these ICUs exceeded the requirements of the Facility Guidelines Institute Guidelines to meet those of the SCCM Guidelines. Yet, the award-winning ICUs of both decades also used several features that had very little or no supporting research evidence. Since they all were able to create an optimal critical care environment for which they were awarded, having knowledge of the physical design of these award-winning ICUs may help design better ICUs.

Burden of Clostridium difficile infection in the United States.

PubMed

Lessa, Fernanda C; Mu, Yi; Bamberg, Wendy M; Beldavs, Zintars G; Dumyati, Ghinwa K; Dunn, John R; Farley, Monica M; Holzbauer, Stacy M; Meek, James I; Phipps, Erin C; Wilson, Lucy E; Winston, Lisa G; Cohen, Jessica A; Limbago, Brandi M; Fridkin, Scott K; Gerding, Dale N; McDonald, L Clifford

2015-02-26

The magnitude and scope of Clostridium difficile infection in the United States continue to evolve. In 2011, we performed active population- and laboratory-based surveillance across 10 geographic areas in the United States to identify cases of C. difficile infection (stool specimens positive for C. difficile on either toxin or molecular assay in residents ≥ 1 year of age). Cases were classified as community-associated or health care-associated. In a sample of cases of C. difficile infection, specimens were cultured and isolates underwent molecular typing. We used regression models to calculate estimates of national incidence and total number of infections, first recurrences, and deaths within 30 days after the diagnosis of C. difficile infection. A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care-associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 (95% confidence interval [CI], 397,100 to 508,500). The incidence was estimated to be higher among females (rate ratio, 1.26; 95% CI, 1.25 to 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 to 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 to 9.31). The estimated number of first recurrences of C. difficile infection was 83,000 (95% CI, 57,000 to 108,900), and the estimated number of deaths was 29,300 (95% CI, 16,500 to 42,100). The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care-associated infections than among community-associated infections (30.7% vs. 18.8%, P<0.001). C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011. (Funded by the Centers for Disease Control and Prevention.).

[Factors affecting the recovery in the intensive care unit].

PubMed

Turkov, P N; Nikitin, V V; Antsupova, M A; Podkopaev, V N; Panfilova, R P; Ivanova, I N; Nesterova, L I

2013-01-01

Urgency of the problem is defined by economical, regulatory and legislative acts, regional social and moral factors. There is critical situation in Russian Pediatric Healthcare system. This situation is due to inadequate funding, high medical technologies inaccessibility for some Russian children, their adverse health state. The article presents a retrospective analysis of intensive therapy and resuscitation outcomes with technical equipment and work environment assessment in the intensive care unit of Tushinskaya city pediatric clinic for the period from 2007 to 2011. Anaesthetic and emergency care quality and safety depend on several factors: permanent equipment improvement, comprehensive analysis of every fatal case and full implementation of "Anti-epidemic (prophylactic) actions plan" and "Program of monitoring compliance with the sanitary norms".

Accelerated recovery after cardiac operations.

PubMed

Kaplan, Mehmet; Kut, Mustafa Sinan; Yurtseven, Nurgul; Cimen, Serdar; Demirtas, Mahmut Murat

2002-01-01

The accelerated-recovery approach, involving early extubation, early mobility, decreased duration of intensive care unit stay, and decreased duration of hospitalization has recently become a controversial issue in cardiac surgery. We investigated timing of extubation, length of intensive care unit stay, and duration of hospitalization in 225 consecutive cardiac surgery patients. Of the 225 patients, 139 were male and 86 were female; average age was 49.73 +/- 16.95 years. Coronary artery bypass grafting was performed in 127 patients; 65 patients underwent aortic and/or mitral or pulmonary valvular operations; 5 patients underwent valvular plus coronary artery operations; and in 28 patients surgical interventions for congenital anomalies were carried out. The accelerated-recovery approach could be applied in 169 of the 225 cases (75.11%). Accelerated-recovery patients were extubated after an average of 3.97 +/- 1.59 hours, and the average duration of stay in the intensive care unit was 20.93 +/- 2.44 hours for these patients. Patients were discharged if they met all of the following criteria: hemodynamic stability, cooperativeness, ability to initiate walking exercises within wards, lack of pathology in laboratory investigations, and psychological readiness for discharge. Mean duration of hospitalization for accelerated-recovery patients was 4.24 +/- 0.75 days. Two patients (1.18%) who were extubated within the first 6 hours required reintubation. Four patients (2.36%) who were sent to the wards returned to intensive care unit due to various reasons and 6 (3.55%) of the discharged patients were rehospitalized. Approaches for decreasing duration of intubation, intensive care unit stay and hospitalization may be applied in elective and uncomplicated cardiac surgical interventions with short duration of aortic cross-clamping and cardiopulmonary bypass, without risking patients. Frequencies of reintubation, return to intensive care unit, and rehospitalization are quite low with this approach.

A Critical Analysis of Foster Youth Advisory Boards in the United States

ERIC Educational Resources Information Center

Forenza, Brad; Happonen, Robin G.

2016-01-01

Background: The enactment of the John H. Chafee Foster Care Independence Act brought welcome attention to young people aging out of foster care, and sought to include them in both case planning and policy dialog. Foster Youth Advisory Boards help to promote such inclusion, though the implementation of those boards has not been formally analyzed.…

A Conceptual Model for Youth-Led Programs as a Promising Approach to Early Childhood Care and Education

ERIC Educational Resources Information Center

Ponguta, Liliana Angelica; Rasheed, Muneera Abdul; Reyes, Chin Regina; Yousafzai, Aisha Khizar

2018-01-01

The international community has set forth global targets that include calls for universal access to high-quality early childhood care and education (ECCE), as indicated in the United Nations' Sustainable Development Goals. One major impediment to achieving this target is the lack of a skilled workforce. In this paper, we argue the case for…

The evaluation of complex interventions in palliative care: an exploration of the potential of case study research strategies.

PubMed

Walshe, Catherine

2011-12-01

Complex, incrementally changing, context dependent and variable palliative care services are difficult to evaluate. Case study research strategies may have potential to contribute to evaluating such complex interventions, and to develop this field of evaluation research. This paper explores definitions of case study (as a unit of study, a process, and a product) and examines the features of case study research strategies which are thought to confer benefits for the evaluation of complex interventions in palliative care settings. Ten features of case study that are thought to be beneficial in evaluating complex interventions in palliative care are discussed, drawing from exemplars of research in this field. Important features are related to a longitudinal approach, triangulation, purposive instance selection, comprehensive approach, multiple data sources, flexibility, concurrent data collection and analysis, search for proving-disproving evidence, pattern matching techniques and an engaging narrative. The limitations of case study approaches are discussed including the potential for subjectivity and their complex, time consuming and potentially expensive nature. Case study research strategies have great potential in evaluating complex interventions in palliative care settings. Three key features need to be exploited to develop this field: case selection, longitudinal designs, and the use of rival hypotheses. In particular, case study should be used in situations where there is interplay and interdependency between the intervention and its context, such that it is difficult to define or find relevant comparisons.

Experiences of four parents with physical therapy and early mobility of their children in a pediatric critical care unit: A case series.

PubMed

Parisien, Rachel B; Gillanders, Kirstie; Hennessy, Erin K; Herterich, Lisa; Saunders, Kendra; Lati, Jamil; Dos Santos, Stephanie; Hassall, Alison; O'Brien, Kelly K

2016-05-31

The aim of this study was to conduct a preliminary investigation into parents' experiences of physical therapy and early mobility (EM) for their children in a pediatric critical care unit (PCCU). We conducted a series of four qualitative case studies using in-depth semi-structured face-to-face interviews. We recruited parents of children who had undergone surgery and received at least one EM physical therapy intervention while intubated. We conducted a thematic analysis of transcribed interviews to illuminate the factors that influenced EM experiences. Four parents participated in the study. We developed an overview of Parental Experiences with Physical Therapy and Early Mobility in a PCCU, which includes four themes that parents believed influenced their experiences: (1) environmental factors; (2) awareness of physical therapist and health care professional (HCP) roles; (3) communication among parents and HCPs; and (4) parental participation in their child's EM, within the overarching parental experiences in the PCCU. This study affords a preliminary understanding of parents' experiences with physical therapy and EM in a PCCU setting. Results provide an important foundation for future research on mobility in the context of pediatric critical care research and practice.

Technology that achieves the Triple Aim: an economic analysis of the BrainPath™ approach in neurosurgery

PubMed Central

Norton, Sidney P; Dickerson, Evan M; Kulwin, Charles G; Shah, Mitesh V

2017-01-01

Background The Triple Aim is defined as: improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care. The purpose of this analysis was to evaluate the economic value of a new neurosurgical technique, the BrainPath™ approach, for use in patients with subcortical tumors and intracerebral hemorrhage (ICH). Methods Inpatient length of stay (LOS) data were collected for ICH and brain tumor surgical patient cases between August 2013 and November 2015. Patient cases were separated into two groups; BrainPath approach (n = 28) and conventional techniques, such as craniotomy, (n = 208). The average intensive care unit (ICU) LOS was calculated for each group by diagnosis-related group and compared between groups. Results The new surgical technology resulted in surgical intervention in 14 ICH cases which otherwise would have been medically managed due to the hemorrhage location or size of the ICH. A reduction in ICU LOS was seen in this group. Based on the variable direct cost per day in the neuro critical care unit at this academic medical center, 14 patient cases incurred ~ US$210,000 less in direct ICU costs. Surgical resection was possible in two tumor patient cases which would have been biopsied, rather than surgically resected, also due to location of the abnormalities. A total net value of > US$329,000 is attributable to the analyzed approach over a 28-month period. Conclusion This analysis shows positive economic value for the new technology group when ICU LOS and reimbursement are considered against equipment costs, thus achieving Triple Aim objectives. PMID:28894384

Pressure Injury Development in Patients Treated by Critical Care Air Transport Teams: A Case-Control Study.

PubMed

Dukes, Susan F; Maupin, Genny M; Thomas, Marilyn E; Mortimer, Darcy L

2018-04-01

The US Air Force transports critically ill patients from all over the world, with transport times commonly ranging from 6 to 11 hours. Few outcome measures have been tracked for these patients. Traditional methods to prevent pressure injuries in civilian hospitals are often not feasible in the military transport environment. The incidence rate and risk factors are described of en route-related pressure injuries for patients overseen by the Critical Care Air Transport Team. This retrospective, case-control, medical records review investigated risk factors for pressure injury in patients who developed a pressure injury after their transport flight compared with those with no documented pressure injuries. The pressure injury rate was 4.9%. Between 2008 and 2012, 141 patients in whom pressure injuries developed and who had received care by the team were matched with 141 patients cared for by the team but did not have pressure injury. According to regression analysis, body mass index and 2 or more Critical Care Air Transport Team transports per patient were associated with pressure injury development. Although the pressure injury rate of 4.9% in this cohort of patients is consistent with that reported by civilian critical care units, the rate must be interpreted with caution, because civilian study data frequently represent the entire intensive care unit length of stay. Targeted interventions for patients with increased body mass index and 2 or more critical care air transports per patient may help decrease the development of pressure injury in these patients. ©2018 American Association of Critical-Care Nurses.

Patterns of Unit and Item Nonresponse in the CAHPS® Hospital Survey

PubMed Central

Elliott, Marc N; Edwards, Carol; Angeles, January; Hambarsoomians, Katrin; Hays, Ron D

2005-01-01

Objective To examine the predictors of unit and item nonresponse, the magnitude of nonresponse bias, and the need for nonresponse weights in the Consumer Assessment of Health Care Providers and Systems (CAHPS®) Hospital Survey. Methods A common set of 11 administrative variables (41 degrees of freedom) was used to predict unit nonresponse and the rate of item nonresponse in multivariate models. Descriptive statistics were used to examine the impact of nonresponse on CAHPS Hospital Survey ratings and reports. Results Unit nonresponse was highest for younger patients and patients other than non-Hispanic whites (p<.001); item nonresponse increased steadily with age (p<.001). Fourteen of 20 reports of ratings of care had significant (p<.05) but small negative correlations with nonresponse weights (median −0.06; maximum −0.09). Nonresponse weights do not improve overall precision below sample sizes of 300–1,000, and are unlikely to improve the precision of hospital comparisons. In some contexts, case-mix adjustment eliminates most observed nonresponse bias. Conclusions Nonresponse weights should not be used for between-hospital comparisons of the CAHPS Hospital Survey, but may make small contributions to overall estimates or demographic comparisons, especially in the absence of case-mix adjustment. PMID:16316440

Implementing Value-Based Payment Reform: A Conceptual Framework and Case Examples.

PubMed

Conrad, Douglas A; Vaughn, Matthew; Grembowski, David; Marcus-Smith, Miriam

2016-08-01

This article develops a conceptual framework for implementation of value-based payment (VBP) reform and then draws on that framework to systematically examine six distinct multi-stakeholder coalition VBP initiatives in three different regions of the United States. The VBP initiatives deploy the following payment models: reference pricing, "shadow" primary care capitation, bundled payment, pay for performance, shared savings within accountable care organizations, and global payment. The conceptual framework synthesizes prior models of VBP implementation. It describes how context, project objectives, payment and care delivery strategies, and the barriers and facilitators to translating strategy into implementation affect VBP implementation and value for patients. We next apply the framework to six case examples of implementation, and conclude by discussing the implications of the case examples and the conceptual framework for future practice and research. © The Author(s) 2015.

An evaluation of the diagnostic accuracy of the 1991 American College of Chest Physicians/Society of Critical Care Medicine and the 2001 Society of Critical Care Medicine/European Society of Intensive Care Medicine/American College of Chest Physicians/American Thoracic Society/Surgical Infection Society sepsis definition.

PubMed

Zhao, Huifang; Heard, Stephen O; Mullen, Marie T; Crawford, Sybil; Goldberg, Robert J; Frendl, Gyorgy; Lilly, Craig M

2012-06-01

Limited research has been conducted to compare the test characteristics of the 1991 and 2001 sepsis consensus definitions. This study assessed the accuracy of the two sepsis consensus definitions among adult critically ill patients compared to sepsis case adjudication by three senior clinicians. Observational study of patients admitted to intensive care units. Seven intensive care units of an academic medical center. A random sample of 960 patients from all adult intensive care unit patients between October 2007 and December 2008. None. Sensitivity, specificity, and the area under the receiver operating characteristic curve for the two consensus definitions were calculated by comparing the number of patients who met or did not meet consensus definitions vs. the number of patients who were or were not diagnosed with sepsis by adjudication. The 1991 sepsis definition had a high sensitivity of 94.6%, but a low specificity of 61.0%. The 2001 sepsis definition had a slightly increased sensitivity but a decreased specificity, which were 96.9% and 58.3%, respectively. The areas under the receiver operating characteristic curve for the two definitions were not statistically different (0.778 and 0.776, respectively). The sensitivities and areas under the receiver operating characteristic curve of both definitions were lower at the 24-hr time window level than those of the intensive care unit stay level, though their specificities increased slightly. Fever, high white blood cell count or immature forms, low Glasgow coma score, edema, positive fluid balance, high cardiac index, low PaO2/FIO2 ratio, and high levels of creatinine and lactate were significantly associated with sepsis by both definitions and adjudication. Both the 1991 and the 2001 sepsis definition have a high sensitivity but low specificity; the 2001 definition has a slightly increased sensitivity but a decreased specificity compared to the 1991 definition. The diagnostic performances of both definitions were suboptimal. A parsimonious set of significant predictors for sepsis diagnosis is likely to improve current sepsis case definitions.

Multi-purpose HealthCare Telemedicine Systems with mobile communication link support.

PubMed

Kyriacou, E; Pavlopoulos, S; Berler, A; Neophytou, M; Bourka, A; Georgoulas, A; Anagnostaki, A; Karayiannis, D; Schizas, C; Pattichis, C; Andreou, A; Koutsouris, D

2003-03-24

The provision of effective emergency telemedicine and home monitoring solutions are the major fields of interest discussed in this study. Ambulances, Rural Health Centers (RHC) or other remote health location such as Ships navigating in wide seas are common examples of possible emergency sites, while critical care telemetry and telemedicine home follow-ups are important issues of telemonitoring. In order to support the above different growing application fields we created a combined real-time and store and forward facility that consists of a base unit and a telemedicine (mobile) unit. This integrated system: can be used when handling emergency cases in ambulances, RHC or ships by using a mobile telemedicine unit at the emergency site and a base unit at the hospital-expert's site, enhances intensive health care provision by giving a mobile base unit to the ICU doctor while the telemedicine unit remains at the ICU patient site and enables home telemonitoring, by installing the telemedicine unit at the patient's home while the base unit remains at the physician's office or hospital. The system allows the transmission of vital biosignals (3-12 lead ECG, SPO2, NIBP, IBP, Temp) and still images of the patient. The transmission is performed through GSM mobile telecommunication network, through satellite links (where GSM is not available) or through Plain Old Telephony Systems (POTS) where available. Using this device a specialist doctor can telematically "move" to the patient's site and instruct unspecialized personnel when handling an emergency or telemonitoring case. Due to the need of storing and archiving of all data interchanged during the telemedicine sessions, we have equipped the consultation site with a multimedia database able to store and manage the data collected by the system. The performance of the system has been technically tested over several telecommunication means; in addition the system has been clinically validated in three different countries using a standardized medical protocol.

Patient and Family Experience: A Comparison of Intensive Care and Overall Hospitalization.

PubMed

Lah, Soowhan; Wilson, Emily L; Rozenblum, Ronen; Hirshberg, Eliotte L; Hopkins, Ramona O; Orme, James; Brown, Samuel M

2017-05-01

The Hospital Consumer Assessment of Healthcare Providers and Systems survey is the most commonly used instrument for measuring patients' perceptions of the quality of inpatient care. To determine if the hospital survey can also be used to measure patients' experience of intensive care as indicated by scores on a parallel questionnaire, the Patient Perception of Quality. Scores on both instruments of all adult patients admitted to an intensive care unit from 2007 through 2012 were analyzed. A total of 1766 matching pairs of hospital and critical care surveys were identified. Patients' ratings of the overall hospital and critical care experiences had low correlation: r = 0.32 (95% CI, 0.28-0.37). Using the standard reporting convention, 77% of the participants rated the hospital as 9 or 10 on a 10-point scale, and 65% rated the intensive care unit as 5 on a 5-point scale. Although the hospital survey was always completed by the patient, the critical care survey was completed by a patient's family member or friend in 76% of cases and by the patient in 24%. Patient-completed critical care surveys had more correlation with hospital surveys ( r = 0.45) than did critical care surveys completed by family members ( r = 0.30), but the overall correlation remained modest. Scores on the hospital survey were at best modestly associated with scores on the critical care survey and did not reflect the specific experiences of patients and patients' families in the intensive care unit. ©2017 American Association of Critical-Care Nurses.

Clinical parameters that predict the need for medium or intensive care admission in intentional drug overdose patients: A retrospective cohort study.

PubMed

van den Oever, Huub L A; van Dam, Mirja; van 't Riet, Esther; Jansman, Frank G A

2017-02-01

Many patients with intentional drug overdose (IDO) are admitted to a medium (MC) or intensive care unit (IC) without ever requiring MC/IC related interventions. The objective of this study was to develop a decision tool, using parameters readily available in the emergency room (ER) for patients with an IDO, to identify patients requiring admission to a monitoring unit. Retrospective cohort study among cases of IDO with drugs having potentially acute effects on neurological, circulatory or ventilatory function, admitted to the MC/IC unit between 2007 and 2013. A decision tool was developed, using 6 criteria, representing intubation, breathing, oxygenation, cardiac conduction, blood pressure, and consciousness. Cases were labeled as 'high acuity' if one or more criteria were present. Among 255 cases of IDO that met the inclusion criteria, 197 were identified as "high acuity". Only 70 of 255 cases underwent one or more MC/IC related interventions, of which 67 were identified as 'high acuity by the decision tool (sensitivity 95.7%). In a population of patients with intentional drug overdose with agents having potentially acute effect on vital functions, 95.7% of MC/IC interventions could be predicted by clinical assessment, supplemented with electrocardiogram and blood gas analysis, in the ER. Copyright © 2016 Elsevier Inc. All rights reserved.

Creating advantages through franchising in healthcare: a qualitative, multiple embedded case study on the role of the business format.

PubMed

Nijmeijer, Karlijn J; Huijsman, Robbert; Fabbricotti, Isabelle N

2014-11-02

Business format franchising is an organizational form that originates from the business sector. It is increasingly used in healthcare, being a promising organizational form for improving the competitiveness and efficiency of organizations, the quality of care, and the professional work environment. However, evidence is lacking concerning how these healthcare franchises should be designed to actually deliver the promised benefits. This study explores how the design of the central element in franchising, the business format (i.e., brand name, support systems, specification of the products and services), helps or hinders the achievement of positive results. A qualitative comparative embedded case study was conducted. The cases focused on three Dutch healthcare franchises providing mental healthcare, hospital care and care for the intellectually disabled. The data were collected through document analyses, observations, and 96 in-depth, semi-structured interviews with franchisors and unit actors (franchisees, unit managers, professionals). The interviews were recorded and transcribed verbatim. A conceptual model based on a systematic review of studies in other industries was used as an initial method for coding the data. New inductive codes were used to enrich and extend the analysis. The data were subjected to within-case and cross-case comparative thematic analyses. Different business format designs have different effects on results, as perceived by franchisors and unit actors. The analysis revealed how this variation in perceived effects can be explained by different dynamics with regard to system-wide adaptation, local adaptation, professionals' resistance to change, ease of knowledge sharing, bureaucracy, overhead, uniform brand presentation, accelerating effects and reliable performance levels. The analysis resulted in a new typology of four types of business formats, showing how combinations of business format elements facilitate or hinder the achievement of different types of results. Practitioners using healthcare franchising as a model to improve client-related, strategic, organizational and professional results should carefully consider how to design their business format in order to facilitate the achievement of desired results. The developed typology can be used as a starting point for these practitioners and as a basis for future scholarly research. Further quantitative research is recommended to confirm the results.

Experience of Adjunct Novice Clinical Nursing Faculty: An Interpretive Case Study

ERIC Educational Resources Information Center

Mann, Carol

2013-01-01

The purpose of this qualitative interpretive case study was to describe the experience of adjunct novice clinical nursing faculty who has less than three years teaching experience or feels novice in this setting. The nursing shortage in the United States is well documented and is forecasted to have significant impacts on the health care delivery…

Improvement of antibiotic therapy and ICU survival in severe non-pneumococcal community-acquired pneumonia: a matched case-control study.

PubMed

Gattarello, Simone; Lagunes, Leonel; Vidaur, Loreto; Solé-Violán, Jordi; Zaragoza, Rafael; Vallés, Jordi; Torres, Antoni; Sierra, Rafael; Sebastian, Rosa; Rello, Jordi

2015-09-10

We aimed to compare intensive care unit mortality due to non-pneumococcal severe community-acquired pneumonia between the periods 2000-2002 and 2008-2014, and the impact of the improvement in antibiotic strategies on outcomes. This was a matched case-control study enrolling 144 patients with non-pneumococcal severe pneumonia: 72 patients from the 2000-2002 database (CAPUCI I group) were paired with 72 from the 2008-2014 period (CAPUCI II group), matched by the following variables: microorganism, shock at admission, invasive mechanical ventilation, immunocompromise, chronic obstructive pulmonary disease, and age over 65 years. The most frequent microorganism was methicillin-susceptible Staphylococcus aureus (22.1%) followed by Legionella pneumophila and Haemophilus influenzae (each 20.7%); prevalence of shock was 59.7%, while 73.6% of patients needed invasive mechanical ventilation. Intensive care unit mortality was significantly lower in the CAPUCI II group (34.7% versus 16.7%; odds ratio (OR) 0.78, 95% confidence interval (CI) 0.64-0.95; p = 0.02). Appropriate therapy according to microorganism was 91.5% in CAPUCI I and 92.7% in CAPUCI II, while combined therapy and early antibiotic treatment were significantly higher in CAPUCI II (76.4 versus 90.3% and 37.5 versus 63.9%; p < 0.05). In the multivariate analysis, combined antibiotic therapy (OR 0.23, 95% CI 0.07-0.74) and early antibiotic treatment (OR 0.07, 95% CI 0.02-0.22) were independently associated with decreased intensive care unit mortality. In non-pneumococcal severe community-acquired pneumonia , early antibiotic administration and use of combined antibiotic therapy were both associated with increased intensive care unit survival during the study period.

Clinical Profile of Hypertensive Emergencies in an Intensive Care Unit.

PubMed

Dhadke, Shubhangi V; Dhadke, Vithal N; Batra, Dhruv S

2017-05-01

To study the prevalence of hypertensive emergencies in an ICU set up and to study the clinical presentation of hypertensive emergencies related to cardiovascular, neurological and renovascular system. Type of Study: Cross-sectional, descriptive study. Two years from 1st December 2011 till 30th November 2013. 50 patients of hypertensive emergencies admitted to the intensive care unit of Dr. V.M. Govt. Medical College, Solapur were studied. Inclusion criteria All patients above 18 years of age. Systolic blood pressure > 180 mmHg Diastolic blood pressure > 120 mm Hg Exclusion criteria Pregnancy Patients with diabetes mellitus We classified as hypertensive emergencies all cases in which the increase in blood pressure was associated with one or more of the following types of acute or ongoing end-organ damage: hypertensive encephalopathy; stroke (cerebral infarction or intracerebral or subarachnoid hemorrhage, transient ischemic attack); acute pulmonary edema, left ventricular failure; acute myocardial infarction or unstable angina, progressive renal insufficiency features suggestive of retinopathy. All these conditions were diagnosed clinically or by approprriate diagnostic tests. most common presenting complaint in patients was breathlessness seen in 17 patients (34%), followed by neurological deficit in 14 patients (28%). Thirteen patients (26%) had complaints of headache, whereas 12 (24%) patients complained of chest pain on admission. Other symptoms included vomiting, giddiness, psychomotor agitation, and decreased urine output. Out of a total of 4076 admissions during the study period in the intensive care unit we had 50 cases of hypertensive emergencies with prevalence of 1.22% in our intensive care unit. Most common organ involvement was the retina followed by cardiovascular system, renal and then the central nervous system.

Variability of cutaneous and nasal population levels between patients colonized and infected by multidrug-resistant bacteria in two Brazilian intensive care units.

PubMed

Damaceno, Quésia; Nicoli, Jacques R; Oliveira, Adriana

2015-01-01

To compare cutaneous and nasal population levels between patients colonized and infected by multidrug-resistant organisms in two intensive care units. A prospective cohort study was performed in adult intensive care units of two hospitals in Belo Horizonte, Brazil (April 2012 to February 2013). Clinical and demographic data were first collected by reviewing patients' charts. Then, samples collected with nasal, groin, and perineum swabs were cultivated in selective media for 48 h at 37°C. After isolation, determination of antimicrobial susceptibility and biochemical identification were performed. A total of 53 cases of colonization were observed by the following bacteria in decreasing frequencies: imipenem-resistant Acinetobacter baumannii (50.9%), vancomycin-resistant Enterococcus faecalis (43.4%), extended-spectrum beta-lactamase-producing Klebsiella pneumoniae (37.7%), imipenem-resistant Pseudomonas aeruginosa (32.1%), oxacillin-resistant Staphylococcus aureus (7.5%), and imipenem-resistant Klebsiella pneumoniae (5.7%). Among these colonization cases, 26 (49.0%) were followed by infection with bacteria phenotypically similar to those of the colonization. A relation between high population levels of colonization by most of the multidrug-resistant organisms at anatomical sites and a subsequent infection was observed. After colonization/infection, bacterial population levels decreased progressively and spontaneously until disappearance by day 45 in all the anatomical sites and for all the multidrug-resistant organisms. There was a correlation between high population levels of colonization by multidrug-resistant organisms at anatomical sites and a subsequent infection. Reduction in multidrug-resistant organism populations after colonization at anatomical sites could be a preventive measure to reduce evolution to infection as well as transmission of these bacteria between patients in intensive care unit.

Risk factors for hospital-associated venous thromboembolism in critically ill children following cardiothoracic surgery or therapeutic cardiac catheterisation.

PubMed

Atchison, Christie M; Amankwah, Ernest; Wilhelm, Jean; Arlikar, Shilpa; Branchford, Brian R; Stock, Arabela; Streiff, Michael; Takemoto, Clifford; Ayala, Irmel; Everett, Allen; Stapleton, Gary; Jacobs, Marshall L; Jacobs, Jeffrey P; Goldenberg, Neil A

2018-02-01

Paediatric hospital-associated venous thromboembolism is a leading quality and safety concern at children's hospitals. The aim of this study was to determine risk factors for hospital-associated venous thromboembolism in critically ill children following cardiothoracic surgery or therapeutic cardiac catheterisation. We conducted a retrospective, case-control study of children admitted to the cardiovascular intensive care unit at Johns Hopkins All Children's Hospital (St. Petersburg, Florida, United States of America) from 2006 to 2013. Hospital-associated venous thromboembolism cases were identified based on ICD-9 discharge codes and validated using radiological record review. We randomly selected two contemporaneous cardiovascular intensive care unit controls without hospital-associated venous thromboembolism for each hospital-associated venous thromboembolism case, and limited the study population to patients who had undergone cardiothoracic surgery or therapeutic cardiac catheterisation. Odds ratios and 95% confidence intervals for associations between putative risk factors and hospital-associated venous thromboembolism were determined using univariate and multivariate logistic regression. Among 2718 admissions to the cardiovascular intensive care unit during the study period, 65 met the criteria for hospital-associated venous thromboembolism (occurrence rate, 2%). Restriction to cases and controls having undergone the procedures of interest yielded a final study population of 57 hospital-associated venous thromboembolism cases and 76 controls. In a multiple logistic regression model, major infection (odds ratio=5.77, 95% confidence interval=1.06-31.4), age ⩽1 year (odds ratio=6.75, 95% confidence interval=1.13-160), and central venous catheterisation (odds ratio=7.36, 95% confidence interval=1.13-47.8) were found to be statistically significant independent risk factors for hospital-associated venous thromboembolism in these children. Patients with all three factors had a markedly increased post-test probability of having hospital-associated venous thromboembolism. Major infection, infancy, and central venous catheterisation are independent risk factors for hospital-associated venous thromboembolism in critically ill children following cardiothoracic surgery or cardiac catheter-based intervention, which, in combination, define a high-risk group for hospital-associated venous thromboembolism.

Prevalence of syphilis in pregnancy and prenatal syphilis testing in Brazil: birth in Brazil study.

PubMed

Domingues, Rosa Maria Soares Madeira; Szwarcwald, Celia Landmann; Souza Junior, Paulo Roberto Borges; Leal, Maria do Carmo

2014-10-01

Determine the coverage rate of syphilis testing during prenatal care and the prevalence of syphilis in pregnant women in Brazil. This is a national hospital-based cohort study conducted in Brazil with 23,894 postpartum women between 2011 and 2012. Data were obtained using interviews with postpartum women, hospital records, and prenatal care cards. All postpartum women with a reactive serological test result recorded in the prenatal care card or syphilis diagnosis during hospitalization for childbirth were considered cases of syphilis in pregnancy. The Chi-square test was used for determining the disease prevalence and testing coverage rate by region of residence, self-reported skin color, maternal age, and type of prenatal and child delivery care units. Prenatal care covered 98.7% postpartum women. Syphilis testing coverage rate was 89.1% (one test) and 41.2% (two tests), and syphilis prevalence in pregnancy was 1.02% (95% CI 0.84; 1.25). A lower prenatal coverage rate was observed among women in the North region, indigenous women, those with less education, and those who received prenatal care in public health care units. A lower testing coverage rate was observed among residents in the North, Northeast, and Midwest regions, among younger and non-white skin-color women, among those with lower education, and those who received prenatal care in public health care units. An increased prevalence of syphilis was observed among women with < 8 years of education (1.74%), who self-reported as black (1.8%) or mixed (1.2%), those who did not receive prenatal care (2.5%), and those attending public (1.37%) or mixed (0.93%) health care units. The estimated prevalence of syphilis in pregnancy was similar to that reported in the last sentinel surveillance study conducted in 2006. There was an improvement in prenatal care and testing coverage rate, and the goals suggested by the World Health Organization were achieved in two regions. Regional and social inequalities in access to health care units, coupled with other gaps in health assistance, have led to the persistence of congenital syphilis as a major public health problem in Brazil.

Prevalence of syphilis in pregnancy and prenatal syphilis testing in Brazil: Birth in Brazil study

PubMed Central

Domingues, Rosa Maria Soares Madeira; Szwarcwald, Celia Landmann; Souza, Paulo Roberto Borges; Leal, Maria do Carmo

2014-01-01

OBJECTIVE Determine the coverage rate of syphilis testing during prenatal care and the prevalence of syphilis in pregnant women in Brazil. METHODS This is a national hospital-based cohort study conducted in Brazil with 23,894 postpartum women between 2011 and 2012. Data were obtained using interviews with postpartum women, hospital records, and prenatal care cards. All postpartum women with a reactive serological test result recorded in the prenatal care card or syphilis diagnosis during hospitalization for childbirth were considered cases of syphilis in pregnancy. The Chi-square test was used for determining the disease prevalence and testing coverage rate by region of residence, self-reported skin color, maternal age, and type of prenatal and child delivery care units. RESULTS Prenatal care covered 98.7% postpartum women. Syphilis testing coverage rate was 89.1% (one test) and 41.2% (two tests), and syphilis prevalence in pregnancy was 1.02% (95%CI 0.84;1.25). A lower prenatal coverage rate was observed among women in the North region, indigenous women, those with less education, and those who received prenatal care in public health care units. A lower testing coverage rate was observed among residents in the North, Northeast, and Midwest regions, among younger and non-white skin-color women, among those with lower education, and those who received prenatal care in public health care units. An increased prevalence of syphilis was observed among women with < 8 years of education (1.74%), who self-reported as black (1.8%) or mixed (1.2%), those who did not receive prenatal care (2.5%), and those attending public (1.37%) or mixed (0.93%) health care units. CONCLUSIONS The estimated prevalence of syphilis in pregnancy was similar to that reported in the last sentinel surveillance study conducted in 2006. There was an improvement in prenatal care and testing coverage rate, and the goals suggested by the World Health Organization were achieved in two regions. Regional and social inequalities in access to health care units, coupled with other gaps in health assistance, have led to the persistence of congenital syphilis as a major public health problem in Brazil. PMID:25372167

Women's experience of transfer from midwifery unit to hospital obstetric unit during labour: a qualitative interview study.

PubMed

Rowe, Rachel E; Kurinczuk, Jennifer J; Locock, Louise; Fitzpatrick, Ray

2012-11-15

Midwifery units offer care to women with straightforward pregnancies, but unforeseen complications can arise during labour or soon after birth, necessitating transfer to a hospital obstetric unit. In England, 21% of women planning birth in freestanding midwifery units are transferred; in alongside units, the transfer rate is 26%. There is little high quality contemporary evidence on women's experience of transfer. We carried out a qualitative interview study, using semi-structured interviews, with women who had been transferred from a midwifery unit (freestanding or alongside) in England up to 12 months prior to interview. Maximum variation sampling was used. Interviews with 30 women took place between March 2009 and March 2010. Thematic analysis using constant comparison and exploration of deviant cases was carried out. Most women hoped for or expected a natural birth and did not expect to be transferred. Transfer was disappointing for many; sensitive and supportive care and preparation for the need for transfer helped women adjust to their changing circumstances. A small number of women, often in the context of prolonged labour, described transfer as a relief. For women transferred from freestanding units, the ambulance journey was a "limbo" period. Women wondered, worried or were fearful about what was to come and could be passive participants who felt like they were being "transported" rather than cared for. For many this was a direct contrast with the care they experienced in the midwifery unit. After transfer, most women appreciated the opportunity to talk about their experience to make sense of what happened and help them plan for future pregnancies, but did not necessarily seek this out if it was not offered. Transfer affects a significant minority of women planning birth in midwifery units and is therefore a concern for women and midwives. Transfer is not expected by women, but sensitive care and preparation can help women adjust to changing circumstances. Particular sensitivity around decision-making may be required by midwives caring for women during prolonged labour. Some apparently straightforward changes to practice have the potential to make an important difference to women's experience of ambulance transfer.

Women’s experience of transfer from midwifery unit to hospital obstetric unit during labour: a qualitative interview study

PubMed Central

2012-01-01

Background Midwifery units offer care to women with straightforward pregnancies, but unforeseen complications can arise during labour or soon after birth, necessitating transfer to a hospital obstetric unit. In England, 21% of women planning birth in freestanding midwifery units are transferred; in alongside units, the transfer rate is 26%. There is little high quality contemporary evidence on women’s experience of transfer. Methods We carried out a qualitative interview study, using semi-structured interviews, with women who had been transferred from a midwifery unit (freestanding or alongside) in England up to 12 months prior to interview. Maximum variation sampling was used. Interviews with 30 women took place between March 2009 and March 2010. Thematic analysis using constant comparison and exploration of deviant cases was carried out. Results Most women hoped for or expected a natural birth and did not expect to be transferred. Transfer was disappointing for many; sensitive and supportive care and preparation for the need for transfer helped women adjust to their changing circumstances. A small number of women, often in the context of prolonged labour, described transfer as a relief. For women transferred from freestanding units, the ambulance journey was a “limbo” period. Women wondered, worried or were fearful about what was to come and could be passive participants who felt like they were being “transported” rather than cared for. For many this was a direct contrast with the care they experienced in the midwifery unit. After transfer, most women appreciated the opportunity to talk about their experience to make sense of what happened and help them plan for future pregnancies, but did not necessarily seek this out if it was not offered. Conclusions Transfer affects a significant minority of women planning birth in midwifery units and is therefore a concern for women and midwives. Transfer is not expected by women, but sensitive care and preparation can help women adjust to changing circumstances. Particular sensitivity around decision-making may be required by midwives caring for women during prolonged labour. Some apparently straightforward changes to practice have the potential to make an important difference to women’s experience of ambulance transfer. PMID:23153261

Ketamine for Analgosedation in the Intensive Care Unit: A Systematic Review.

PubMed

Patanwala, Asad E; Martin, Jennifer R; Erstad, Brian L

2017-07-01

To evaluate the evidence for the use of intravenous ketamine for analgosedation in the intensive care unit. MEDLINE and EMBASE were queried from inception until July 2015. Search terms used included ketamine, intensive care, and critical care. The search retrieved 584 articles to be screened for inclusion. The intent was to include randomized controlled studies using sustained intravenous infusions (>24 hours) of ketamine in the critically ill patients. One trial evaluated opioid consumption as an outcome in postoperative critically ill patients who were randomized to ketamine or saline infusions. The mean cumulative morphine consumption at 48 hours was significantly lower in the ketamine group (58 ± 35 mg) compared to the morphine-only group (80 ± 37 mg; P < .05). Other trials showed the potential safety of ketamine in terms of cerebral hemodynamics in patients with traumatic brain injury, improved gastrointestinal motility, and decreased vasopressor requirements. The observational study and case reports suggest that ketamine is safe and effective and may have a role in patients who are refractory to other therapies. Ketamine use may decrease analgesic consumption in the intensive care unit. Additional trials are needed to further delineate the role of ketamine for analgosedation.

An evaluation of the clinical and cost-effectiveness of alternative care locations for critically ill adult patients with acute traumatic brain injury.

PubMed

Grieve, R; Sadique, Z; Gomes, M; Smith, M; Lecky, F E; Hutchinson, P J A; Menon, D K; Rowan, K M; Harrison, D A

2016-08-01

For critically ill adult patients with acute traumatic brain injury (TBI), we assessed the clinical and cost-effectiveness of: (a) Management in dedicated neurocritical care units versus combined neuro/general critical care units within neuroscience centres. (b) 'Early' transfer to a neuroscience centre versus 'no or late' transfer for those who present at a non-neuroscience centre. The Risk Adjustment In Neurocritical care (RAIN) Study included prospective admissions following acute TBI to 67 UK adult critical care units during 2009-11. Data were collected on baseline case-mix, mortality, resource use, and at six months, Glasgow Outcome Scale Extended (GOSE), and quality of life (QOL) (EuroQol 5D-3L). We report incremental effectiveness, costs and cost per Quality-Adjusted Life Year (QALY) of the alternative care locations, adjusting for baseline differences with validated risk prediction models. We tested the robustness of results in sensitivity analyses. Dedicated neurocritical care unit patients (N = 1324) had similar six-month mortality, higher QOL (mean gain 0.048, 95% CI -0.002 to 0.099) and increased average costs compared with those managed in combined neuro/general units (N = 1341), with a lifetime cost per QALY gained of £14,000. 'Early' transfer to a neuroscience centre (N = 584) was associated with lower mortality (odds ratio 0.52, 0.34-0.80), higher QOL for survivors (mean gain 0.13, 0.032-0.225), but positive incremental costs (£15,001, £11,123 to £18,880) compared with 'late or no transfer' (N = 263). The lifetime cost per QALY gained for 'early' transfer was £11,000. For critically ill adult patients with acute TBI, within neuroscience centres management in dedicated neurocritical care units versus combined neuro/general units led to improved QoL and higher costs, on average, but these differences were not statistically significant. This study finds that 'early' transfer to a neuroscience centre is associated with reduced mortality, improvement in QOL and is cost-effective.

Maintaining Professional Nursing Boundaries in the Pediatric Home Care Setting.

PubMed

Petosa, Sarah Diane

Pediatric home care nurses often become a valuable part of the family unit, and this can blur the professional boundary between nurse and patient. Home care professionals must educate themselves as well as patients and family members about the integrity of their professional relationship, and prevent boundary crossing before it occurs. This article highlights four case studies that describe situations of boundary crossing that could have been managed differently. Strategies for maintaining professional boundaries with patients and their families are provided.

Vital Signs: Health Care–Associated Legionnaires’ Disease Surveillance Data from 20 States and a Large Metropolitan Area — United States, 2015

PubMed Central

Barskey, Albert E.; Shah, Priti P.; Schrag, Stephanie; Whitney, Cynthia G.; Arduino, Matthew J.; Reddy, Sujan C.; Kunz, Jasen M.; Hunter, Candis M.; Raphael, Brian H.; Cooley, Laura A.

2017-01-01

Background Legionnaires’ disease, a severe pneumonia, is typically acquired through inhalation of aerosolized water containing Legionella bacteria. Legionella can grow in the complex water systems of buildings, including health care facilities. Effective water management programs could prevent the growth of Legionella in building water systems. Methods Using national surveillance data, Legionnaires’ disease cases were characterized from the 21 jurisdictions (20 U.S. states and one large metropolitan area) that reported exposure information for ≥90% of 2015 Legionella infections. An assessment of whether cases were health care–associated was completed; definite health care association was defined as hospitalization or long-term care facility residence for the entire 10 days preceding symptom onset, and possible association was defined as any exposure to a health care facility for a portion of the 10 days preceding symptom onset. All other Legionnaires’ disease cases were considered unrelated to health care. Results A total of 2,809 confirmed Legionnaires’ disease cases were reported from the 21 jurisdictions, including 85 (3%) definite and 468 (17%) possible health care–associated cases. Among the 21 jurisdictions, 16 (76%) reported 1–21 definite health care–associated cases per jurisdiction. Among definite health care–associated cases, the majority (75, 88%) occurred in persons aged ≥60 years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term care facilities). The case fatality rate was 25% for definite and 10% for possible health care–associated Legionnaires’ disease. Conclusions and Implications for Public Health Practice Exposure to Legionella from health care facility water systems can result in Legionnaires’ disease. The high case fatality rate of health care–associated Legionnaires’ disease highlights the importance of case prevention and response activities, including implementation of effective water management programs and timely case identification. PMID:28594788

Scaling up paediatric HIV care with an integrated, family-centred approach: an observational case study from Uganda.

PubMed

Luyirika, Emmanuel; Towle, Megan S; Achan, Joyce; Muhangi, Justus; Senyimba, Catherine; Lule, Frank; Muhe, Lulu

2013-01-01

Family-centred HIV care models have emerged as an approach to better target children and their caregivers for HIV testing and care, and further provide integrated health services for the family unit's range of care needs. While there is significant international interest in family-centred approaches, there is a dearth of research on operational experiences in implementation and scale-up. Our retrospective case study examined best practices and enabling factors during scale-up of family-centred care in ten health facilities and ten community clinics supported by a non-governmental organization, Mildmay, in Central Uganda. Methods included key informant interviews with programme management and families, and a desk review of hospital management information systems (HMIS) uptake data. In the 84 months following the scale-up of the family-centred approach in HIV care, Mildmay experienced a 50-fold increase of family units registered in HIV care, a 40-fold increase of children enrolled in HIV care, and nearly universal coverage of paediatric cotrimoxazole prophylaxis. The Mildmay experience emphasizes the importance of streamlining care to maximize paediatric capture. This includes integrated service provision, incentivizing care-seeking as a family, creating child-friendly service environments, and minimizing missed paediatric testing opportunities by institutionalizing early infant diagnosis and provider-initiated testing and counselling. Task-shifting towards nurse-led clinics with community outreach support enabled rapid scale-up, as did an active management structure that allowed for real-time review and corrective action. The Mildmay experience suggests that family-centred approaches are operationally feasible, produce strong coverage outcomes, and can be well-managed during rapid scale-up.

Emergency residential care settings: A model for service assessment and design.

PubMed

Graça, João; Calheiros, Maria Manuela; Patrício, Joana Nunes; Magalhães, Eunice Vieira

2018-02-01

There have been calls for uncovering the "black box" of residential care services, with a particular need for research focusing on emergency care settings for children and youth in danger. In fact, the strikingly scant empirical attention that these settings have received so far contrasts with the role that they often play as gateway into the child welfare system. To answer these calls, this work presents and tests a framework for assessing a service model in residential emergency care. It comprises seven studies which address a set of different focal areas (e.g., service logic model; care experiences), informants (e.g., case records; staff; children/youth), and service components (e.g., case assessment/evaluation; intervention; placement/referral). Drawing on this process-consultation approach, the work proposes a set of key challenges for emergency residential care in terms of service improvement and development, and calls for further research targeting more care units and different types of residential care services. These findings offer a contribution to inform evidence-based practice and policy in service models of residential care. Copyright © 2017 Elsevier Ltd. All rights reserved.

Provision of acute and elective general surgical care at a tertiary facility in the era of subspecialisation.

PubMed

Klopper, J H; Rayamajhi, S; Venter, J J; De Villiers, D J; Almgla, N; Kloppers, J C

2017-10-31

The need for an acute care and general surgical unit (ACGSU) to provide care for patients previously managed on an ad hoc basis by subspecialist units was recognised by the provincial government of the Western Cape Province, South Africa, the management of Groote Schuur Hospital (GSH) and the Department of Surgery. To describe the resulting ACGSU and its functioning. Data available from administrative records, patient files and operating room forms were collected in spreadsheet form for the period July 2013 - November 2016 inclusive. The ACGSU comprised a medical care team of four consultants and four to five trainees. A total of 7 571 patients were seen during the study period, the majority (66.1%) referred from the GSH Emergency Centre. Skin and soft-tissue infections formed the major disease complex. A total of 3 144 operative records were available. The most common procedures were wound debridement and inguinal hernia repairs. Trainees acted as primary surgeon in most cases. Complications (Clavien-Dindo grades I - V) were noted in 25.0% of patients. The ACGSU provides patient management that would otherwise complicate care in the subspecialist surgical units. It serves as a training ground for registrars and stands as a model for other institutions. Further research into the effect on patient care is planned.

Severe influenza in children: incidence and risk factors.

PubMed

Principi, Nicola; Esposito, Susanna

2016-10-01

The identification of factors that can predispose to the development of severe influenza is essential to enable the implementation of optimal prevention and control measures for vulnerable populations. Unfortunately, data in the pediatric age group remain difficult to interpret. However, epidemiological data seem to suggest that the most severe influenza cases, those who are hospitalized, those who are admitted to the intensive care unit, and those who died, occur in children in the first 2 years of life and in school age patients. Expert commentary: Immaturity of the immune system, and in particular of the mechanisms that usually recognize influenza viruses and activate cytokine and chemokine responses to reduce viral replication, might explain the high hospitalization rate observed in the youngest patients. Some underlying chronic conditions favour the development of the severe cases, sometime leading to death, although both admission to the intensive care unit and death can occur in otherwise healthy subjects.

The epidemiology of trauma in an intensive care unit in Bahrain.

PubMed

Ruehsen, M M; Abdul-Wahab, A W

1989-01-01

Injuries resulting from trauma are over-represented in Bahrain's intensive care unit beds. Using data from 1984 and 1985, this study examines the most severe etiologic agents and high-risk population groups among ICU trauma patients. Road traffic accidents were the principal cause of admission, accounting for 57% of all injury admissions. Most occurred in pedestrians suffering from severe head injury. Poisonings were the second largest category, followed by falls. In comparison with medical cases admitted to the ICU during the same 2-year period, the trauma cases included a disproportionate number of children and males in their most productive years of life, further adding to the economic burden which injuries have inflicted on this small country. The authors call for a new approach, namely passive prevention such as environmental modifications and legislation and tertiary prevention such as improvement of the country's underutilized ambulance service.

Classification of cardiac patient states using artificial neural networks

PubMed Central

Kannathal, N; Acharya, U Rajendra; Lim, Choo Min; Sadasivan, PK; Krishnan, SM

2003-01-01

Electrocardiogram (ECG) is a nonstationary signal; therefore, the disease indicators may occur at random in the time scale. This may require the patient be kept under observation for long intervals in the intensive care unit of hospitals for accurate diagnosis. The present study examined the classification of the states of patients with certain diseases in the intensive care unit using their ECG and an Artificial Neural Networks (ANN) classification system. The states were classified into normal, abnormal and life threatening. Seven significant features extracted from the ECG were fed as input parameters to the ANN for classification. Three neural network techniques, namely, back propagation, self-organizing maps and radial basis functions, were used for classification of the patient states. The ANN classifier in this case was observed to be correct in approximately 99% of the test cases. This result was further improved by taking 13 features of the ECG as input for the ANN classifier. PMID:19649222

Postoperative Conversion Disorder Presenting as Inspiratory Stridor and Hemiparesis in a Pediatric Patient.

PubMed

Nelson, Erik J; Wu, Jennifer Y

2017-01-17

BACKGROUND Postoperative conversion disorder is rare and has been reported. The diagnosis is usually made after all major organic causes have been ruled out. CASE REPORT We describe a case of a 13-year-old female who presented in the post-anesthesia care unit with acute-onset inspiratory stridor and unresponsiveness to verbal or painful stimuli after receiving a general anesthetic for upper endoscopy. Later in the post-anesthesia care unit, she presented with acute-onset right hemiplegia and sensory loss. She was first evaluated for causes of her stridor and unresponsiveness. The evaluation revealed paradoxical vocal cord movement, and all laboratory test values were normal. For her hemiplegia and sensory loss, she was evaluated for stroke with head MRI and CT scans, which were normal. CONCLUSIONS After extensive workup and consideration of multiple etiologies for her presenting signs and symptoms, the most likely diagnosis was conversion disorder.

Adaptive control of bivalirudin in the cardiac intensive care unit.

PubMed

Zhao, Qi; Edrich, Thomas; Paschalidis, Ioannis Ch

2015-02-01

Bivalirudin is a direct thrombin inhibitor used in the cardiac intensive care unit when heparin is contraindicated due to heparin-induced thrombocytopenia. Since it is not a commonly used drug, clinical experience with its dosing is sparse. In earlier work [1], we developed a dynamic system model that accurately predicts the effect of bivalirudin given dosage over time and patient physiological characteristics. This paper develops adaptive dosage controllers that regulate its effect to desired levels. To that end, and in the case that bivalirudin model parameters are available, we develop a Model Reference Control law. In the case that model parameters are unknown, an indirect Model Reference Adaptive Control scheme is applied to estimate model parameters first and then adapt the controller. Alternatively, direct Model Reference Adaptive Control is applied to adapt the controller directly without estimating model parameters first. Our algorithms are validated using actual patient data from a large hospital in the Boston area.

Exiting Foster Care: A Case Study of Former Foster Children Enrolled in Higher Education in Kansas

ERIC Educational Resources Information Center

Schwandt, Jamie R.

2013-01-01

In the United States, foster care is provided to children to avert maltreatment and abuse of children in distressed families by providing a temporary home or a foster home. Courts with jurisdiction over families have been charged by Congress to find appropriate homes when necessary circumstances occur. In fiscal year 2009, there were 423,773…

Guideline-conforming timing of invasive management in troponin-positive or high-risk ACS without persistent ST-segment elevation in German chest pain units. Urban university maximum care vs. rural regional primary care.

PubMed

Breuckmann, F; Remberg, F; Böse, D; Lichtenberg, M; Kümpers, P; Pavenstädt, H; Waltenberger, J; Fischer, D

2016-03-01

This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility. All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy. The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p = 0.17). Guideline-adherent timing was achieved in 88.1 % (site I) or 82.9 % (site II; p = 0.18) of cases. Intervention rates were high in both sites (site I-75.5 % vs. site II-75.3 %; p = 0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites. In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85 % of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.

Integration of intensive care treatment and neurorehabilitation in patients with disorders of consciousness: a program description and case report.

PubMed

Eifert, Bernd; Maurer-Karattup, Petra; Schorl, Martin

2013-10-01

Severe brain injuries frequently result in disorders of consciousness, requiring intensive care unit treatment. We present a rehabilitative system that integrates neurorehabilitation into intensive care treatment. The system will be described using the case report of a young man who was in a vegetative state after a severe traumatic brain injury that resulted in major medical problems and complications. Despite these challenges, interdisciplinary therapies can be applied throughout the rehabilitative process. The patient in our case report showed significant improvements and functional gains during the course of treatment. Additional data from other patients support the feasibility of this system and show that integrating neurorehabilitation into intensive care treatment is possible and can lead to improved outcomes in this patient population. We will discuss the advantages, special features, and limitations of the system. Additional studies are needed to further demonstrate the efficacy of this approach compared with standard treatment. Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Determinant roles of environmental contamination and noncompliance with standard precautions in the risk of hepatitis C virus transmission in a hemodialysis unit.

PubMed

Girou, Emmanuelle; Chevaliez, Stéphane; Challine, Dominique; Thiessart, Michaël; Morice, Yoann; Lesprit, Philippe; Tkoub-Scheirlinck, Latifa; Soing-Altrach, Sophan; Cizeau, Florence; Cavin, Celine; André, Martine; Dahmanne, Djamel; Lang, Philippe; Pawlotsky, Jean-Michel

2008-09-01

Nosocomial transmission is the second most frequent cause of hepatitis C virus (HCV) infection. A prospective observational study was conducted to assess the roles of environmental contamination and noncompliance with standard precautions in HCV cross-transmission in a hemodialysis unit. Patients undergoing chronic hemodialysis in a French university hospital unit were systematically screened, revealing 2 sporadic cases of HCV transmission. An investigation was launched to determine whether the patients were infected in the hemodialysis unit and the possible roles of environmental contamination and noncompliance with standard precautions. We examined possible relationships among new cases of HCV infection, environmental contamination by blood and HCV RNA, and compliance with guidelines on hand hygiene and glove use. Two patients experienced seroconversion to HCV during the study period. Phylogenetic analyses showed that 1 of these patients was infected with the same strain as that affecting a chronically infected patient also treated in the unit. Of 740 environmental surface samples, 82 (11%) contained hemoglobin; 6 (7%) of those contained HCV RNA. The rate of compliance with hand hygiene was 37% (95% confidence interval, 35%-39%), and gloves were immediately removed after patient care in 33% (95% confidence interval, 29%-37%) of cases. A low ratio of nurses to patients and poor hand hygiene were independent predictors of the presence of hemoglobin on environmental surfaces. Blood-contaminated surfaces may be a source of HCV cross-transmission in a hemodialysis unit. Strict compliance with hand hygiene and glove use and strict organization of care procedures are needed to reduce the risk of HCV cross-transmission among patients undergoing hemodialysis.

Critical illness polyneuropathy: a case report.

PubMed

Celik, Canan; Ucan, Halil; Alemdaroglu, Ebru; Oktay, Fugen

2011-01-01

Critical illness polyneuropathy (CIP) is defined as a common complication of critically ilness patients who were admitted to the intensive care unit due to sepsis, multiple trauma and/or multi-organ failure. We aimed to present a patient who was diagnosed as CIP. He was admitted to our outpatient clinic due to weakness and pain in his lower extremities. He had been followed in an intensive care unit due to suicid five months ago. There were symmetrically and predominantly muscle weakness, sensory impairment, absence of deep tendon reflexes in his lower extremities. Electrophysiological evaluation demonstrated motor and sensory axonal distal polyneuropathy predominantly in lower extremities. At follow up, he had high fever, and elevated acute phase responses. Therefore source of infection was investigated and was suspected to a diagnosis of infective endocarditis. He was discharged to be hospitalized in cardiology clinic. With this case, we think that physiatrists should take into consideration a diagnosis of critical illness polyneuropathy in patients with symmetric motor weakness. In CIP, muscle weakness, sensory loss, neuropathic pain, and autonomic problems lengthened the rehabilitation period. Due to a diagnosis of infective endocarditis in our case, we point out that source of infection should be carefully investigated if there is acute phase responses in CIP patients even if during rehabilitation period.

Improving the quality of primary care by allocating performance-based targets, in a diverse insured population.

PubMed

Peled, Ronit; Porath, Avi; Wilf-Miron, Rachel

2016-11-21

Primary Care Health organizations, operating under universal coverage and a regulated package of benefits, compete mainly over quality of care. Monitoring, primary care clinical performance, has been repeatedly proven effective in improving the quality of care. In 2004, Maccabi Healthcare Services (MHS), the second largest Israeli HMO, launched its Performance Measurement System (PMS) based on clinical quality indicators. A unique module was built in the PMS to adjust for case mix while tailoring targets to the local units. This article presents the concept and formulas developed to adjust targets to the units' current performance, and analyze change in clinical indicators over a six year period, between sub-population groups. Six process and intermediate outcome indicators, representing screening for breast and colorectal cancer and care for patients with diabetes and cardiovascular disease, were selected and analyzed for change over time (2003-2009) in overall performance, as well as the difference between the lowest and the highest socio-economic ranks (SERs) and Arab and non-Arab members. MHS demonstrated a significant improvement in the selected indicators over the years. Performance of members from low SERs and Arabs improved to a greater extent, as compared to members from high ranks and non-Arabs, respectively. The performance measurement system, with its module for tailoring of units' targets, served as a managerial vehicle for bridging existing gaps by allocating more resources to lower performing units. This concept was proven effective in improving performance while reducing disparities between diverse population groups.

How different technologies can fit nursing processes to empower staff and increase quality of care. An Italian case study.

PubMed

Bollini, Giovanna; Lolli, Angela; Zaza, Raffaele; Origgi, Gianni; Bragagia, Silvia; Locatelli, Paolo; Restifo, Nicola

2009-01-01

The rapid evolution of healthcare and the need to contain costs, to decrease the time of patients' hospitalization, and to improve the quality of care has led the nursing profession to face new challenges. This paper describes the case study of A.O. Ospedale Niguarda in Milan (Italy), a public healthcare provider where the key role of Nursing is being recognized according to international common practice. Also considering the context of Italian healthcare, attention will be drawn to concrete actions carried out on the organizational side and also for what concerns IT tools supporting nursing activities. This was done aiming with success at rising nurses' knowledge level of the patient, support its activities, increase quality of care, in a precise managerial and methodological framework. We will describe four cases of projects (Intensive Care Unit patient record, First Aid Station care reporting, pressure ulcers management, transfusion traceability) carried out by Niguarda with the support of its partner Fondazione Politecnico di Milano, set up to support bedside nursing activities with the most suitable technology for the purpose.

eHealth Advances in Support of People with Complex Care Needs: Case Examples from Canada, Scotland and the US.

PubMed

Gray, Carolyn Steele; Mercer, Stewart; Palen, Ted; McKinstry, Brian; Hendry, Anne

2016-01-01

Information technology (IT) in healthcare, also referred to as eHealth technologies, may offer a promising solution to the provision of better care and support for people who have multiple conditions and complex care needs, and their caregivers. eHealth technologies can include electronic medical records, telemonitoring systems and web-based portals, and mobile health (mHealth) technologies that enable information sharing between providers, patients, clients and their families. IT often acts as an enabler of improved care delivery, rather than being an intervention per se. But how are different countries seeking to leverage adoption of these technologies to support people who have chronic conditions and complex care needs? This article presents three case examples from Ontario (Canada), Scotland and Kaiser Permanente Colorado (United States) to identify how these jurisdictions are currently using technology to address multimorbidity. A SWOT (strengths, weaknesses, opportunities, threats) analysis is presented for each case and a final discussion addresses the future of eHealth for complex care needs. The case reports presented in this manuscript mark the foundational work of the Multi-National eHealth Research Partnership Supporting Complex Chronic Disease and Disability (the eCCDD Network); a CIHR-funded project intended to support the international development and uptake of eHealth tools for people with complex care needs.

Anaphylactoid reaction during first hemofiltration with a PUREMA (registered trademark) polysulfone membrane

DTIC Science & Technology

2013-05-17

wide range of clinical presentations from mild to life threatening. We present a case of a 34 year old woman in the Burn Intensive Care Unit , who...P., Lundy J. B., Renz E. M., Chung K. K., 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS...ES) United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 8. PERFORMING ORGANIZATION REPORT NUMBER 9. SPONSORING/MONITORING

A before and after study of medical students' and house staff members' knowledge of ACOVE quality of pharmacologic care standards on an acute care for elders unit.

PubMed

Jellinek, Samantha P; Cohen, Victor; Nelson, Marcia; Likourezos, Antonios; Goldman, William; Paris, Barbara

2008-06-01

The Assessing Care of Vulnerable Elders (ACOVE) comprehensive set of quality assessment tools for ill older persons is a standard designed to measure overall care delivered to vulnerable elders (ie, those aged > or =65 years) at the level of a health care system or plan. The goal of this research was to quantify the pretest and posttest results of medical students and house staff participating in a pharmacotherapist-led educational intervention that focused on the ACOVE quality of pharmacologic care standards. This was a before and after study assessing the knowledge ofACOVE standards following exposure to an educational intervention led by a pharmacotherapist. It was conducted at the 29-bed Acute Care for Elders (ACE) unit of Maimonides Medical Center, a 705-bed, independent teaching hospital located in Brooklyn, New York. Participants included all medical students and house staff completing a rotation on the ACE unit from August 2004 through May 2005 who completed both the pre-and posttests. A pharmacotherapist provided a 1-hour active learning session reviewing the evidence supporting the quality indicators and reviewed case-based questions with the medical students and house staff. Educational interventions also occurred daily through pharmacotherapeutic consultations and during work rounds. Medical students and house staff were administered the same 15-question, patient-specific, case-based, multiple-choice pre-and posttest to assess knowledge of the standards before and after receiving the intervention. A total of 54 medical students and house staff (median age, 28.58 years; 40 men, 14 women) completed the study. Significantly higher median scores were achieved on the multiple-choice test after the intervention than before (median scores, 14/15 [93.3%] vs 12/15 [80.0%], respectively; P = 0.001). A pharmacotherapist-led educational intervention improved the scores of medical students and house staff on a test evaluating knowledge of evidence-based recommendations for pharmacotherapy in the elderly.

Antifreeze on a freezing morning: ethylene glycol poisoning in a 2-year-old

PubMed Central

Hann, Gayle; Duncan, Dana; Sudhir, Gopakumar; West, Peter; Sohi, Dalbir

2012-01-01

This case report describes the presentation and management of a 2-year-old child who ingested a potentially fatal amount of ethylene glycol (EG). There are few published cases worldwide of EG poisoning in children managed with fomepizole. All cases described in the literature were managed in a paediatric intensive care unit. In this case, the child presented irritable, pale and confused with high anion gap metabolic acidosis. As there were no paediatric intensive care beds available in the region, the child was successfully managed in a high dependency area in our district general hospital. The child fully recovered and was discharged home in 7 days. The authors believe that multi-disciplinary team management and the use of fomepizole contributed to the positive outcome and this case raised many useful learning points. PMID:22605809

Sociodemographic risk factors associated with low birthweight in United Arab Emirates.

PubMed

Bener, A; Abdulrazzaq, Y M; Dawodu, A

1996-07-01

This case-control study was undertaken to determine sociodemographic risk factors for low birth weight in Al-Ain (United Arab Emirates) over a 12-month period in 1992-93. A total of 3485 live births occurred of which 293 (8.4%) were low birth weight. The risk factors considered were mother's occupation, house conditions, place of residence (urban or rural), maternal smoking habits, antenatal care, availability of help in the home, maternal BMI and educational status. Multiple logistic regression analysis showed that mother's occupation, maternal smoking, antenatal care, and lack of help in the home were associated with increased risk of low birth weight.

Respiratory Acid-Base Disorders in the Critical Care Unit.

PubMed

Hopper, Kate

2017-03-01

The incidence of respiratory acid-base abnormalities in the critical care unit (CCU) is unknown, although respiratory alkalosis is suspected to be common in this population. Abnormal carbon dioxide tension can have many physiologic effects, and changes in Pco 2 may have a significant impact on outcome. Monitoring Pco 2 in CCU patients is an important aspect of critical patient assessment, and identification of respiratory acid-base abnormalities can be valuable as a diagnostic tool. Treatment of respiratory acid-base disorders is largely focused on resolution of the primary disease, although mechanical ventilation may be indicated in cases with severe respiratory acidosis. Published by Elsevier Inc.

Purchaser-provider: the international dimension.

PubMed

Mason, A; Morgan, K

1995-01-28

Purchaser-provider systems in health care are being implemented in several countries and are under consideration in many more. These new arrangements are described for the United Kingdom, Finland, New Zealand, and Australia, and in each case responsibility for funding, purchasing, providing, and ownership is identified. The four systems, along with managed care organisations in the United States, are also compared with regard to several important features. There is a fundamental similarity between these purchaser-provider arrangements but several key differences are well worth systematic study. This is a major challenge for academic bodies in Britain and other countries, and the opportunity to learn from each other should not be missed.

[Palliative sedation at a university palliative care unit--a descriptive analysis].

PubMed

Hopprich, A; Günther, L D; Laufenberg-Feldmann, R; Reinholz, U; Weber, M

2016-04-01

Palliative sedation (pS) is indicated in the presence of end-stage disease with treatment-refractory symptoms not tolerable for the patient. We investigated the practice of pS at a university palliative care unit. Before starting pS the following data were documented: indication and decision making, type of sedation, life expectancy evaluated by the physician using the palliative prognostic index. Over the time of pS communication skills, depth of sedation, relief in symptoms, substitution of fluid and nutrition and used medications were collected. During evaluation time 99 patients died. 34 patients received pS (34 %). All patients suffered from cancer. Indications for palliative sedation were: terminal restlessness (56 %), dyspnea (39 %), pain (32 %), psychological distress (15 %), agitated delir (9 %), vomiting (3 %) and bleeding (3 %) (multiple nominations possible). In 31 cases (91 %) nurses were included for decision making. In 33 cases continuous sedation were initiated immediately (median duration 27.5 hours). The most applied medication was midazolam (94 %), sometimes combined with neuroleptics (44 %) and propofol (15 %). 91 % of the patients additionally received opioids. Artificial fluid was substituted in two cases. Palliative sedation started in the median 27.5 hours before death. The final physician assessment revealed complete symptom relief in 12 patients (35 %), very strong symptom relief in 20 patients (59 %) and moderate symptom relief in 2 patients (6 %). pS was successfully used as last resort for relief of treatment-refractory symptoms in one third of decedents at the investigated palliative care unit. © Georg Thieme Verlag KG Stuttgart · New York.

Nosocomial Legionnaire's disease--a case report and review of the literature.

PubMed

Woo, J H; Kim, S A; Park, C S; Choi, T Y; Chang, I C; Lee, I S

1992-01-01

We report a case of nosocomial legionellosis in a 63 year-old man who was managed with neurosurgery under the diagnosis of subarachnoidal hemorrhage and complicated pneumonia in the intensive care unit. A legionella species was reported from sputum culture and direct immunofluorescent antibody test revealed L. pneumophila (serogroup 2). Our patient's pneumonia was cured with medical therapy including erythromycin and was the first case of microbiologically confirmed legionellosis in Korea.

THE PANC 3 SCORE PREDICTING SEVERITY OF ACUTE PANCREATITIS.

PubMed

Beduschi, Murilo Gamba; Mello, André Luiz Parizi; VON-Mühlen, Bruno; Franzon, Orli

2016-03-01

About 20% of cases of acute pancreatitis progress to a severe form, leading to high mortality rates. Several studies suggested methods to identify patients that will progress more severely. However, most studies present problems when used on daily practice. To assess the efficacy of the PANC 3 score to predict acute pancreatitis severity and its relation to clinical outcome. Acute pancreatitis patients were assessed as to sex, age, body mass index (BMI), etiology of pancreatitis, intensive care need, length of stay, length of stay in intensive care unit and mortality. The PANC 3 score was determined within the first 24 hours after diagnosis and compared to acute pancreatitis grade of the Revised Atlanta classification. Out of 64 patients diagnosed with acute pancreatitis, 58 met the inclusion criteria. The PANC 3 score was positive in five cases (8.6%), pancreatitis progressed to a severe form in 10 cases (17.2%) and five patients (8.6%) died. Patients with a positive score and severe pancreatitis required intensive care more often, and stayed for a longer period in intensive care units. The PANC 3 score showed sensitivity of 50%, specificity of 100%, accuracy of 91.4%, positive predictive value of 100% and negative predictive value of 90.6% in prediction of severe acute pancreatitis. The PANC 3 score is useful to assess acute pancreatitis because it is easy and quick to use, has high specificity, high accuracy and high predictive value in prediction of severe acute pancreatitis.

THE PANC 3 SCORE PREDICTING SEVERITY OF ACUTE PANCREATITIS

PubMed Central

BEDUSCHI, Murilo Gamba; MELLO, André Luiz Parizi; VON-MÜHLEN, Bruno; FRANZON, Orli

2016-01-01

Background : About 20% of cases of acute pancreatitis progress to a severe form, leading to high mortality rates. Several studies suggested methods to identify patients that will progress more severely. However, most studies present problems when used on daily practice. Objective : To assess the efficacy of the PANC 3 score to predict acute pancreatitis severity and its relation to clinical outcome. Methods : Acute pancreatitis patients were assessed as to sex, age, body mass index (BMI), etiology of pancreatitis, intensive care need, length of stay, length of stay in intensive care unit and mortality. The PANC 3 score was determined within the first 24 hours after diagnosis and compared to acute pancreatitis grade of the Revised Atlanta classification. Results : Out of 64 patients diagnosed with acute pancreatitis, 58 met the inclusion criteria. The PANC 3 score was positive in five cases (8.6%), pancreatitis progressed to a severe form in 10 cases (17.2%) and five patients (8.6%) died. Patients with a positive score and severe pancreatitis required intensive care more often, and stayed for a longer period in intensive care units. The PANC 3 score showed sensitivity of 50%, specificity of 100%, accuracy of 91.4%, positive predictive value of 100% and negative predictive value of 90.6% in prediction of severe acute pancreatitis. Conclusion : The PANC 3 score is useful to assess acute pancreatitis because it is easy and quick to use, has high specificity, high accuracy and high predictive value in prediction of severe acute pancreatitis. PMID:27120730

Significant reduction of central line-associated bloodstream infection rates in a tertiary neonatal unit.

PubMed

Rallis, Dimitrios; Karagianni, Paraskevi; Papakotoula, Ifigeneia; Nikolaidis, Nikolaos; Tsakalidis, Christos

2016-04-01

To evaluate the effectiveness of a quality initiative in reducing central line-associated bloodstream infections (CLABSIs) in our neonatal intensive care unit, we designed a prospective study (January 2012-September 2013) estimating CLABSI incidence before and after our implementation. CLABSI rates were significantly decreased after our intervention, from 12 cases per 1,000 central vascular catheter (CVC) days during the preinterventional period to 3.4 cases per 1,000 CVC days during the postinterventional period (P = .004). Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Integrated hospital emergency care improves efficiency.

PubMed

Boyle, A A; Robinson, S M; Whitwell, D; Myers, S; Bennett, T J H; Hall, N; Haydock, S; Fritz, Z; Atkinson, P

2008-02-01

There is uncertainty about the most efficient model of emergency care. An attempt has been made to improve the process of emergency care in one hospital by developing an integrated model. The medical admissions unit was relocated into the existing emergency department and came under the 4-hour target. Medical case records were redesigned to provide a common assessment document for all patients presenting as an emergency. Medical, surgical and paediatric short-stay wards were opened next to the emergency department. A clinical decision unit replaced the more traditional observation unit. The process of patient assessment was streamlined so that a patient requiring admission was fully clerked by the first attending doctor to a level suitable for registrar or consultant review. Patients were allocated directly to specialty on arrival. The effectiveness of this approach was measured with routine data over the same 3-month periods in 2005 and 2006. There was a 16.3% decrease in emergency medical admissions and a 3.9% decrease in emergency surgical admissions. The median length of stay for emergency medical patients was reduced from 7 to 5 days. The efficiency of the elective surgical services was also improved. Performance against the 4-hour target declined but was still acceptable. The number of bed days for admitted surgical and medical cases rose slightly. There was an increase in the number of medical outliers on surgical wards, a reduction in the number of incident forms and formal complaints and a reduction in income for the hospital. Integrated emergency care has the ability to use spare capacity within emergency care. It offers significant advantages beyond the emergency department. However, improved efficiency in processing emergency patients placed the hospital at a financial disadvantage.

Klebsiella pneumoniae bloodstream infections in neonates in a hospital in the Kingdom of Saudi Arabia.

PubMed

Al-Rabea, A A; Burwen, D R; Eldeen, M A; Fontaine, R E; Tenover, F; Jarvis, W R

1998-09-01

To identify risk factors for Klebsiella pneumoniae bloodstream infections (BSI) in neonates in a hospital in the Kingdom of Saudi Arabia (KSA). Two case-control studies among hospitalized neonates during February 15-May 14, 1991, and a procedural and microbiological investigation. Hospital A, a maternity and children's hospital in KSA. Case patients had a blood culture positive for K pneumoniae after >2 days of hospitalization and had no evidence of a nonblood primary site of infection. When the 20 case patients were compared with controls, hospitalization in a critical-care unit (odds ratio [OR], 5.5; 95% confidence interval [CI95], 1.20-51.1; P=.03) was identified as a risk factor. When the case patients were compared with a second set of controls matched by critical-care status, receipt of a particular intravenous fluid (D10%/0.2NS; OR, 11.0; CI95, 1.42-85.2; P=.009) or a blood product (OR undefined; P=.04) were identified as risk factors. Infusates were administered via umbilical catheters for most case and control patients (19/20 vs 15/20, P>.05); catheters were manipulated more frequently in patients in critical-care units. Umbilical catheter tip, skin, or mucus membrane K pneumoniae colonization occurred in 47% and 53% of evaluated case and control patients, respectively. Available K pneumoniae isolates from blood cultures and colonization sites had identical antimicrobial susceptibility patterns. Emphasis on handwashing, careful preparation and administration of infusates, and aseptic technique for catheter insertion, maintenance, and manipulation was temporally associated with resolution of the epidemic. This outbreak was probably due to infusion therapy practices that led to BSI in nursery patients colonized with K pneumoniae. Both catheter-related infections and extrinsic contamination of infusates may have occurred. Hospital personnel should be aware of their potential to spread nosocomial pathogens from person to person and should implement Centers for Disease Control and Prevention recommendations to decrease nosocomial BSIs.

A Technical Evaluation of Wireless Connectivity from Patient Monitors to an Anesthesia Information Management System During Intensive Care Unit Surgery.

PubMed

Simpao, Allan F; Galvez, Jorge A; England, W Randall; Wartman, Elicia C; Scott, James H; Hamid, Michael M; Rehman, Mohamed A; Epstein, Richard H

2016-02-01

Surgical procedures performed at the bedside in the neonatal intensive care unit (NICU) at The Children's Hospital of Philadelphia were documented using paper anesthesia records in contrast to the operating rooms, where an anesthesia information management system (AIMS) was used for all cases. This was largely because of logistical problems related to connecting cables between the bedside monitors and our portable AIMS workstations. We implemented an AIMS for documentation in the NICU using wireless adapters to transmit data from bedside monitoring equipment to a portable AIMS workstation. Testing of the wireless AIMS during simulation in the presence of an electrosurgical generator showed no evidence of interference with data transmission. Thirty NICU surgical procedures were documented via the wireless AIMS. Two wireless cases exhibited brief periods of data loss; one case had an extended data gap because of adapter power failure. In comparison, in a control group of 30 surgical cases in which wired connections were used, there were no data gaps. The wireless AIMS provided a simple, unobtrusive, portable alternative to paper records for documenting anesthesia records during NICU bedside procedures.

[Ulcerating Herpes simplex infections in intensive care patients].

PubMed

Fischer, M; Wohlrab, J; Radke, J; Marsch, W C; Soukup, J

2002-11-01

Herpes simplex infections are potentially a life-threatening situation for immunocompromised as well as critically ill patients. The correct diagnosis is made more difficult in comatose patients by the fact that the characteristic symptom of extreme pain cannot be registered. The clinical dermatological findings (polycyclic configuration, easily bleeding ulcers) are thus especially important in patients under intensive care conditions. As examples, the cases of 3 critically ill patients (subarachnoid bleeding or head injury) developing therapy-resistant, flat sacral or perioral skin ulcers with peripheral blisters are presented. Herpes simplex virus was confirmed immunohistologically and in the smear test. All patients subsequently died. These cases emphasize that patients in the intensive care unit are in danger of developing a chronic persistent Herpes simplex infection due to latent immunosuppression. Chronic persistent Herpes infections may be underrated in intensive therapy, and must always be ruled out in case of therapy-resistant erosions or ulcerations.

Febrile illness in healthcare workers caring for Ebola virus disease patients in a high-resource setting.

PubMed

Fink, Douglas; Cropley, Ian; Jacobs, Michael; Mepham, Stephen

2017-01-26

Ebola virus disease (EVD) patients treated in high-resource facilities are cared for by large numbers of healthcare staff. Monitoring these healthcare workers (HCWs) for any illness that may represent transmission of Ebola virus is important both for the individuals and to minimise the community risk. International policies for monitoring HCWs vary considerably and their effectiveness is unknown. Here we describe the United Kingdom (UK) experience of illness in HCWs who cared for three patients who acquired EVD in West Africa. Five of these 93 high-level isolation unit (HLIU) HCWs presented with fever within 21 days of working on the unit; one of these five presented outside of the UK. This article discusses different approaches to monitoring of HCW symptom reporting. The potential impact of these approaches on HLIU staff recruitment, including travel restrictions, is also considered. An international surveillance system enhancing collaboration between national public health authorities may assist HLIU HCW monitoring in case they travel. This article is copyright of The Authors, 2017.

Febrile illness in healthcare workers caring for Ebola virus disease patients in a high-resource setting

PubMed Central

Fink, Douglas; Cropley, Ian; Jacobs, Michael; Mepham, Stephen

2017-01-01

Ebola virus disease (EVD) patients treated in high-resource facilities are cared for by large numbers of healthcare staff. Monitoring these healthcare workers (HCWs) for any illness that may represent transmission of Ebola virus is important both for the individuals and to minimise the community risk. International policies for monitoring HCWs vary considerably and their effectiveness is unknown. Here we describe the United Kingdom (UK) experience of illness in HCWs who cared for three patients who acquired EVD in West Africa. Five of these 93 high-level isolation unit (HLIU) HCWs presented with fever within 21 days of working on the unit; one of these five presented outside of the UK. This article discusses different approaches to monitoring of HCW symptom reporting. The potential impact of these approaches on HLIU staff recruitment, including travel restrictions, is also considered. An international surveillance system enhancing collaboration between national public health authorities may assist HLIU HCW monitoring in case they travel. PMID:28182538

Patient relationship management: an overview and study of a follow-up system.

PubMed

Oinas-Kukkonen, Harri; Räisänen, Teppo; Hummastenniemi, Niko

2008-01-01

Customer relationship management research is utilized to explain the need for a more patient-oriented support in patient care. This article presents a European study on how various hospital units of a single healthcare organization have utilized a patient relationship management system--in particular a patient treatment follow-up system--and how it affects patient care and the knowledge work performed by the medical staff. Eight physicians were interviewed at a university hospital on whether patient treatment was improved through a follow-up system that had been in use in the case organization for three years. The interviewees represented various hospital units, and all of them had used the system at their own unit. The results indicate that it is possible to improve patient care through more personalized treatment. The follow-up treatment system seems to be a tool to create and maintain better communication with the patients rather than just a technological solution. It may help better understand and analyze both individual patients and patient groups. For individual physicians it provides a way to reflect professional skills. The system was lacking in its support for one-to-one communication with patients. Nevertheless, the system is an example of patient relationship management which may help healthcare units to move towards a more patient-oriented care.

Cluster of Ebola cases among Liberian and U.S. health care workers in an Ebola treatment unit and adjacent hospital -- Liberia, 2014.

PubMed

Forrester, Joseph D; Hunter, Jennifer C; Pillai, Satish K; Arwady, M Allison; Ayscue, Patrick; Matanock, Almea; Monroe, Ben; Schafer, Ilana J; Nyenswah, Tolbert G; De Cock, Kevin M

2014-10-17

The ongoing Ebola virus disease (Ebola) epidemic in West Africa, like previous Ebola outbreaks, has been characterized by amplification in health care settings and increased risk for health care workers (HCWs), who often do not have access to appropriate personal protective equipment. In many locations, Ebola treatment units (ETUs) have been established to optimize care of patients with Ebola while maintaining infection control procedures to prevent transmission of Ebola virus. These ETUs are considered essential to containment of the epidemic. In July 2014, CDC assisted the Ministry of Health and Social Welfare of Liberia in investigating a cluster of five Ebola cases among HCWs who became ill while working in an ETU, an adjacent general hospital, or both. No common source of exposure or chain of transmission was identified. However, multiple opportunities existed for transmission of Ebola virus to HCWs, including exposure to patients with undetected Ebola in the hospital, inadequate use of personal protective equipment during cleaning and disinfection of environmental surfaces in the hospital, and potential transmission from an ill HCW to another HCW. No evidence was found of a previously unrecognized mode of transmission. Prevention recommendations included reinforcement of existing infection control guidance for both ETUs and general medical care settings, including measures to prevent cross-transmission in co-located facilities.

Anesthesia for left ventricular assist device insertion: a case series and review.

PubMed

Broussard, David; Donaldson, Emilie; Falterman, Jason; Bates, Michael

2011-01-01

From October 2008 to June 2010, a total of 42 patients had the HeartMate II left ventricular assist device inserted surgically at Ochsner Medical Center in New Orleans, LA. A retrospective electronic record review was conducted on this series of patients to analyze elements of perioperative anesthetic care, including general anesthetic care, echocardiographic considerations, and blood product usage. Etomidate was used to induce anesthesia for 34 of 42 patients (81%) in this series, with an average dose of 16.5 mg (±6 mg). The average intraoperative fentanyl dose was 1,318 µg (±631 µg). On average, patients were extubated 91 hours (±72 hours) after arrival to the intensive care unit and left on day 9 (±5 days). The average left ventricular ejection fraction of the patients in this series was 13% (±5%). Sixteen patients were evaluated as having severe right-heart dysfunction preoperatively. Two of 42 patients required surgical closure of echocardiographically identified patent foramen ovale. Twelve of 42 patients underwent surgical correction of tricuspid regurgitation. On average, 3 units (±2.6 units) of fresh frozen plasma were transfused intraoperatively and 10 units postoperatively. Intraoperative red blood cell usage averaged 1.1 units (maximum, 7 units), with an average 9.3 units administered in the first 48 hours postoperatively.

Dexmedetomidine infusion as adjunctive therapy to benzodiazepines for acute alcohol withdrawal.

PubMed

Darrouj, Jamil; Puri, Nitin; Prince, Erin; Lomonaco, Anthony; Spevetz, Antoinette; Gerber, David R

2008-11-01

To report a case of alcohol withdrawal and delirium tremens successfully treated with adjunctive dexmedetomidine. A 30-year-old man with a history of alcohol abuse was admitted to the general medical unit because of altered mental status and agitation. He was initially treated for alcohol withdrawal with benzodiazepines; his condition then deteriorated and he was transferred to the intensive care unit. Because of the patient's poor response to benzodiazepines (oxazepam and lorazepam, with midazolam the last one used), intravenous dexmedetomidine was started at an initial dose of 0.2 microg/kg/h and titrated to 0.7 microg/kg/h to the patient's comfort. Midazolam was subsequently tapered to discontinuation due to excessive sedation. In the intensive care unit, the patient's symptoms remained controlled with use of dexmedetomidine alone. He remained in the intensive care unit for 40 hours; dexmedetomidine was then tapered to discontinuation and the patient was transferred back to the general medical unit on oral oxazepam and thiamine, which had been started in the emergency department. He was discharged after 5 days. A review of the PubMed database (1989-2007) failed to identify any other instances of dexmedetomidine having been used as the principal agent to treat alcohol withdrawal. The use of sedative to treat delirium tremens is well documented, with benzodiazepines being the agents of choice. The clinical utility of benzodiazepines is limited by their stimulation of the gamma-aminobutyric acid receptors, an effect not shared by dexmedetomidine, a central alpha(2)-receptor agonist that induces a state of cooperative sedation and does not suppress respiratory drive. In patients with delirium tremens, dexmedetomidine should be considered as an option for primary treatment. This case illustrates the need for further studies to investigate other potential uses for dexmedetomidine.

[Opinion of professionals in an intensive care unit on the limitations of therapeutic effort].

PubMed

González-Castro, A; Azcune, O; Peñasco, Y; Rodríguez, J C; Domínguez, M J; Rojas, R

2016-01-01

To determine the opinion held by professionals in an intensive care unit on the limitation of therapeutic effort process at the end-of-life (LTE). To collect this information, and then use it to improve the basic aspects that the LTE have on the quality of care by intensive care unit staff. A prospective descriptive study was carried out in the Intensive Care Unit of a third level public university hospital. A questionnaire was prepared that included questions on their demographic profile and others to provide an ethical valuation profile, as well as to find out the knowledge and information that the professional had on the LTE. Descriptive study of the sample and comparative statistics were performed using the chi-squared statistical test. A total of 65 valid questionnaires were obtained from a convenience sample of 70 professionals. Almost all of them (98%) were in favour of the limitation of therapeutic effort. The LTE was considered as some kind of euthanasia (active or passive) in up to 28% of the replies, valuations by professional categories is shown in. More than three-quarters (77%) had the belief that not to start treatment was not the same as withdrawing an already established treatment. Just over half (52%) of the respondents believe the value that should have more weight when considering LET would be the prognosis of the current illness of the patient, and 46% the future quality of life of the patient. The economic cost of treatment to be applied was not considered in any case. The LTE is approved by the majority of professionals in our Intensive Care Unit. Although a non-negligible percentage understood it as a form of euthanasia. Copyright © 2016 SECA. Publicado por Elsevier España, S.L.U. All rights reserved.

Factors associated with HIV/AIDS treatment dropouts in a special care unit in the City of Rio de Janeiro, RJ, Brazil.

PubMed

Schilkowsky, Louise Bastos; Portela, Margareth Crisóstomo; Sá, Marilene de Castilho

2011-06-01

This study aimed to identify factors associated with the health care of patients with HIV/AIDS who drop out. The study was developed in a specialized health care unit of a University hospital in Rio de Janeiro, Brazil, considering a stratified sample of adult patients including all dropout cases (155) and 44.0% of 790 cases under regular follow-up. Bivariate analyses were used to identify associations between health care dropout and demographic, socioeconomic and clinical variables. Logistic and Cox regression models were used to identify the independent effects of the explanatory variables on risk for dropout, in the latter by incorporating information on the outcome over time. Patients were, on average, 35 years old, predominantly males (66.4%) and of a low socioeconomic level (45.0%). In both models, health care dropout was consistently associated with being unemployed or having an unstable job, using illicit drugs and having psychiatric background--positive association; and with age, having AIDS, and having used multiple antiretroviral regimens--negative association. In the logistic regression, dropping out was also positively associated with time between diagnosis and the first outpatient visit, while in the Cox model, the hazard for dropping out was positively associated with being single, and negatively associated with a higher educational level. The results of this work allow for the identification of HIV/AIDS patients more likely to drop out from health care.

Telemedicine and its transformation of emergency care: a case study of one of the largest US integrated healthcare delivery systems.

PubMed

Sharma, Rahul; Fleischut, Peter; Barchi, Daniel

2017-12-01

Innovative methods for delivering healthcare via the use of technology are rapidly growing. Despite the passage of the Affordable Care Act, emergency department visits have continued to rise nationally. Healthcare systems must devise solutions to face these increasing volumes and also deliver high quality care. In response to the changing healthcare landscape, New York Presbyterian Hospital has implemented a comprehensive enterprise wide digital health portfolio which includes the first mobile stroke treatment unit on the east coast and the first emergency department-based digital emergency care program in New York City.

Economic Evaluation of a General Hospital Unit for Older People with Delirium and Dementia (TEAM Randomised Controlled Trial)

PubMed Central

Tanajewski, Lukasz; Franklin, Matthew; Gkountouras, Georgios; Berdunov, Vladislav; Harwood, Rowan H.; Goldberg, Sarah E.; Bradshaw, Lucy E.; Gladman, John R. F.; Elliott, Rachel A.

2015-01-01

Background One in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months. Objective To examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care. Methods Six hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%). Results The total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost-effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded. Conclusions The MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation. Trial Registration ClinicalTrials.gov NCT01136148 PMID:26684872

Intensive symptom control of opioid-refractory dyspnea in congestive heart failure: Role of milrinone in the palliative care unit.

PubMed

Silvestre, Julio; Montoya, Maria; Bruera, Eduardo; Elsayem, Ahmed

2015-12-01

We describe an exemplary case of congestive heart failure (CHF) symptoms controlled with milrinone. We also analyze the benefits and risks of milrinone administration in an unmonitored setting. We describe the case of a patient with refractory leukemia and end-stage CHF who developed severe dyspnea after discontinuation of milrinone. At that point, despite starting opioids, she had been severely dyspneic and anxious, requiring admission to the palliative care unit (PCU) for symptom control. After negotiation with hospital administrators, milrinone was administered in an unmonitored setting such as the PCU. A multidisciplinary team approach was also provided. Milrinone produced a dramatic improvement in the patient's symptom scores and performance status. The patient was eventually discharged to home hospice on a milrinone infusion with excellent symptom control. This case suggests that milrinone may be of benefit for short-term inpatient administration for dyspnea management, even in unmonitored settings and consequently during hospice in do-not-resuscitate (DNR) patients. This strategy may reduce costs and readmissions to the hospital related to end-stage CHF.

Academic Underachievement and Exclusion of People Who Have Been Looked after in Local Authority Care

ERIC Educational Resources Information Center

Mallon, James

2005-01-01

Although higher education for 50% of all school leavers by 2010 is the stated aim of the United Kingdom government, it is clear that initiatives aimed at widening access do not reach those most in need. This is nowhere more true than in the case of people who have spent all or part of their childhood in the care of local authorities, and who…

An exploratory examination of medical gas booms versus traditional headwalls in intensive care unit design.

PubMed

Pati, Debajyoti; Evans, Jennie; Waggener, Laurie; Harvey, Tom

2008-01-01

Should power, medical gases, and monitoring and communications systems be located in a headwall or a ceiling-mounted boom in intensive care unit (ICU) rooms? Often, only the financial costs could be determined for the options, whereas data regarding its potential influence on teamwork, safety, and efficiency are lacking. Hence, purchase decisions are more arbitrary than evidence based. This study simulated care delivery in settings with a traditional headwall and a ceiling boom. Observed were the way the following elements were managed and the extent either system affected flexibility, ergonomics, and teamwork: tubing for intravenous fluids, medical gases, and suction drainage; monitoring leads and equipment power cords; and the medical equipment itself. Simulation runs involving 6 scenarios were conducted with the voluntary participation of 2 physicians, 2 nurse practitioners, 2 respiratory therapists, and 4 registered nurses at a children's tertiary care center in December 2007. Analysis suggests that booms have an advantage over headwalls in case of high-acuity ICU patients and when procedures are performed inside patient rooms. However, in case of lower-acuity ICU patients, as well as when procedures are not typically conducted in the patient room, booms may not provide a proportionate level of advantage when compared with the additional cost involved in its procurement.

Wound botulism acquired in the Amazonian rain forest of Ecuador.

PubMed

Reller, Megan E; Douce, Richard W; Maslanka, Susan E; Torres, Darwin S; Manock, Stephen R; Sobel, Jeremy

2006-04-01

Wound botulism results from colonization of a contaminated wound by Clostridium botulinum and the anaerobic in situ production of a potent neurotoxin. Between 1943, when wound botulism was first recognized, and 1990, 47 laboratory-confirmed cases, mostly trauma-associated, were reported in the United States. Since 1990, wound botulism associated with injection drug use emerged as the leading cause of wound botulism in the United States; 210 of 217 cases reported to the Centers for Disease Control and Prevention between 1990 and 2002 were associated with drug injection. Despite the worldwide distribution of Clostridium botulinum spores, wound botulism has been reported only twice outside the United States, Europe, and Australia. However, wound botulism may go undiagnosed and untreated in many countries. We report two cases, both with type A toxin, from the Ecuadorian rain forest. Prompt clinical recognition, supportive care, and administration of trivalent equine botulinum antitoxin were life-saving.

Pan-Britain, mixed-methods study of multidisciplinary teams teaching parents to manage children's long-term kidney conditions at home: Study protocol

PubMed Central

2012-01-01

Background Care of children and young people (children) with long-term kidney conditions is usually managed by multidisciplinary teams. Published guidance recommends that whenever possible children with long-term conditions remain at home, meaning parents may be responsible for performing the majority of clinical care-giving. Multidisciplinary team members, therefore, spend considerable time promoting parents' learning about care-delivery and monitoring care-giving. However, this parent-educative aspect of clinicians' role is rarely articulated in the literature so little evidence exists to inform professionals' parent-teaching interventions. Methods/Design This ongoing study addresses this issue using a combination of quantitative and qualitative methods involving the twelve children's kidney units in England, Scotland and Wales. Phase I involves a survey of multidisciplinary team members' parent-teaching interventions using: i) A telephone-administered questionnaire to determine: the numbers of professionals from different disciplines in each team, the information/skills individual professionals relay to parents and the teaching strategies/interventions they use. Data will be managed using SPSS to produce descriptive statistics ii) Digitally-recorded, qualitative group or individual interviews with multidisciplinary team members to explore their accounts of the parent-teaching component of their role. Interviews will be transcribed anonymously and analysed using Framework Technique. Sampling criteria will be derived from analysis to identify one/two unit(s) for subsequent in-depth study Phase II involves six prospective, ethnographic case-studies of professional-parent interactions during parent-teaching encounters. Parents of six children with a long-term kidney condition will be purposively sampled according to their child's age, diagnosis, ethnicity and the clinical care-giving required; snowball sampling will identify the professionals involved in each case-study. Participants will provide signed consent; data gathering will involve a combination of: minimally-obtrusive observations in the clinical setting and families' homes; de-briefing interviews with participants to obtain views on selected interactions; focussed 'verbatim' field-notes, and case-note reviews. Data gathering will focus on communication between parents and professionals as parents learn care-giving skills and knowledge. Interviews will be digitally recorded and transcribed anonymously. Discussion This study involves an iterative-inductive approach and will provide a unique, detailed insight into the social context in which professionals teach and parents learn; it will inform professionals' parent-educative roles, educational curricula, and health care policy PMID:22333296

Pan-Britain, mixed-methods study of multidisciplinary teams teaching parents to manage children's long-term kidney conditions at home: study protocol.

PubMed

Swallow, Veronica M; Allen, Davina; Williams, Julian; Smith, Trish; Crosier, Jean; Lambert, Heather; Qizalbash, Leila; Wirz, Lucy; Webb, Nicholas J A

2012-02-14

Care of children and young people (children) with long-term kidney conditions is usually managed by multidisciplinary teams. Published guidance recommends that whenever possible children with long-term conditions remain at home, meaning parents may be responsible for performing the majority of clinical care-giving. Multidisciplinary team members, therefore, spend considerable time promoting parents' learning about care-delivery and monitoring care-giving. However, this parent-educative aspect of clinicians' role is rarely articulated in the literature so little evidence exists to inform professionals' parent-teaching interventions. This ongoing study addresses this issue using a combination of quantitative and qualitative methods involving the twelve children's kidney units in England, Scotland and Wales. Phase I involves a survey of multidisciplinary team members' parent-teaching interventions using:i) A telephone-administered questionnaire to determine: the numbers of professionals from different disciplines in each team, the information/skills individual professionals relay to parents and the teaching strategies/interventions they use. Data will be managed using SPSS to produce descriptive statisticsii) Digitally-recorded, qualitative group or individual interviews with multidisciplinary team members to explore their accounts of the parent-teaching component of their role. Interviews will be transcribed anonymously and analysed using Framework Technique. Sampling criteria will be derived from analysis to identify one/two unit(s) for subsequent in-depth studyPhase II involves six prospective, ethnographic case-studies of professional-parent interactions during parent-teaching encounters. Parents of six children with a long-term kidney condition will be purposively sampled according to their child's age, diagnosis, ethnicity and the clinical care-giving required; snowball sampling will identify the professionals involved in each case-study. Participants will provide signed consent; data gathering will involve a combination of: minimally-obtrusive observations in the clinical setting and families' homes; de-briefing interviews with participants to obtain views on selected interactions; focussed 'verbatim' field-notes, and case-note reviews. Data gathering will focus on communication between parents and professionals as parents learn care-giving skills and knowledge. Interviews will be digitally recorded and transcribed anonymously. This study involves an iterative-inductive approach and will provide a unique, detailed insight into the social context in which professionals teach and parents learn; it will inform professionals' parent-educative roles, educational curricula, and health care policy.

Development and initial validation of the Bedside Paediatric Early Warning System score

PubMed Central

2009-01-01

Introduction Adverse outcomes following clinical deterioration in children admitted to hospital wards is frequently preventable. Identification of children for referral to critical care experts remains problematic. Our objective was to develop and validate a simple bedside score to quantify severity of illness in hospitalized children. Methods A case-control design was used to evaluate 11 candidate items and identify a pragmatic score for routine bedside use. Case-patients were urgently admitted to the intensive care unit (ICU). Control-patients had no 'code blue', ICU admission or care restrictions. Validation was performed using two prospectively collected datasets. Results Data from 60 case and 120 control-patients was obtained. Four out of eleven candidate-items were removed. The seven-item Bedside Paediatric Early Warning System (PEWS) score ranges from 0–26. The mean maximum scores were 10.1 in case-patients and 3.4 in control-patients. The area under the receiver operating characteristics curve was 0.91, compared with 0.84 for the retrospective nurse-rating of patient risk for near or actual cardiopulmonary arrest. At a score of 8 the sensitivity and specificity were 82% and 93%, respectively. The score increased over 24 hours preceding urgent paediatric intensive care unit (PICU) admission (P < 0.0001). In 436 urgent consultations, the Bedside PEWS score was higher in patients admitted to the ICU than patients who were not admitted (P < 0.0001). Conclusions We developed and performed the initial validation of the Bedside PEWS score. This 7-item score can quantify severity of illness in hospitalized children and identify critically ill children with at least one hours notice. Prospective validation in other populations is required before clinical application. PMID:19678924

All patient refined-diagnostic related group and case mix index in acute care palliative medicine.

PubMed

Lagman, Ruth L; Walsh, Declan; Davis, Mellar P; Young, Brett

2007-03-01

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.

Palliative Care in Advanced Cancer Patients: How and When?

PubMed Central

Yennurajalingam, Sriram

2012-01-01

Cancer patients develop severe physical and psychological symptoms as a result of their disease and treatment. Their families commonly suffer great emotional distress as a result of caregiving. Early palliative care access can improve symptom control and quality of life and reduce the cost of care. Preliminary results show that early palliative care access can also extend survival. Unfortunately, only a minority of cancer centers in the U.S. have the two most important resources for palliative care delivery: outpatient palliative care centers and inpatient palliative care units. In this article, we use a case presentation to discuss the impact of early palliative care access in light of the currently available evidence, and we recommend ways to improve early access to palliative care through education and research. PMID:22252934

Theory Building and Modeling in a Sinking and Floating Unit: A Case Study of Third and Fourth Grade Students' Developing Epistemologies of Science

ERIC Educational Resources Information Center

Kawasaki, Keiko; Rupert Herrenkohl, Leslie; Yeary, Sherry

2004-01-01

The purpose of this paper is to carefully examine the evolution of students' theory building and modeling, critical components of scientific epistemologies, over a unit of study on sinking and floating in one third/fourth grade classroom. The study described in this paper follows in the tradition of Design Experiments ( Brown 1992 , Collins 1990 )…

Neonatal bacterial meningitis: Results from a cross-sectional hospital based study.

PubMed

Softić, Izeta; Tahirović, Husref; Hasanhodžić, Mensuda

2015-01-01

The aim of the study was to determine the epidemiological characteristics of bacterial meningitis observed in neonates born in the Department of Gynaecology and Obstetrics, University Clinical Centre Tuzla, Bosnia and Herzegovina, admitted to Intensive care unit (NICU) or readmitted, because of suspected infection, after discharge from the nursery. This study was carried out from July 1, 2012 to June 30, 2013. During this period 4136 neonates were born. All neonates admitted to the Intensive care unit with signs and symptoms of systemic infections, and neonates readmitted to the Intensive care unit, after discharge from the nursery for sepsis work up were included in the study. Eighteen of 200 neonates (9%) admitted or readmitted to the NICU developed meningitis. 61% cases were late onset meningitis. The overall incidence was 4.4/1000 live births. The mortality rate was 11.1%. The mean age of symptom presentation was 8.7 days. The most common clinical features were: fever, respiratory distress and jaundice. Significant risk factors for acquiring meningitis were: male gender, Caesarean delivery, stained amniotic fluid. Positive CSF finding were detected in 6/18 (33.3%) of cases. Gram-positive bacteria were more frequently responsible for confirmed meningitis. In all neonates with meningitis blood culture was examined and 5 (50%) yielded Gram-negative bacteria. The high rates of neonatal meningitis with predominant late onset may suggest nosocomial origin. Measures to improve antenatal, intrapartum and delivery care and measures during NICU hospitalisation are necessary to lower the risk of nosocomial infections. Copyright © 2015 by Academy of Sciences and Arts of Bosnia and Herzegovina.

Time motion analysis of nursing work in ICU, telemetry and medical-surgical units.

PubMed

Schenk, Elizabeth; Schleyer, Ruth; Jones, Cami R; Fincham, Sarah; Daratha, Kenn B; Monsen, Karen A

2017-11-01

This study examined nurses' work, comparing nursing interventions and locations across three units in a United States hospital using Omaha System standardized terminology as the organizing framework. The differences in nurses' acute-care work across unit types are not well understood. Prior investigators have used time-motion methodologies; few have compared differences across units, nor used standardized terminology. Nurse-observers recorded locations and interventions of nurses on three acute-care units using hand-held devices and web-based TimeCaT ™ software. Nursing interventions were mapped to Omaha System terms. Unit-differences were analysed. Nurses changed locations approximately every 2 min, and averaged approximately one intervention/minute. Unit differences were found in both the interventions performed and the locations. Most interventions were case-management related, demonstrating the nurses' patient management/coordination role. Unit differences in nursing interventions and location were found among three unit types. Omaha System terminology, as well as the observational method used, were found to be feasible and practical. Nursing work varies by unit, yet managers have not been armed with empirical data with which to make more informed decisions about nurses' work priorities, clinical outcomes, patient satisfaction, staff satisfaction and cost. The results from this study will help them to do so. © 2017 John Wiley & Sons Ltd.

Quality of care for elderly patients hospitalized for pneumonia in the United States, 2006 to 2010.

PubMed

Lee, Jonathan S; Nsa, Wato; Hausmann, Leslie R M; Trivedi, Amal N; Bratzler, Dale W; Auden, Dana; Mor, Maria K; Baus, Kristie; Larbi, Fiona M; Fine, Michael J

2014-11-01

Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes. To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care. Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for Medicare & Medicaid Services (CMS). Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics. Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P < .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P < .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P < .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P < .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P < .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission. Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.

Quality of care provided in two Scottish rural community maternity units: a retrospective case review.

PubMed

Denham, Sara; Humphrey, Tracy; Taylor, Ruth

2017-06-21

Women in Scotland with uncomplicated pregnancies are encouraged by professional bodies and national guidelines to access community based models of midwife-led care for their labour and birth. The evidence base for these guidelines relates to comparisons of predominantly urban birth settings in England. There appears to be little evidence available about the quality of the care during the antenatal, birth and post birth periods available for women within the Scottish Community Maternity Unit (CMU) model. The research aim was to explore the safety and effectiveness of the maternity services provided at two rural Community Maternity Units in Scotland, both 40 miles by main road access from a tertiary obstetric unit. Following appropriate NHS and University ethical approval, an anonymous retrospective review of consecutive maternity records for all women who accessed care at the CMUs over a 12 month period (June 2011 to May 2012) was undertaken in 2013 -14. Data was extracted using variables chosen to provide a description of the socio-demographics of the cohort and the process and outcomes of the care provided. Data were analysed using descriptive statistics. Regarding effectiveness, the correct care pathway was allocated to 97.5% of women, early access to antenatal care achieved by 95.7% of women, 94.8% of women at one CMU received continuity of carer and 78.6% of those clinically eligible accessed care in labour. 11.9% were appropriately transferred to obstetrician-led care antenatally and 16.9% were transferred in labour. All women received one-to one care in labour and 67.1% of babies born at the CMUs were breastfed at birth. Regarding safety, severe morbidity for women was rare, perineal trauma of 3rd degree tear occurred for 0.3% of women and 1.0% experienced an episiotomy. Severe post partum haemorrhage occurred for 0.3% of women. Babies admitted to the Neonatal unit were discharged within 48 hrs. These findings support the recommendations of professional bodies and national guidelines. Maternity service provision at rural CMUs achieved a consistently high standard of safety and effectiveness when measured against national standards and international evidence.

The Birmingham Burn Centre archive: A photographic history of post-war burn care in the United Kingdom.

PubMed

Hardwicke, Joseph; Kohlhardt, Angus; Moiemen, Naiem

2015-06-01

The Medical Research Council Burns and Industrial Injuries Unit at the Birmingham Accident Hospital pioneered civilian burn care and research in the United Kingdom during the post-war years. A photographic archive has been discovered that documents this period from 1945 to 1975. The aim of this project was to sort, digitize and archive the images in a secure format for future reference. The photographs detail the management of burns patients, from injury causation and surgical intervention, to nursing care, rehabilitation and long-term follow-up. A total of 2650 images files were collected from over 600 patients. Many novel surgical, nursing, dressing and rehabilitation strategies are documented and discussed. We have chosen to report part of the archive under the sections of (1) aseptic and antimicrobial burn care; (2) burn excision and wound closure; (3) rehabilitation, reconstruction and long-term outcomes; (4) accident prevention; and (5) response to a major burns incident. The Birmingham collection gives us a valuable insight into the approach to civilian burn care in the post-war years, and we present a case from the archive to the modern day, the longest clinical photographic follow-up to date. Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.

A Systematic Review of the Liaison Nurse Role on Patient's Outcomes after Intensive Care Unit Discharge.

PubMed

Tabanejad, Zeinab; Pazokian, Marzieh; Ebadi, Abbas

2014-10-01

This review focuses on the impact of liaison nurse in nursing care of patient after ICU discharge on patient's outcomes, compared with patients that are not taken care of by liaison nurses. The role of the ICU liaison nurse has transpired to solve the gap between intensive care unit and wards. Therefore, we aimed to review the outcomes of all studies in this field. A systematic review of intervention studies between 2004 and 2013 was undertaken using standard and sensitive keywords such as liaison nurse, intensive care unit, and patient outcomes in the following databases: Science direct, PubMed, Scopus, Ovid, Oxford, Wiley, Scholar, and Mosby. Then, the articles which had the inclusion criteria after quality control were selected for a systematic review. From 662 retrieved articles, six articles were analyzed in a case study and four articles showed a statistically significant effect of the liaison nurse on the patient's outcomes such as reducing delays in patient discharge, effective discharge planning, improvement in survival for patients at the risk for readmission. Liaison nurses have a positive role on the outcomes of patients who are discharged from the ICU and more research should be done to examine the exact function of liaison nurses and other factors that influence outcomes in patients discharged from ICU.

Food Protein-Induced Enterocolitis Instead of Necrotizing Enterocolitis? A Neonatal Intensive Care Unit Case Series.

PubMed

Lenfestey, Mary W; de la Cruz, Diomel; Neu, Josef

2018-05-23

Necrotizing enterocolitis is an important disease in infants born premature. However, other disease entities present with similar signs and symptoms. This series reviews 5 atypical cases initially diagnosed as necrotizing enterocolitis that may be more consistent with food protein-induced enterocolitis. Food protein-induced enterocolitis may be underdiagnosed in this population. Copyright © 2018 Elsevier Inc. All rights reserved.

Risk Factors and Predictors for Candidemia in Pediatric Intensive Care Unit Patients: Implications for Prevention

PubMed Central

Zaoutis, Theoklis E.; Prasad, Priya A.; Localio, A. Russell; Coffin, Susan E.; Bell, Louis M.; Walsh, Thomas J.; Gross, Robert

2013-01-01

Summary Few data exist on risk factors for candidemia in pediatric intensive care unit (PICU) patients who are at high risk of mortality from infection. We conducted a population-based case-control study to determine risk factors and predictors for candidemia in the PICU. Background Candida species are the leading cause of invasive fungal infections in hospitalized children and are the third most common isolates recovered from pediatric healthcare-associated bloodstream infection in the US [1]. Few data exist on risk factors for candidemia in pediatric intensive care unit (PICU) patients. Methods We conducted a population-based case-control study of PICU patients at Children's Hospital of Philadelphia (CHOP) from 1997-2004. Cases were identified using laboratory records, controls were selected from PICU rosters. Controls were matched to cases by incidence density sampling, adjusting for time at risk. Following conditional multivariate analysis, we performed weighted multivariate analysis to determine predicted probabilities for candidemia given certain risk factor combinations. Results We identified 101 cases of candidemia(incidence,3.5/1,000 PICU admissions). Factors independently associated with candidemia included presence of a central venous catheter(OR 30.4;CI,7.7,119.5), malignancy(OR 4.0;CI,1.23,13.1), use of vancomycin for >3 days in the prior two weeks(OR 6.2;CI,2.4,16), and receipt of agents with activity against anaerobic organisms for >3 days in the prior two weeks(OR 3.5;CI, 1.5,8.4). Predicted probability of various combinations of the factors above ranged from 10.7%-46%. The 30-day mortality rate was 44% in cases compared to 14% in controls (OR 4.22;CI,2.35,7.60). Conclusions To our knowledge, this is the first study to evaluate independent risk factors and to determine a population of children in PICUs at high risk for developing candidemia. Future efforts should focus on validation of these risk factors identified in a different PICU population and development of interventions for prevention of candidemia in critically ill children. PMID:20636126

C-A4-01: Computerized Clinical Decision Support During Drug Ordering for Long-term Care Residents With Renal Insufficiency

PubMed Central

Field, Terry S; Rochon, Paula; Lee, Monica; Gavendo, Linda; Baril, Joann L; Gurwitz, Jerry H

2010-01-01

Objective: To determine whether a computerized clinical decision support system (CDSS) providing patient specific recommendations in real- time improves the quality of prescribing for long-term care residents with renal insufficiency. Design: A randomized trial within the long-stay units of a large long-term care facility. Randomization was within blocks by unit type. Alerts related to medication prescribing for residents with renal insufficiency were displayed to prescribers in the intervention units and hidden but tracked in control units. Measurement: The proportions of final drug orders that were appropriate were compared between intervention and control units within alert categories: recommended medication doses; recommended administration frequencies; recommendations to avoid the drug; 4) warnings of missing information. Results: The rates of alerts were nearly equal in the intervention and control units: 2.5 per 1000 resident days in the intervention units and 2.4 in the control units. The proportions of dose alerts for which the final drug orders were appropriate were similar between the intervention and control units (relative risk 0.95, 95% confidence interval 0.83, 1.1). For the remaining alert categories significantly higher proportions of final drug orders were appropriate in the intervention units: relative risk 2.4 for maximum frequency (1.4, 4.4); 2.6 for drugs that should be avoided (1.4, 5.0); and 1.8 for alerts to acquire missing information (1.1, 3.4). Overall, final drug orders were appropriate significantly more often than a relative risk 1.2 (1.0, 1.4). By tracking personnel time and expenditures, we estimated the cost of developing the CDSS as $48,668.57. Drug costs saved during the 12 months of the trial are estimated at $2,137. Conclusion: Clinical decision support for physicians prescribing medications for long-term care residents with renal insufficiency can improve the quality of prescribing decisions. However, patient well-being and quality of care rather than the business case related to cost savings are likely to be the key drivers for adoption of this HIT application.

How qualitative research can contribute to research in the intensive care unit.

PubMed

Sinuff, Tasnim; Cook, Deborah J; Giacomini, Mita

2007-06-01

A qualitative research design can provide unique contributions to research in the intensive care unit. Qualitative research includes the entire process of research: the methodology (conceptualization of the research question, choosing the appropriate qualitative strategy, designing the protocol), methods (conducting the research using qualitative methods within the chosen qualitative strategy, analysis of the data, verification of the findings), and writing the narrative. The researcher is the instrument and the data are the participants' words and experiences that are collected and coded to present experiences, discover themes, or build theories. A number of strategies are available to conduct qualitative research and include grounded theory, phenomenology, case study, and ethnography. Qualitative methods can be used to understand complex phenomena that do not lend themselves to quantitative methods of formal hypothesis testing. Qualitative research may be used to gain insights about organizational and cultural issues within the intensive care unit and to improve our understanding of social interaction and processes of health care delivery. In this article, we outline the rationale for, and approaches to, using qualitative research to inform critical care issues. We provide an overview of qualitative methods available and how they can be used alone or in concert with quantitative methods. To illustrate how our understanding of social phenomena such as patient safety and behavior change has been enhanced we use recent qualitative studies in acute care medicine.

Contemporary antithrombotic strategies in patients with acute coronary syndrome admitted to cardiac care units in Italy: The EYESHOT Study.

PubMed

De Luca, Leonardo; Leonardi, Sergio; Cavallini, Claudio; Lucci, Donata; Musumeci, Giuseppe; Caporale, Roberto; Abrignani, Maurizio G; Lupi, Alessandro; Rakar, Serena; Gulizia, Michele M; Bovenzi, Francesco M; De Servi, Stefano

2015-10-01

Several new antithrombotic therapies have emerged for the treatment of acute coronary syndrome (ACS). We sought to assess contemporary patterns of antithrombotic therapies use in patients with ACS. EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units) was a nationwide, prospective registry aimed to evaluate antithrombotic strategies employed in patients admitted to intensive cardiac care units (CCUs) for an ACS in Italy. Over a three-week period, 203 CCUs enrolled 2585 consecutive patients: 41.2% with ST-elevation myocardial infarction (STEMI) and 58.8% with non-ST elevation ACS (NSTE-ACS). During hospitalisation, low-molecular-weight heparins, aspirin, and clopidogrel were the most commonly used antithrombotic therapies. Among patients treated with percutaneous coronary intervention (PCI, n=1755), any crossover of heparin therapy occurred in 30.8% of cases, while switching from one P2Y12 inhibitor to another occurred in 3.6% of cases in the CathLab and in 14.2% before discharge. Of the 790 patients who did not receive revascularisation, switching of a P2Y12 inhibitor occurred in 5.7% of cases. At discharge, a new P2Y12 inhibitor (ticagrelor or prasugrel) in association with aspirin was prescribed in 59.5% of STEMI and 33.9% of NSTE-ACS patients: the most powerful predictor for prescription was PCI (odds ratio (OR) 6.18; 95% confidence interval (CI) 4.76-8.01; p<0.0001), whereas age ≥ 75 years was strongly associated with clopidogrel use (OR 0.28; 95% CI 0.22-0.36; p<0.0001). The EYESHOT registry shows the current pattern of antithrombotic treatments for ACS patients admitted to Italian CCUs and provides insights which may help to improve the clinical care of such patients. © The European Society of Cardiology 2014.

Predictive Factors of Long-Term Stay in the ICU after Cardiac Surgery: Logistic CASUS Score, Serum Bilirubin Dosage and Extracorporeal Circulation Time

PubMed Central

Pimentel, Marcio Fernandes; Soares, Marcelo José Ferreira; Murad Junior, Jamil Alli; de Oliveira, Marcos Aurelio Barboza; Faria, Fernanda Luiza; Faveri, Vinicius Zani; Iano, Yuzo; Guido, Rodrigo Capobianco

2017-01-01

Objective To test the capacity of the Logistic CASUS Score on the second postoperative day, the total serum bilirubin dosage on the second postoperative day and the extracorporeal circulation time, as possible predictive factors of long-term stay in Intensive Care Unit after cardiac surgery. Methods Eight-two patients submitted to cardiac surgery with extracorporeal circulation were selected. The Logistic CASUS Score on the second postoperative day was calculated and bilirubin dosage on the second postoperative day was measured. The extracorporeal circulation time was also registered. Patients were divided into two groups: Group A, those who were discharged up to the second day of postoperative care; Group B, those who were discharged after the second day of postoperative care. Results In this study, 40 cases were listed in Group A and 42 cases in Group B. The mean extracorporeal circulation time was 83.9±29.4 min in Group A and 95.8±29.31 min in Group B. Extracorporeal circulation time was not significant in this study (P=0.0735). The level of P significance of bilirubin dosage on the second postoperative day was 0.0003 and an area under the ROC curve of 0.708 with a cut-off point at 0.51 mg/dl was registered. The level of P significance of Logistic CASUS Score on the second postoperative day was 0.0001 and an area under the ROC curve of 0.723 with a cut-off point at 0.40% was registered. Conclusion The Logistic CASUS Score on the second postoperative day has shown to be better than the bilirubin dosage on the second postoperative day as a predictive tool for calculating the length of stay in intensive care unit during the postoperative care period of patients. Notwithstanding, extracorporeal circulation time has failed to prove itself as an efficient tool to predict an extended length of stay in intensive care unit. PMID:29211215

Predictive Factors of Long-Term Stay in the ICU after Cardiac Surgery: Logistic CASUS Score, Serum Bilirubin Dosage and Extracorporeal Circulation Time.

PubMed

Pimentel, Marcio Fernandes; Soares, Marcelo José Ferreira; Murad, Jamil Alli; Oliveira, Marcos Aurelio Barboza de; Faria, Fernanda Luiza; Faveri, Vinicius Zani; Iano, Yuzo; Guido, Rodrigo Capobianco

2017-01-01

To test the capacity of the Logistic CASUS Score on the second postoperative day, the total serum bilirubin dosage on the second postoperative day and the extracorporeal circulation time, as possible predictive factors of long-term stay in Intensive Care Unit after cardiac surgery. Eight-two patients submitted to cardiac surgery with extracorporeal circulation were selected. The Logistic CASUS Score on the second postoperative day was calculated and bilirubin dosage on the second postoperative day was measured. The extracorporeal circulation time was also registered. Patients were divided into two groups: Group A, those who were discharged up to the second day of postoperative care; Group B, those who were discharged after the second day of postoperative care. In this study, 40 cases were listed in Group A and 42 cases in Group B. The mean extracorporeal circulation time was 83.9±29.4 min in Group A and 95.8±29.31 min in Group B. Extracorporeal circulation time was not significant in this study (P=0.0735). The level of P significance of bilirubin dosage on the second postoperative day was 0.0003 and an area under the ROC curve of 0.708 with a cut-off point at 0.51 mg/dl was registered. The level of P significance of Logistic CASUS Score on the second postoperative day was 0.0001 and an area under the ROC curve of 0.723 with a cut-off point at 0.40% was registered. The Logistic CASUS Score on the second postoperative day has shown to be better than the bilirubin dosage on the second postoperative day as a predictive tool for calculating the length of stay in intensive care unit during the postoperative care period of patients. Notwithstanding, extracorporeal circulation time has failed to prove itself as an efficient tool to predict an extended length of stay in intensive care unit.

[The heart failure patient: a case report].

PubMed

Alconero-Camarero, Ana Rosa; Arozamena-Pérez, Jorge; García-Garrido, Lluïsa

2014-01-01

Given its prevalence, high mortality rate, morbidity, chronicity and use of resources, heart failure (HF) is a priority issue from a social and health standpoint, due to the ageing population and to lack of adherence to and the complexity of treatment. For these reasons, an individualized care plan needs to be established to meet the real and potential needs of the patient diagnosed with HF. A clinical case is presented of a patient admitted to the Cardiology Critical Care (CCC) unit of a tertiary hospital. A patient care plan was prepared following the steps of the scientific method and relying on the NANDA taxonomy, and the NOC and NIC to design goals and nursing interventions, respectively. Copyright © 2013 Elsevier España, S.L. All rights reserved.

Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study.

PubMed

Sagaon-Teyssier, Luis; Fressard, Lisa; Mora, Marion; Maradan, Gwenaëlle; Guagliardo, Valérie; Suzan-Monti, Marie; Dray-Spira, Rosemary; Spire, Bruno

2016-08-01

To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics. Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS. Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior. Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Innovations In Diabetes Care Around the World: Case Studies Of Care Transformation Through Accountable Care Reforms.

PubMed

Thoumi, Andrea; Udayakumar, Krishna; Drobnick, Elizabeth; Taylor, Andrea; McClellan, Mark

2015-09-01

The rising prevalence, health burden, and cost of chronic diseases such as diabetes have accelerated global interest in innovative care models that use approaches such as community-based care and information technology to improve or transform disease prevention, diagnosis, and treatment. Although evidence on the effectiveness of innovative care models is emerging, scaling up or extending these models beyond their original setting has been difficult. We developed a framework to highlight policy barriers-institutional, regulatory, and financial-to the diffusion of transformative innovations in diabetes care. The framework builds on accountable care principles that support higher-value care, or better patient-level outcomes at lower cost. We applied this framework to three case studies from the United States, Mexico, and India to describe how innovators and policy leaders have addressed barriers, with a focus on important financing barriers to provider and consumer payment. The lessons have implications for policy reform to promote innovation through new funding approaches, institutional reforms, and performance measures with the goal of addressing the growing burdens of diabetes and other chronic diseases. Project HOPE—The People-to-People Health Foundation, Inc.

[Decreasing the Output of Biomedical Waste in the Intensive Care Unit].

PubMed

Shen, Ming-Yi; Chang, Chun-Chu; Li, Mung-Yeng; Lin, Jui-Hsiang

2017-10-01

Advancing healthcare technologies have increased the use of disposable supplies that are made with PVC (polyvinyl chloride). Furthermore, biomedical effluents are steadily increasing due to severe patient treatment requirements in intensive care units. If these biomedical wastes are not properly managed and disposed, they will cause great harm to the environment and to public health. The statistics from an intensive care unit at one medical center in northern Taiwan show that the per-person biomedical effluents produced in 2014 increased 8.51% over 2013 levels. The main reasons for this increase included the low accuracy of classification of the contents of biomedical effluent collection buckets and of personnel effluents in the intensive care unit and the generally poor selection and designation of appropriate containers. Improvement measures were implemented in order to decrease the per-day weight of biomedical effluents by 10% per person (-0.22 kg/person/day). The project team developed various strategies, including creating classification-related slogans and posting promotional posters, holding education and training using actual case studies, establishing an "environmental protection pioneer" team, and promoting the use of appropriate containers. The implementation of the project decreased the per-day weight of biomedical effluents by 13.2% per person. Implementation of the project effectively reduced the per-person daily output of biological wastes and improved the waste separation behavior of healthcare personnel in the unit, giving patients and their families a better healthcare environment and helping advance the cause of environmental protection worldwide.

Short-term Vision Loss Following Whipple Surgery: A Case Report.

PubMed

Gollapalli, Lakshman; Kumar, Aashish J; Sood, Kunal; Muppuri, Rudram

2017-04-15

Occipital seizures may result in visual deficits and may be an ictal or postictal phenomenon. A 71-year-old woman underwent pancreatoduodenectomy (Whipple procedure). During recovery in the postanesthesia care unit, the patient complained of blindness. Upon transfer to the intensive care unit, an electroencephalogram indicated bilateral occipital and hemispheric seizure activity. The patient was treated with antiseizure medication, and vision normalized within 3 days. Subtherapeutic concentration of free phenytoin was confirmed. Our experience suggests that electroencephalogram evaluation should be considered in the workup of postoperative patients who present with acute-onset blindness and in whom the cause remains ambiguous even in the absence of obvious clinical signs of seizures.

Anxiety levels of mothers whose infants have been cared for in unit level-I of a neonatal intensive care unit in Turkey.

PubMed

Erdem, Yurdagül

2010-06-01

In most cases, admission of an infant to the intensive care unit is unexpected and is stressful for their mothers. The aim of this study is to examine factors affecting anxiety level of mothers whose infant is admitted to the neonatal intensive care unit. Anxiety disorders figure among the most frequent psychiatric disorders in the population, and anxiety symptoms are among the most common. A descriptive correlational design. Neonatal intensive care unit of Women's Health and Diseases, Education and Research Hospital in Turkey. A total of 151 women who had an infant in NICU. A questionnaire form was used and included two instruments. The first measured characteristics of mothers and infants, and the second was the 'State-Trait Anxiety Inventory'. Of the mothers, 33.8% were between the ages 25-29, 41.7% of the subjects had a primary education, 89.4% were housewives, 64.9% had social security and 58.9% of subjects had low family incomes. Of the 151 subjects, 75.5% had planned their pregnancy, and 41.7% were primiparas. It was determined that maternal age, education, income; planned pregnancy, having complications of pregnancy, receiving antenatal care, type of labour, gestational age of the infant at birth, reasons for hospitalisation of the infant and birth weight did not affect maternal anxiety levels. Maternal anxiety was significantly (p < 0.05) related to the infants' gender and duration of hospitalisation, with statistically significant differences. Anxiety in mothers was significantly higher if their infant was a boy. This finding can be a result of mother's cultural and religious values. A better understanding of the psychosocial aspects such as cultural values and norms affecting maternal and child health of the perinatal period will contribute to improved health care and better outcomes. Nurses will be better prepared to assist mothers of babies in the NICU to cope with the experience through exploration of these aspects of the mother, infant and experience.

Initiation of a ring approach to infection prevention and control at non-Ebola health care facilities - Liberia, January-February 2015.

PubMed

Nyenswah, Tolbert; Massaquoi, Moses; Gbanya, Miatta Zenabu; Fallah, Mosoka; Amegashie, Fred; Kenta, Adolphus; Johnson, Kumblytee L; Yahya, Disu; Badini, Mehboob; Soro, Lacina; Pessoa-Silva, Carmem L; Roger, Isabelle; Selvey, Linda; VanderEnde, Kristin; Murphy, Matthew; Cooley, Laura A; Olsen, Sonja J; Christie, Athalia; Vertefeuille, John; Navin, Thomas; McElroy, Peter; Park, Benjamin J; Esswein, Eric; Fagan, Ryan; Mahoney, Frank

2015-05-15

From mid-January to mid-February 2015, all confirmed Ebola virus disease (Ebola) cases that occurred in Liberia were epidemiologically linked to a single index patient from the St. Paul Bridge area of Montserrado County. Of the 22 confirmed patients in this cluster, eight (36%) sought and received care from at least one of 10 non-Ebola health care facilities (HCFs), including clinics and hospitals in Montserrado and Margibi counties, before admission to an Ebola treatment unit. After recognition that three patients in this emerging cluster had received care from a non-Ebola treatment unit, and in response to the risk for Ebola transmission in non-Ebola treatment unit health care settings, a focused infection prevention and control (IPC) rapid response effort for the immediate area was developed to target facilities at increased risk for exposure to a person with Ebola (Ring IPC). The Ring IPC approach, which provided rapid, intensive, and short-term IPC support to HCFs in areas of active Ebola transmission, was an addition to Liberia's proposed longer term national IPC strategy, which focused on providing a comprehensive package of IPC training and support to all HCFs in the country. This report describes possible health care worker exposures to the cluster's eight patients who sought care from an HCF and implementation of the Ring IPC approach. On May 9, 2015, the World Health Organization (WHO) declared the end of the Ebola outbreak in Liberia.

[Consequence of secondary complications during the rehabilitation of patients with severe brain injury].

PubMed

Dénes, Zoltán

2009-01-25

Recovery from brain injury is not only determined by the primary injury, but a very important element is the development of secondary complications which have a major role in determining the possibility of the achievement of available maximal functional abilities and the quality of life of the patients and their family after rehabilitation. This is why during medical treatment the prevention of secondary complications is at least as important as the prevention of primary injury. Determination of the most important secondary complications after severe brain injury, and observation of these effects on the rehabilitation process. Retrospective study in the Brain Injury Rehabilitation unit of the National Institute for Medical Rehabilitation in Hungary. 166 patients were treated with brain injury; the mean age of the patients was 33 (8-83) years in 2004. The majority of patients suffered traumatic brain injury in traffic accidents (125/166), while the rest of them through falls or acts of violence. Sixty-four patients were admitted directly from an intensive care unit, 18 from a second hospital ward (traumatology, neurosurgery or neurology) and the rest of the patients were treated in several different units before they were admitted for rehabilitation. The time that has elapsed between injury and rehabilitation admission was 50 days (21-177). At the time of admission 27 patients were in a vegetative state, 38 patients in a minimal conscious state, and 101 patients had already regained consciousness. 83 patients were hemiparetic, 54 presented tetraparesis, and 1 paraparesis, but 28 patients were not paretic. The most frequent complications in patients with severe brain injury at admission in our rehabilitation unit were: contractures (47%), pressure sores (35%), respiratory (14%) and urinary (11%) tract infections, malnutrition (20%). The functional outcome was worse in the cases arriving with secondary complications during the same rehabilitation period. The length of stay in the rehabilitation unit was much longer in these cases. We strongly suggest that actions to prevent secondary complications must be started at the acute care unit. After acute care, rehabilitation of patients with severe brain injury should be performed in specialised centers with multidisciplinary team for different functional deficits (physical, cognitive, communicative, psycho-social impairments). Early and direct admission from the neurologic intensive care unit to the rehabilitation centrum seems to be optimal for best patient outcome, because this lowers the chance for the development of secondary complications.

Creating the Business Case for Achieving Health Equity.

PubMed

Chin, Marshall H

2016-07-01

Health care organizations have increasingly acknowledged the presence of health care disparities across race/ethnicity and socioeconomic status, but significantly fewer have made health equity for diverse patients a true priority. Lack of financial incentives is a major barrier to achieving health equity. To create a business case for equity, governmental and private payors can: 1) Require health care organizations to report clinical performance data stratified by race, ethnicity, and socioeconomic status. 2) Incentivize preventive care and primary care. Implement more aggressive shared savings plans, update physician relative value unit fee schedules, and encourage partnerships across clinical and non-clinical sectors. 3) Incentivize the reduction of health disparities with equity accountability measures in payment programs. 4) Align equity accountability measures across public and private payors. 5) Assist safety-net organizations. Provide adequate Medicaid reimbursement, risk-adjust clinical performance scores for sociodemographic characteristics of patients, provide support for quality improvement efforts, and calibrate cuts to Disproportionate Share Hospital (DSH) payments to the pace of health insurance expansion. 6) Conduct demonstration projects to test payment and delivery system reform interventions to reduce disparities. Commitment to social justice is essential to achieve health equity, but insufficient without a strong business case that makes interventions financially feasible.

Evolution and prognosis of long intensive care unit stay patients suffering a deterioration: A multicenter study.

PubMed

Hernández-Tejedor, Alberto; Cabré-Pericas, Lluís; Martín-Delgado, María Cruz; Leal-Micharet, Ana María; Algora-Weber, Alejandro

2015-06-01

The prognosis of a patient who deteriorates during a prolonged intensive care unit (ICU) stay is difficult to predict. We analyze the prognostic value of the serialized Sequential Organ Failure Assessment (SOFA) score and other variables in the early days after a complication and to build a new predictive score. EPIPUSE (Evolución y pronóstico de los pacientes con ingreso prolongado en UCI que sufren un empeoramiento, Evolution and prognosis of long intensive care unit stay patients suffering a deterioration) study is a prospective, observational study during a 3-month recruitment period in 75 Spanish ICUs. We focused on patients admitted in the ICU for 7 days or more with complications of adverse events that involve organ dysfunction impairment. Demographics, clinical variables, and serialized SOFA after a supervening clinical deterioration were recorded. Univariate and multivariate analyses were performed, and a predictive model was created with the most discriminating variables. We included 589 patients who experienced 777 cases of severe complication or adverse event. The entire sample was randomly divided into 2 subsamples, one for development purposes (528 cases) and the other for validation (249 cases). The predictive model maximizing specificity is calculated by minimum SOFA + 2 * cardiovascular risk factors + 2 * history of any oncologic disease or immunosuppressive treatment + 3 * dependence for basic activities of daily living. The area under the receiver operating characteristic curve is 0.82. A 14-point cutoff has a positive predictive value of 100% (92.7%-100%) and negative predictive value of 51% (46.4%-55.5%) for death. EPIPUSE model can predict mortality with a specificity and positive predictive value of 99% in some groups of patients. Copyright © 2015 Elsevier Inc. All rights reserved.

Does introduction of a Patient Data Management System (PDMS) improve the financial situation of an intensive care unit?

PubMed

Castellanos, Ixchel; Schüttler, Jürgen; Prokosch, Hans-Ulrich; Bürkle, Thomas

2013-09-16

Patient Data Management Systems (PDMS) support clinical documentation at the bedside and have demonstrated effects on completeness of patient charting and the time spent on documentation. These systems are costly and raise the question if such a major investment pays off. We tried to answer the following questions: How do costs and revenues of an intensive care unit develop before and after introduction of a PDMS? Can higher revenues be obtained with improved PDMS documentation? Can we present cost savings attributable to the PDMS? Retrospective analysis of cost and reimbursement data of a 25 bed Intensive Care Unit at a German University Hospital, three years before (2004-2006) and three years after (2007-2009) PDMS implementation. Costs and revenues increased continuously over the years. The profit of the investigated ICU was fluctuating over the years and seemingly depending on other factors as well. We found a small increase in profit in the year after the introduction of the PDMS, but not in the following years. Profit per case peaked at 1039 € in 2007, but dropped subsequently to 639 € per case. We found no clear evidence for cost savings after the PDMS introduction. Our cautious calculation did not consider additional labour costs for IT staff needed for system maintenance. The introduction of a PDMS has probably minimal or no effect on reimbursement. In our case the observed increase in profit was too small to amortize the total investment for PDMS implementation.This may add some counterweight to the literature, where expectations for tools such as the PDMS can be quite unreasonable.

Use of the ketogenic diet in the neonatal intensive care unit-Safety and tolerability.

PubMed

Thompson, Lindsey; Fecske, Erin; Salim, Mohammad; Hall, Ara

2017-02-01

Drug-resistant epilepsy poses a challenge in neonatal patients, especially those in the neonatal intensive care unit (NICU), who have various secondary comorbidities. We present results of four children with a history of drug-resistant epilepsy for whom a ketogenic diet was initiated and used in the NICU. A nonfasting induction into ketosis over 1-2 weeks was utilized, with gradual increases in the ketogenic ratio every 2-3 days. Data were collected retrospectively from a database, which included medical history, daily progress notes, relevant laboratory data, and imaging and diagnostic information. The ketogenic diet was well tolerated in all cases. The most common side effects observed were constipation, hypoglycemia, and weight loss. Serum β-hydroxybutyrate levels demonstrated improved reliability as a marker of ketosis when compared to urine ketones in this population. Perceived benefits to the infants included improved seizure control, increased alertness, and decreased need for invasive respiratory support. These cases demonstrate that the use of the ketogenic diet for treatment of neonatal encephalopathy and refractory epilepsy can be undertaken safely in the NICU and is well tolerated by carefully screened neonates and infants. Wiley Periodicals, Inc. © 2017 International League Against Epilepsy.

First Neonatal Demise with Travel-Associated Zika Virus Infection in the United States of America

PubMed Central

Zacharias, Nikolaos; Whitty, Janice; Noblin, Sarah; Tsakiri, Sophia; Garcia, Jose; Covinsky, Michael; Bhattacharjee, Meenakshi; Saulino, David; Tatevian, Nina; Blackwell, Sean

2017-01-01

Zika virus is increasingly recognized as a fetal pathogen worldwide. We describe the first case of neonatal demise with travel-associated Zika virus infection in the United States of America, including a novel prenatal ultrasound finding. A young Latina presented to our health care system in Southeast Texas for prenatal care at 23 weeks of gestation. Fetal Dandy–Walker malformation, asymmetric cerebral ventriculomegaly, single umbilical artery, hypoechoic fetal knee, dorsal foot edema, and mild polyhydramnios were noted upon initial screening prenatal sonography at 26 weeks. A growth-restricted, microcephalic, and arthrogrypotic infant was delivered alive at 36 weeks but died within an hour despite resuscitation. The neonatal karyotype was normal. Flavivirus IgM antibodies were identified in the serum of the puerpera, once she disclosed that she had traveled from El Salvador to Texas in the early second trimester. Zika virus was identified in the umbilical cord and neonatal brain. Fetal arthritis may precede congenital arthrogryposis in cases of Zika virus infection and may be detectable by prenatal sonography. Physician and health care system vigilance is required to optimally address the significant and enduring Zika virus global health threat. PMID:28413694

Telemedicine in support of peacekeeping operations overseas: an audit.

PubMed

Navein, J; Hagmann, J; Ellis, J

1997-01-01

Since 1993, the Department of Defense has augmented the medical support for Army units on peacekeeping operations in Macedonia through the medium of telemedicine. This project, known as Operation Primetime 1, was the first satellite-based telemedicine system deployed in support of remote primary-care physician in the U.S. military. Its declared aims are: (1) to improve the standard of care; (2) to reduce evacuations; (3) to support junior physicians in the field; and (4) to improve the military effectiveness of the deployed units. This paper audits the success in attaining those goals for the period January 1994 to April 1995. A log was collated from the referring units and questionnaires completed by both referring and consulting physicians. The referring physicians were interviewed on their return from Macedonia, and a more detailed study was undertaken of cases in which a change in outcome was noted. Follow-up interview of consultants was not possible. A total of 53 consults were undertaken on 47 patients. The use of telemedicine affected the decision to evacuate 13 times (13/47), with a net reduction of 9 evacuations. Management of individual cases was changed in 30 of the 47 cases in which telemedicine was used. Physician confidence and military effectiveness were also improved. The level of utilization of the system was largely dependent on a training and sustainment program. Units and General Medical Officers who were trained in the clinical use of telemedicine and the technical sustainment of the equipment used the system; those who were not, did not. Most patients (45/47) were treated satisfactorily with a single consult. Telemedicine under these circumstances seems to be cost effective. The deployed sites chose the referral centers that provided the best service. Telemedicine is a valuable tool capable of augmenting medical support to deployed military units. A successful deployed telemedicine project requires an integrated support package that includes adequate provision for training and equipment sustainment at both ends of the link. Experience with telemedicine in Operation Primetime indicates the potential for substantial cost savings as well as cost-effective medical care. Further application of telemedicine should be encouraged. Successful deployment of telemedicine projects may hinge on an integrated support package.

Acute myocardial infarction quality of care: the Strong Heart Study.

PubMed

Best, Lyle G; Butt, Amir; Conroy, Britt; Devereux, Richard B; Galloway, James M; Jolly, Stacey; Lee, Elisa T; Silverman, Angela; Yeh, Jeun-Liang; Welty, Thomas K; Kedan, Ilan

2011-01-01

Evaluate the quality of care provided patients with acute myocardial infarction and compare with similar national and regional data. Case series. The Strong Heart Study has extensive population-based data related to cardiovascular events among American Indians living in three rural regions of the United States. Acute myocardial infarction cases (72) occurring between 1/1/2001 and 12/31/2006 were identified from a cohort of 4549 participants. The proportion of cases that were provided standard quality of care therapy, as defined by the Healthcare Financing Administration and other national organizations. The provision of quality services, such as administration of aspirin on admission and at discharge, reperfusion therapy within 24 hours, prescription of beta blocker medication at discharge, and smoking cessation counseling were found to be 94%, 91%, 92%, 86% and 71%, respectively. The unadjusted, 30 day mortality rate was 17%. Despite considerable challenges posed by geographic isolation and small facilities, process measures of the quality of acute myocardial infarction care for participants in this American Indian cohort were comparable to that reported for Medicare beneficiaries nationally and within the resident states of this cohort.

Nurse work environment and quality of care by unit types: A cross-sectional study.

PubMed

Ma, Chenjuan; Olds, Danielle M; Dunton, Nancy E

2015-10-01

Nursing unit is the micro-organization in the hospital health care system in which integrated patient care is provided. Nursing units of different types serve patients with distinct care goals, clinical tasks, and social structures and norms. However, empirical evidence is sparse on unit type differences in quality of care and its relation with nurse work environment. Nurse work environment has been found as an important nursing factor predicting nurse and patient outcomes. To examine the unit type differences in nurse-reported quality of care, and to identify the association between unit work environment and quality of care by unit types. This is a cross-sectional study using nurse survey data (2012) from US hospitals nationwide. The nurse survey collected data on quality of care, nurse work environment, and other work related information from staff nurses working in units of various types. Unit types were systematically classified across hospitals. The unit of analysis was the nursing unit, and the final sample included 7677 units of 14 unit types from 577 hospitals in 49 states in the US. Multilevel regressions were used to assess the relationship between nurse work environment and quality of care across and by unit types. On average, units had 58% of the nurses reporting excellent quality of care and 40% of the nurses reporting improved quality of care over the past year. Unit quality of care varied by unit types, from 43% of the nurses in adult medical units to 73% of the nurses in interventional units rating overall quality of care on unit as excellent, and from 35% of the nurses in adult critical care units to 44% of the nurses in adult medical units and medical-surgical combined units reporting improved quality of care. Estimates from regressions indicated that better unit work environments were associated with higher quality of care when controlling various hospital and unit covariates; and this association persisted among units of different types. Unit type differences exist in the overall quality of care as well as achievement in improving quality of care. The low rates of nurses reporting improvement in the quality of nursing care to patients suggest that further interventions focusing at the unit-level are needed for achieving high care quality. Findings from our study also suggest that improving nurse work environments can be an effective strategy to improve quality of care. Copyright © 2015 Elsevier Ltd. All rights reserved.

Theory Building and Modeling in a Sinking and Floating Unit: A Case Study of Third and Fourth Grade Students' Developing Epistemologies of Science. Research Report

ERIC Educational Resources Information Center

Kawasaki, Keiko; Herrenkohl, Leslie Rupert; Yeary, Sherry A.

2004-01-01

The purpose of this paper is to carefully examine the evolution of students' theory building and modeling, critical components of scientific epistemologies, over a unit of study on sinking and floating in one third/fourth grade classroom. The study described in this paper follows in the tradition of Design Experiments (Brown 1992, Collins 1990)…

Exploring the Readability of Consent Forms in Human Research in the United States Army

DTIC Science & Technology

2005-03-01

subjects: autonomy (respect for persons), beneficence, and justice. Readability of consent forms 12 The report also defined how these principles apply to...Regional Medical Command, Fort Sam Houston, Texas CPT Heidi P. Mon) U.S. Army-Baylor University Graduate Program in Health Care Administration March...United States v. Karl Brandt, 1947). The opinion in that case included 10 basic principles for human research, called the Nuremberg Code

[Central Patients Admission (CPA) unit--connecting inpatient and outpatient care].

PubMed

Fleck, Martin; Zeuner, Martin; Schölmerich, Jürgen

2009-12-15

Due to the novel reimbursement policies, hospitals face substantial conflicts regarding best patient care and optimal utilization of resources. In order to optimize patient treatment, a central patients admission (CPA) unit has been established. All patients electively referred to the hospital were primarily treated by a medical specialist at the CPA unit. According to an appropriateness evaluation protocol established with the medical service of the health insurances of Bavaria ("MDK-Bayern"), patients were treated as inpatients or outpatients. The impact of this novel admission procedure was assessed for a period of 30 months. Within 30 months following establishment of the CPA unit, 10% of the patients were treated as outpatients, whereas 90% of referred patients were admitted as inpatients. Nonetheless, numbers of inpatients increased by 20.7% after 24 months compared to 12 months following establishment of the CPA unit with a substantial increase of patients referred by external medical specialists. In addition, there were no cases of inappropriate admission. The CPA unit is an ideal instrument for treating patients cross-sectorally as well as more effectively and economically advocating reorganization. Establishment of a CPA unit leads to greater satisfaction among patients, referring physicians, and medical staff.

Contracting for intensive care services.

PubMed

Dorman, S

1996-01-01

Purchasers will increasingly expect clinical services in the NHS internal market to provide objective measures of their benefits and cost effectiveness in order to maintain or develop current funding levels. There is limited scientific evidence to demonstrate the clinical effectiveness of intensive care services in terms of mortality/morbidity. Intensive care is a high-cost service and studies of cost-effectiveness need to take account of case-mix variations, differences in admission and discharge policies, and other differences between units. Decisions over development or rationalisation of intensive care services should be based on proper outcome studies of well defined patient groups. The purchasing function itself requires development in order to support effective contracting.

Bacterial adhesion forces to Ag-impregnated contact lens cases and transmission to contact lenses.

PubMed

Qu, Wenwen; Busscher, Henk J; van der Mei, Henny C; Hooymans, Johanna M M

2013-03-01

To measure adhesion forces of Pseudomonas aeruginosa, Staphylococcus aureus, and Serratia marcescens to a rigid contact lens (CL), standard polypropylene, and Ag-impregnated lens cases using atomic force microscopy and determine bacterial transmission from lens case to CL. Adhesion forces of bacterial strains to Ag-impregnated and polypropylene lens cases and a rigid CL were measured using atomic force microscopy. Adhesion forces were used to calculate Weibull distributions, from which transmission probabilities from lens case to CL were derived. Transmission probabilities were compared with actual transmission of viable bacteria from a lens case to the CL in 0.9% NaCl and in an antimicrobial lens care solution. Bacterial transmission probabilities from polypropylene lens cases based on force analysis coincided well for all strains with actual transmission in 0.9% NaCl. Bacterial adhesion forces on Ag-impregnated lens cases were much smaller than that on polypropylene and CLs, yielding a high probability of transmission. Comparison with actual bacterial transmission indicated bacterial killing due to Ag ions during colony-forming unit transmission from an Ag-impregnated lens case, especially for P. aeruginosa. Transmission of viable bacteria from Ag-impregnated lens cases could be further decreased by use of an antimicrobial lens care solution instead of 0.9% NaCl. Bacterial transmission probabilities are higher from Ag-impregnated lens cases than from polypropylene lens cases because of small adhesion forces, but this is compensated for by enhanced bacterial killing due to Ag impregnation, especially when in combination with an antimicrobial lens care solution. This calls for a balanced combination of antimicrobial lens care solutions and surface properties of a lens case and CL.

The business case for nursing in long-term care.

PubMed

Horn, Susan D

2008-05-01

Lower nurse staffing in hospitals has been associated with adverse patient outcomes; results in nursing homes (NHs) are less clear. We examined the association between nurses' direct care time and outcomes in long-stay NH residents and potential cost savings from decreased adverse outcomes versus additional wages for adequate nurse staffing. Data were from the National Pressure Ulcer Long-Term Care Study of 1,376 at-risk residents from 82 NHs. Primary data came from medical records. Hospital, pressure ulcer (PrU) treatment, and urinary tract infection (UTI) costs were from national statistics or cost-identification studies. Time horizon was 1 year. More registered nurse (RN) direct care time/resident/day was associated with fewer PrUs, hospitalizations, and UTIs. Annual net societal benefit was $3,191/resident/year in high-risk NH units with 30-40 min of RN time/resident/day versus units with <10 min. Thus, after controlling for important variables, more RN time/day was strongly associated with better outcomes and lower societal cost.

Reduction in hospitalwide incidence of infection or colonization with methicillin-resistant Staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts.

PubMed

Harrington, Glenys; Watson, Kerrie; Bailey, Michael; Land, Gillian; Borrell, Susan; Houston, Leanne; Kehoe, Rosaleen; Bass, Pauline; Cockroft, Emma; Marshall, Caroline; Mijch, Anne; Spelman, Denis

2007-07-01

To evaluate the impact of serial interventions on the incidence of methicillin-resistant Staphylococcus aureus (MRSA). Longitudinal observational study before and after interventions. The Alfred Hospital is a 350-bed tertiary referral hospital with a 35-bed intensive care unit (ICU). A series of interventions including the introduction of an antimicrobial hand-hygiene gel to the intensive care unit and a hospitalwide MRSA surveillance feedback program that used statistical process control charts but not active surveillance cultures. Serial interventions were introduced between January 2003 and May 2006. The incidence and rates of new patients colonized or infected with MRSA and episodes of MRSA bacteremia in the intensive care unit and hospitalwide were compared between the preintervention and intervention periods. Segmented regression analysis was used to calculate the percentage reduction in new patients with MRSA and in episodes of MRSA bacteremia hospitalwide in the intervention period. The rate of new patients with MRSA in the ICU was 6.7 cases per 100 patient admissions in the intervention period, compared with 9.3 cases per 100 patient admissions in the preintervention period (P=.047). The hospitalwide rate of new patients with MRSA was 1.7 cases per 100 patient admissions in the intervention period, compared with 3.0 cases per 100 patient admissions in the preintervention period (P<.001). By use of segmented regression analysis, the maximum and conservative estimates for percentage reduction in the rate of new patients with MRSA were 79.5% and 42.0%, respectively, and the maximum and conservative estimates for percentage reduction in the rate of episodes of MRSA bacteremia were 87.4% and 39.0%, respectively. A sustained reduction in the number of new patients with MRSA colonization or infection has been demonstrated using minimal resources and a limited number of interventions.

Saccharomyces boulardii fungaemia in an intensive care unit patient treated with caspofungin

PubMed Central

Lolis, Nikolaos; Veldekis, Dimitrios; Moraitou, Hellen; Kanavaki, Sofia; Velegraki, Aristea; Triandafyllidis, Charis; Tasioudis, Chronis; Pefanis, Angellos; Pneumatikos, Ioannis

2008-01-01

We describe a case of Saccharomyces boulardii fugaemia in a critically ill patient with septic shock treated with a probiotic agent containing this yeast. We attributed this fugaemia to gut translocation. Our use of caspofugin yielded excellent results. PMID:18423057

Rehabilitation for a child with recalcitrant anti-N-methyl-d-aspartate receptor encephalitis: case report and literature review

PubMed Central

Guo, Yao-Hong; Kuan, Ta-Shen; Hsieh, Pei-Chun; Lien, Wei-Chih; Chang, Chun-Kai; Lin, Yu-Ching

2014-01-01

Anti-N-methyl-d-aspartate (anti-NMDA) receptor encephalitis is a newly recognized, potentially fatal, but treatable autoimmune disease. Good outcome predictors include milder severity of symptoms, no need for intensive care unit admission, early aggressive immunotherapy, and prompt tumor removal. We report a case of a young girl aged 3 years 2 months and diagnosed as recalcitrant anti-NMDA receptor encephalitis without any underlying neoplasm. The patient had initial symptoms of behavioral changes that progressed to generalized choreoathetosis and orofacial dyskinesia, which resulted in 6 months of hospitalization in the pediatric intensive care unit. One year after initial onset of the disease, she had only achieved the developmental age of an infant aged 6–8 months in terms of gross and fine motor skills, but she resumed total independence in activities of daily living after receiving extensive immunotherapy and 28 months of rehabilitation. Our brief review will help clinical practitioners become more familiar with this disease and the unique rehabilitation programs. PMID:25473290

Lessons Learned From Transitioning PEPFAR Track 1.0 Care and Treatment Programs: Case Studies in Financial Management Capacity Building in Zambia and Botswana.

PubMed

Kuehn, Chuck; Tidwell, George; Vhugen, Jann; Sharma, Anjali

2015-01-01

In 2008, the United States government mandated transition of internationally managed HIV care and treatment programs to local country ownership. Three case studies illustrate the US Health Resources Services Administration's fiscal assessment and technical assistance (TA) processes to strengthen local organizations' capabilities to absorb and manage United States government funding. Review of initial, TA and follow-up reports reveal that the 1 Botswanan and 2 Zambian organizations closed 10 of 17 financial capacity gaps, with Health Resources Services Administration assisting on 2. Zambian organizations requested and absorbed targeted TA on the basis of the consultant's desk review, their finance staff revised fiscal policies and procedures, and accordingly trained other staff. In Botswana, delays in integrating recommendations necessitated on-site TA for knowledge building and role modeling. Organizational maturity may explain differences in responsiveness, ownership, and required TA approaches. Clarifying expectations of capacity building, funding agreement, and nonmonetary donor involvement can help new organizations determine and act on intervening actions.

An Unusual Complication With the Administration of a Volatile Anesthetic Agent for Status Asthmaticus in the Pediatric Intensive Care Unit: Case Report and Review of the Literature.

PubMed

Shutes, Brittany; Frazier, W Joshua; Tobias, Joseph D

2017-07-01

In severe cases of status asthmaticus, when conventional therapies fail, volatile anesthetic agents remain a therapeutic option. When delivered outside of the operating room setting, specialized delivery techniques are needed to ensure the safe and effective use of volatile anesthetic agents. We present a 16-year-old adolescent with status asthmaticus who required the therapeutic administration of the volatile anesthetic agent, sevoflurane, in the pediatric intensive care unit (PICU). Although initially effective in reducing bronchospasm, progressive hypercarbia developed due to defective functioning of the carbon dioxide absorber of the anesthesia machine. This failure occurred as the soda lime compartment filled with water accumulated from circuit humidification and continuous albuterol therapy. The role of volatile anesthetic agents in the treatment of status asthmaticus in the PICU is discussed, options for delivery outside of the operating room presented, and potential problems with delivery reviewed.

First confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States, updated information on the epidemiology of MERS-CoV infection, and guidance for the public, clinicians, and public health authorities - May 2014.

PubMed

Bialek, Stephanie R; Allen, Donna; Alvarado-Ramy, Francisco; Arthur, Ray; Balajee, Arunmozhi; Bell, David; Best, Susan; Blackmore, Carina; Breakwell, Lucy; Cannons, Andrew; Brown, Clive; Cetron, Martin; Chea, Nora; Chommanard, Christina; Cohen, Nicole; Conover, Craig; Crespo, Antonio; Creviston, Jeanean; Curns, Aaron T; Dahl, Rebecca; Dearth, Stephanie; DeMaria, Alfred; Echols, Fred; Erdman, Dean D; Feikin, Daniel; Frias, Mabel; Gerber, Susan I; Gulati, Reena; Hale, Christa; Haynes, Lia M; Heberlein-Larson, Lea; Holton, Kelly; Ijaz, Kashef; Kapoor, Minal; Kohl, Katrin; Kuhar, David T; Kumar, Alan M; Kundich, Marianne; Lippold, Susan; Liu, Lixia; Lovchik, Judith C; Madoff, Larry; Martell, Sandra; Matthews, Sarah; Moore, Jessica; Murray, Linda R; Onofrey, Shauna; Pallansch, Mark A; Pesik, Nicki; Pham, Huong; Pillai, Satish; Pontones, Pam; Pringle, Kimberly; Pritchard, Scott; Rasmussen, Sonja; Richards, Shawn; Sandoval, Michelle; Schneider, Eileen; Schuchat, Anne; Sheedy, Kristine; Sherin, Kevin; Swerdlow, David L; Tappero, Jordan W; Vernon, Michael O; Watkins, Sharon; Watson, John

2014-05-16

Since mid-March 2014, the frequency with which cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported has increased, with the majority of recent cases reported from Saudi Arabia and United Arab Emirates (UAE). In addition, the frequency with which travel-associated MERS cases have been reported and the number of countries that have reported them to the World Health Organization (WHO) have also increased. The first case of MERS in the United States, identified in a traveler recently returned from Saudi Arabia, was reported to CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by CDC on May 2. A second imported case of MERS in the United States, identified in a traveler from Saudi Arabia having no connection with the first case, was reported to CDC by the Florida Department of Health on May 11, 2014. The purpose of this report is to alert clinicians, health officials, and others to increase awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula. This report summarizes recent epidemiologic information, provides preliminary descriptions of the cases reported from Indiana and Florida, and updates CDC guidance about patient evaluation, home care and isolation, specimen collection, and travel as of May 13, 2014.

Challenges of rehabilitation case mix measurement in Ontario hospitals.

PubMed

Sutherland, Jason Murray; Walker, Jan

2008-03-01

Case mix classification systems have been adopted in many countries as a method to manage and finance healthcare in acute care settings; the most popular systems are based on diagnosis related groups. The most successful of those case mix systems differentiate patient types by reflecting both the intensity of resources consumed and patient acuity. Case mix systems for use with non-acute hospital activity have not been as wide-spread; other than in the United States, little attention has been directed towards case mix classification for rehabilitation activity. In a province with over 13 million inhabitants with 2496 rehabilitation beds, inpatient rehabilitation is an important component of hospital care in Ontario, Canada, and consists of the spectrum of intensive rehabilitation activities intended to restore function. Although case mix adjusted activity has been the currency in Ontario's Integrated Population Based Allocation hospital funding formula, rehabilitation activity has not been subjected to case mix measurement. A project to examine case mix classification for adult inpatient rehabilitation activity was initiated by the Ontario Ministry of Health and Long-Term Care whose outcome was a case mix system and associated cost weights that would result in rehabilitation activity being incorporated into the hospital funding formula. The process described in this study provides Ontario's provincial government with a case mix classification system for adult inpatient rehabilitation activity although there remain areas for improvement.

Computerized Dose Range Checking Using Hard and Soft Stop Alerts Reduces Prescribing Errors in a Pediatric Intensive Care Unit.

PubMed

Balasuriya, Lilanthi; Vyles, David; Bakerman, Paul; Holton, Vanessa; Vaidya, Vinay; Garcia-Filion, Pamela; Westdorp, Joan; Sanchez, Christine; Kurz, Rhonda

2017-09-01

An enhanced dose range checking (DRC) system was developed to evaluate prescription error rates in the pediatric intensive care unit and the pediatric cardiovascular intensive care unit. An enhanced DRC system incorporating "soft" and "hard" alerts was designed and implemented. Practitioner responses to alerts for patients admitted to the pediatric intensive care unit and the pediatric cardiovascular intensive care unit were retrospectively reviewed. Alert rates increased from 0.3% to 3.4% after "go-live" (P < 0.001). Before go-live, all alerts were soft alerts. In the period after go-live, 68% of alerts were soft alerts and 32% were hard alerts. Before go-live, providers reduced doses only 1 time for every 10 dose alerts. After implementation of the enhanced computerized physician order entry system, the practitioners responded to soft alerts by reducing doses to more appropriate levels in 24.7% of orders (70/283), compared with 10% (3/30) before go-live (P = 0.0701). The practitioners deleted orders in 9.5% of cases (27/283) after implementation of the enhanced DRC system, as compared with no cancelled orders before go-live (P = 0.0774). Medication orders that triggered a soft alert were submitted unmodified in 65.7% (186/283) as compared with 90% (27/30) of orders before go-live (P = 0.0067). After go-live, 28.7% of hard alerts resulted in a reduced dose, 64% resulted in a cancelled order, and 7.4% were submitted as written. Before go-live, alerts were often clinically irrelevant. After go-live, there was a statistically significant decrease in orders that were submitted unmodified and an increase in the number of orders that were reduced or cancelled.

Benchmarking and audit of breast units improves quality of care

PubMed Central

van Dam, P.A.; Verkinderen, L.; Hauspy, J.; Vermeulen, P.; Dirix, L.; Huizing, M.; Altintas, S.; Papadimitriou, K.; Peeters, M.; Tjalma, W.

2013-01-01

Quality Indicators (QIs) are measures of health care quality that make use of readily available hospital inpatient administrative data. Assessment quality of care can be performed on different levels: national, regional, on a hospital basis or on an individual basis. It can be a mandatory or voluntary system. In all cases development of an adequate database for data extraction, and feedback of the findings is of paramount importance. In the present paper we performed a Medline search on “QIs and breast cancer” and “benchmarking and breast cancer care”, and we have added some data from personal experience. The current data clearly show that the use of QIs for breast cancer care, regular internal and external audit of performance of breast units, and benchmarking are effective to improve quality of care. Adherence to guidelines improves markedly (particularly regarding adjuvant treatment) and there are data emerging showing that this results in a better outcome. As quality assurance benefits patients, it will be a challenge for the medical and hospital community to develop affordable quality control systems, which are not leading to excessive workload. PMID:24753926

Knowledge of Toxoplasmosis among Doctors and Nurses Who Provide Prenatal Care in an Endemic Region

PubMed Central

da Silva, Laura Berriel; de Oliveira, Raquel de Vasconcelos Carvalhaes; da Silva, Marizete Pereira; Bueno, Wendy Fernandes; Amendoeira, Maria Regina Reis; Neves, Elizabeth de Souza

2011-01-01

Congenital toxoplasmosis is a potentially severe infection and its prevention is most often based on serological screening in pregnant women. Many cases could be prevented by simple precautions during pregnancy. Aiming to assess the knowledge about toxoplasmosis among professionals working in antenatal care in a high prevalent region, a questionnaire was administered to 118 obstetric nurses and physicians attending at primary care units and hospitals. The questionnaire was self-completed and included questions on diagnosis, clinical issues, and prevention. Only 44% of total answers were corrected. Lower scores were observed among those with over 10 years of graduation, working in primary care units, and nurses. Errors were mainly observed in questions of prevention and diagnosis. As congenital toxoplasmosis is a mother-to-child (MTC) transmitted disease, early diagnosis and treatment can prevent serious and irreversible fetal damage. Thus, doctors and nurses who provide prenatal care must be appropriately trained on prophylactic, diagnostic, and clinical aspects of toxoplasmosis. The authors suggest that measures should be taken for continuing education regarding toxoplasmosis in pregnancy. PMID:21747644

Financial impact of nursing professionals staff required in an Intensive Care Unit 1

PubMed Central

de Araújo, Thamiris Ricci; Menegueti, Mayra Gonçalves; Auxiliadora-Martins, Maria; Castilho, Valéria; Chaves, Lucieli Dias Pedreschi; Laus, Ana Maria

2016-01-01

ABSTRACT Objective: to calculate the cost of the average time of nursing care spent and required by patients in the Intensive Care Unit (ICU) and the financial expense for the right dimension of staff of nursing professionals. Method: a descriptive, quantitative research, using the case study method, developed in adult ICU patients. We used the workload index - Nursing Activities Score; the average care time spent and required and the amount of professionals required were calculated using equations and from these data, and from the salary composition of professionals and contractual monthly time values, calculated the cost of direct labor of nursing. Results: the monthly cost of the average quantity of available professionals was US$ 35,763.12, corresponding to 29.6 professionals, and the required staff for 24 hours of care is 42.2 nurses, with a monthly cost of US$ 50,995.44. Conclusion: the numerical gap of nursing professionals was 30% and the monthly financial expense for adaptation of the structure is US$ 15,232.32, which corresponds to an increase of 42.59% in the amounts currently paid by the institution. PMID:27878219

The Elusive Standard of Care.

PubMed

Cooke, Brian K; Worsham, Elizabeth; Reisfield, Gary M

2017-09-01

In medical negligence cases, the forensic expert must explain to a trier of fact what a defendant physician should have done, or not done, in a specific set of circumstances and whether the physician's conduct constitutes a breach of duty. The parameters of the duty are delineated by the standard of care. Many facets of the standard of care have been well explored in the literature, but gaps remain in a complete understanding of this concept. We examine the standard of care, its origins, and who determines the prevailing standard, beginning with an overview of the historical roots of the standard of care and, using case law, tracing its evolution from the 19th century through the early 21st century. We then analyze the locality rule and consider local, state, and national standards of care. The locality rule requires a defendant physician to provide the same degree of skill and care that is required of a physician practicing in the same or similar community. This rule remains alive in some jurisdictions in the United States. Last, we address the relationship between the standard of care and clinical practice guidelines. © 2017 American Academy of Psychiatry and the Law.

Nursing home case-mix instruments: validation of the RUG-III system in Italy.

PubMed

Brizioli, Enrico; Bernabei, Roberto; Grechi, Francesca; Masera, Filippo; Landi, Francesco; Bandinelli, Stefania; Cavazzini, Chiara; Gangemi, Salvatore; Ferrucci, Luigi

2003-06-01

The current Italian reimbursement system for long-term care does not adequately consider the great variability in the health and functional status of older persons who are admitted to long-term care institutions. Furthermore, no procedure is implemented to monitor the quality of care provided to older residents. We conducted this study to verify whether the RUG-III (Resource Utilization Groups-version III), a tool for assessing the case-mix of nursing home residents, which is widely used in the United States and in many European countries, can be effectively used in the Italian health care system. We administered an Italian version of the RUG-III to 1000 older residents of 11 intermediate- and long-term care institutions. We also collected objective information on the amount of care provided directly or indirectly to each resident by nurses, physical therapists, and other health professionals. The RUG-III 44 group classification system explained 61 and 44% of the variance in rehabilitative and nursing wage-adjusted care time, respectively. Our findings provide strong evidence that the RUG-III classification, applied to Italian intermediate- and long-term care institutions, provides a robust estimate of the amount of nursing and rehabilitation resources consumed by older residents.

Nosocomial Legionnaire’s Disease

PubMed Central

Woo, Jun Hee; Kim, Shin Ae; Park, Choon Sik; Choi, Tai Youn; Chang, Ik Chin; Lee, In Soo

1992-01-01

We report a case of nosocomial legionellosis in a 63 year-old man who was managed with neurosurgery under the diagnosis of subarachnoidal hemorrhage and complicated pneumonia in the intensive care unit. A legionella species was reported from sputum culture and direct immunofluorescent antibody test revealed L. pneumophila (serogroup 2). Our patient’s pneumonia was cured with medical therapy including erythromycin and was the first case of microbiologically confirmed legionellosis in Korea. PMID:1477034

An outbreak of Serratia marcescens infection in a special-care baby unit of a community hospital in United Arab Emirates: the importance of the air conditioner duct as a nosocomial reservoir.

PubMed

Uduman, S A; Farrukh, A S; Nath, K N R; Zuhair, M Y H; Ifrah, A; Khawla, A D; Sunita, P

2002-11-01

We report an outbreak of Serratia marcescens infection in a special-care baby unit (SCBU) of a university-affiliated community hospital in the United Arab Emirates. The outbreak involved 36 infants and lasted for 20 weeks. Seven of the colonized infants developed invasive illnesses in the form of bacteraemia (four cases), bacteraemic meningitis (two) and clinical sepsis (one). Three other term infants had purulent conjunctivitis. There were five deaths with an overall mortality of 14%. S. marcescens was cultured from airflow samples from the air conditioning (AC) which was the reservoir of infection in this outbreak. Elimination of the nosocomial source and outbreak containment were eventually achieved by specialized robotic cleaning of the entire AC duct system of the SCBU. Strict adherence to the infection control policies was reinforced to prevent transmission of cross-infection. Copyright 2002 The Hospital Infection Society

[Duties of institutions and heads of health care centers in the area of infection control, information, assessment, registration and financing of benefits provided to TB patients].

PubMed

Zielonka, Tadeusz M

2011-01-01

The Act on preventing and counteracting infections and infectious diseases in humans effective in Poland provides for the duty of the heads of health care outlets and institutions to counteract spreading of TB in units under their management. They are, by all means, responsible for monitoring infections in their respective units, involving development, implementation and monitoring of practical implementation of procedures aiming at limiting dissemination of TB in hospitals and outpatient clinics. Medical service unit managers are also responsible for providing members of their staffs with means of individual protection against infection with Mycobacterium tuberculosis bacillus. Their duties also include notification of all recognized TB cases in their respective units. TB is an infectious diseases included in the occupational disease list. Assessment of TB as occupational disease is the responsibility of provincial TB prevention clinics. The Act also provides for principles of financing of individual benefits available for the insured TB patients and those not insured.

Intralipid therapy does not improve level of consciousness in overdoses with sedating drugs: a case series.

PubMed

Downes, Michael A; Calver, Leonie A; Isbister, Geoffrey K

2014-06-01

To assess the effect of intralipid emulsion therapy (ILE) in sedating drugs presenting to an urban emergency department. Following the introduction of a clinical protocol for the use of ILE a retrospective chart review was undertaken, which describes the use of ILE in treating sedating drug overdose in a facility with a tertiary referral level clinical toxicology unit. Demographic data as well as details of drug ingested, physiological parameters and disposition were extracted from the medical record. Over a 7 month period nine cases were treated with intralipid, of which two were male and the median age was 33 years (17-52 years). Endotracheal intubation was required in seven cases and of the other two, one required a nasopharyngeal airway for several hours while being observed in a critical care area. One patient was managed in the intensive care unit without intubation. The median duration of ventilation in the seven patients was 31 h (22-82 h), and median length of stay for all nine cases was 63 h (24-133 h). This study does not support any clinically significant effect of intralipid in sedating drug overdose. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Prognosis of patients presenting extreme acidosis (pH <7) on admission to intensive care unit.

PubMed

Allyn, Jérôme; Vandroux, David; Jabot, Julien; Brulliard, Caroline; Galliot, Richard; Tabatchnik, Xavier; Combe, Patrice; Martinet, Olivier; Allou, Nicolas

2016-02-01

The purpose was to determine prognosis of patients presenting extreme acidosis (pH <7) on admission to the intensive care unit (ICU) and to identify mortality risk factors. We retrospectively analyzed all patients who presented with extreme acidosis within 24 hours of admission to a polyvalent ICU in a university hospital between January 2011 and July 2013. Multivariate analysis and survival analysis were used. Among the 2156 patients admitted, 77 patients (3.6%) presented extreme acidosis. Thirty (39%) patients suffered cardiac arrest before admission. Although the mortality rate predicted by severity score was 93.6%, death occurred in 52 cases (67.5%) in a median delay of 13 (5-27) hours. Mortality rate depended on reason for admission, varying between 22% for cases linked to diabetes mellitus and 100% for cases of mesenteric infarction (P = .002), cardiac arrest before admission (P < .001), type of lactic acidosis (P = .007), high Simplified Acute Physiology Score II (P = .008), and low serum creatinine (P = .012). Patients with extreme acidosis on admission to ICU have a less severe than expected prognosis. Whereas mortality is almost 100% in cases of cardiac arrest before admission, mortality is much lower in the absence of cardiac arrest before admission, which justifies aggressive ICU therapies. Copyright © 2015 Elsevier Inc. All rights reserved.

Professional and Hospital DISCRIMINATION and the US Court of Appeals Fourth Circuit 1956–1967

PubMed Central

Reynolds, P. Preston

2004-01-01

A series of court cases litigated by the National Association for the Advancement of Colored People Legal Defense and Education Fund between 1956 and 1967 laid the foundation for elimination of overt discrimination in hospitals and professional associations. The landmark case, Simkins v Moses H. Cone Memorial Hospital (1963), challenged the use of public funds to expand segregated hospital care. The second case, Cypress v Newport News Hospital Association (1967), reaffirmed the federal government’s application of Medicare certification guidelines to force hospitals to open up patient admissions, education programs, and staff privileges to all citizens and physicians. Pursuit of a legal strategy against racist policies was an essential element in a national campaign to eliminate discrimination in health care delivery in the United States. PMID:15117685

On opportunity for emergency cesarean hysterectomy and pregnancy outcomes of patients with placenta accreta.

PubMed

Kong, Xiang; Kong, Yan; Yan, Jin; Hu, Jin-Ju; Wang, Fang-Fang; Zhang, Lei

2017-09-01

Effective diagnosis and clinical management of placenta accreta (PA) in China are not clear. The purpose of the study was to analyze the risk factors and diagnosis of PA, maternal and neonatal outcomes in patients with PA. It was a retrospective study of cases with PA, confirmed by histologically and/or clinically suspected during 3 years in 2 tertiary referral hospitals. The incidence rate of patients with PA, who had history of artificial abortion, cesarean section (CS), and placenta previa (PP) was 94%, 70%, and 72%, respectively. In 29 patients of scheduled CS group, 12 cases were performed with cesarean hysterectomy. Mean estimated blood loss (EBL) was 1.5 L, and 17 babies were admitted to neonatal intensive care unit (NICU). In the 18 cases of emergency CS group, 6 cases were performed cesarean hysterectomy. Mean EBL was 2.4 L, and 16 babies were admitted to NICU. The difference of mean EBL, cases of fetal admitted to intensive care unit in 2 groups was significant difference (P < .05).Women with history of uterine curettage, CS or PP are more likely to have PA. PA should be diagnosed early and accurately via ultrasound and magnetic resonance imaging. Maternal and neonatal outcomes in the scheduled CS are better than in emergency CS. Emergency peripartum hysterectomy is a feasible method under the circumstances of heave, fast bleeding, and the failure of conservative surgery.

Patient journey in decompensated heart failure: An analysis in departments of cardiology and geriatrics in the Greater Paris University Hospitals.

PubMed

Laveau, Florent; Hammoudi, Nadjib; Berthelot, Emmanuelle; Belmin, Joël; Assayag, Patrick; Cohen, Ariel; Damy, Thibaud; Duboc, Denis; Dubourg, Olivier; Hagege, Albert; Hanon, Olivier; Isnard, Richard; Jondeau, Guillaume; Labouree, Florian; Logeart, Damien; Mansencal, Nicolas; Meune, Christophe; Pautas, Eric; Wolmark, Yves; Komajda, Michel

2017-01-01

Hospitalization for worsening/acute heart failure is increasing in France, and limited data are available on referral/discharge modalities. To evaluate patients' journeys before and after hospitalization for this condition. On 1 day per week, between October 2014 and February 2015, this observational study enrolled 260 consecutive patients with acute/worsening heart failure in all 10 departments of cardiology and four of the departments of geriatrics in the Greater Paris University Hospitals. First medical contact was an emergency unit in 45% of cases, a general practitioner in 16% of cases, an emergency medical ambulance in 13% of cases and a cardiologist in 13% of cases; 78% of patients were admitted directly after first medical contact. In-hospital stay was 13.2±11.3 days; intensive care unit stay (38% of the population) was 6.4±5 days. In-hospital mortality was 2.7%. Overall, 63% of patients were discharged home, whereas 21% were transferred to rehabilitation units. A post-discharge outpatient visit was made by only 72% of patients within 3 months (after a mean of 45±28 days). Only 53% of outpatient appointments were with a cardiologist. Emergency departments, ambulances and general practitioners are the main points of entry before hospitalization for acute/worsening heart failure. Home discharge occurs in two of three cases. Time to first patient post-discharge visit is delayed. Therefore, actions to improve the patient journey should target primary care physicians and emergency structures, and efforts should be made to reduce the time to the first visit after discharge. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

High turnover stays for pediatric asthma in the United States: analysis of the 2006 Kids' Inpatient Database.

PubMed

Macy, Michelle L; Stanley, Rachel M; Sasson, Comilla; Gebremariam, Achamyeleh; Davis, Matthew M

2010-09-01

Pediatric observation units provide an alternative to traditional hospitalization. The extent to which observation units could replace inpatient care for asthmatic children is unknown. To describe brief inpatient ("high-turnover," HTO) stays for US children hospitalized with a principal discharge diagnosis of asthma, to characterize cases that may be appropriate for observation. We analyzed the 2006 Kids' Inpatient Database, a nationally representative sample of hospital discharges. HTO stays were defined as hospitalizations of 0 or 1 night in duration. We conducted descriptive statistics and case-mix adjusted, sample-weighted regression analysis of HTO stays, and associated hospital charges. Discharges among children aged 2 to 20 years with a principal discharge diagnosis of asthma. HTO stays and total charges. Overall, 34,592 (34%) pediatric asthma hospitalizations were HTO, accounting for 66,278 hospital days in 2006. HTO stays were associated with younger age, uncomplicated asthma, and private insurance. Freestanding children's hospitals had the highest proportion of HTO stays, 38% (95% CI: 34%-42%) compared with 32% (95% CI: 28%-36%) for children's units and 33% (95% CI: 31%-34%) for general hospitals. In multivariate regression analyses, charges were significantly higher across hospital types when HTO stays begin in the emergency department. The presence of a large number of HTO stays for children hospitalized for asthma suggests the need to explore opportunities to restructure care for this condition, perhaps through the development of physically or operationally distinct observation units.

Clinical assessment of the oral cavity of patients hospitalized in an intensive care unit of an emergency hospital

PubMed Central

da Cruz, Maristela Kapitski; de Morais, Teresa Márcia Nascimento; Trevisani, Deny Munari

2014-01-01

Objective To describe the oral health status of patients hospitalized in an intensive care unit. Methods Clinical assessment of the oral cavity was performed in 35 patients at two time-points (up to 48 hours after admission and 72 hours after the first assessment) and recorded in data collection forms. The following data were collected: plaque index, condition of the mucosa, presence or absence of dental prosthesis, number of teeth present, and tongue coating index. Results The prevalence of nosocomial infection was 22% (eight patients), with 50% respiratory tract infections. All patients exhibited oral biofilm, and 20 (57%) showed biofilm visible to the naked eye; tongue coating was present on more than two thirds of the tongue in 24 patients (69%) and was thick in most cases. A significant increase in plaque index (p=0.007) occurred after 72 hours, although the tongue coating index was p<0.001 regarding the area and p=0.5 regarding the thickness. Conclusion The plaque and tongue coating indices increased with the length of hospital stay at the intensive care unit. PMID:25607267

Should religious beliefs be allowed to stonewall a secular approach to withdrawing and withholding treatment in children?

PubMed

Brierley, Joe; Linthicum, Jim; Petros, Andy

2013-09-01

Religion is an important element of end-of-life care on the paediatric intensive care unit with religious belief providing support for many families and for some staff. However, religious claims used by families to challenge cessation of aggressive therapies considered futile and burdensome by a wide range of medical and lay people can cause considerable problems and be very difficult to resolve. While it is vital to support families in such difficult times, we are increasingly concerned that deeply held belief in religion can lead to children being potentially subjected to burdensome care in expectation of 'miraculous' intervention. We reviewed cases involving end-of-life decisions over a 3-year period. In 186 of 203 cases in which withdrawal or limitation of invasive therapy was recommended, agreement was achieved. However, in the 17 remaining cases extended discussions with medical teams and local support mechanisms did not lead to resolution. Of these cases, 11 (65%) involved explicit religious claims that intensive care should not be stopped due to expectation of divine intervention and complete cure together with conviction that overly pessimistic medical predictions were wrong. The distribution of the religions included Protestant, Muslim, Jewish and Roman Catholic groups. Five of the 11 cases were resolved after meeting religious community leaders; one child had intensive care withdrawn following a High Court order, and in the remaining five, all Christian, no resolution was possible due to expressed expectations that a 'miracle' would happen.

Servant leadership: enhancing quality of care and staff satisfaction.

PubMed

Neill, Mark W; Saunders, Nena S

2008-09-01

Servant leadership encompasses a powerful skill set that is particularly effective in implementing a team approach to the delivery of nursing practice. This model encourages the professional growth of nurses and simultaneously promotes the improved delivery of healthcare services through a combination of interdisciplinary teamwork, shared decision making, and ethical behavior. The authors describe the case application of servant leadership principles in a Department of Veterans Affairs Medical Intensive Care Unit located in a large urban center.

Pediatric Critical Care Transport as a Conduit to Terminal Extubation at Home: A Case Series

PubMed Central

Noje, Corina; Bernier, Meghan L.; Costabile, Philomena M.; Klein, Bruce L.; Kudchadkar, Sapna R.

2016-01-01

Objective To present our single-center’s experience with three palliative critical care transports home from the pediatric intensive care unit (PICU) for terminal extubation. Design, Setting, Patients All cases were identified from our institutional Pediatric Transport database. Patients in the case series were terminally ill children unable to separate from mechanical ventilation in the PICU, who were transported home between January 1, 2012 and December 31, 2014 for terminal extubation and end-of-life care according to their families’ wishes. Interventions, Measurements, Main Results The rate of palliative care transports home for terminal extubation during the study period was 2.6 per 100 deaths. The patients were 7 months, 6 years, and 18 years old and had complex chronic conditions. The transfer process was protocolized. The families were approached by the PICU staff during multidisciplinary goals-of-care meetings. Parental expectations were clarified and home hospice care was arranged pre-transfer. All transports were performed by our pediatric critical care transport team, and all terminal extubations were performed by physicians. All patients had unstable medical conditions and urgent needs for transport to comply with the families’ wishes for withdrawal of life-support and death at home. As such, all three cases presented similar logistical challenges, including establishing do-not-resuscitate status pre-transport, having limited time to organize the transport, and coordinating home palliative care services with available community resources. Conclusions Though a relatively infrequent practice in pediatric critical care, transport home for terminal extubation represents a feasible alternative for families seeking out-of-hospital end-of-life care for their critically ill technology-dependent children. Our single-center experience supports the need for development of formal programs for end-of-life critical care transports to include patient screening tools, palliative care home discharge algorithms, transport protocols, and resource utilization and cost analyses. PMID:27801708

Viral Infection in Adults with Severe Acute Respiratory Infection in Colombia

PubMed Central

Remolina, Yuly Andrea; Ulloa, María Mercedes; Vargas, Hernán; Díaz, Liliana; Gómez, Sandra Liliana; Saavedra, Alfredo; Sánchez, Edgar; Cortés, Jorge Alberto

2015-01-01

Objectives To identify the viral aetiology in adult patients with severe acute respiratory infection (SARI) admitted to sentinel surveillance institutions in Bogotá in 2012. Design A cross-sectional study was conducted in which microarray molecular techniques for viral identification were used on nasopharyngeal samples of adult patients submitted to the surveillance system, and further descriptions of clinical features and relevant clinical outcomes, such as mortality, need for critical care, use of mechanical ventilation and hospital stay, were obtained. Setting Respiratory infections requiring hospital admission in surveillance centres in Bogotá, Colombia. Participants Ninety-one adult patients with acute respiratory infection (55% were female). Measurements Viral identification, intensive care unit admission, hospital stay, and mortality. Results Viral identification was achieved for 63 patients (69.2%). Comorbidity was frequently identified and mainly involved chronic pulmonary disease or pregnancy. Influenza, Bocavirus and Adenovirus were identified in 30.8%, 28.6% and 18.7% of the cases, respectively. Admission to the intensive care unit occurred in 42.9% of the cases, while mechanical ventilation was required for 36.3%. The average hospital stay was 9.9 days, and mortality was 15.4%. Antibiotics were empirically used in 90.1% of patients. Conclusions The prevalence of viral aetiology of SARI in this study was high, with adverse clinical outcomes, intensive care requirements and high mortality. PMID:26576054

[Applying back massage protocol to promote an intensive care unit patient's quality of sleep].

PubMed

Fang, Chiu-Shu; Liu, Chin-Fang

2006-12-01

This case report concerns the nursing experience of applying back massage to a patient in an intensive care unit (ICU) from 10 May, 2005, in order to improve the patient's quality of sleep. In order to collect information about his quality of sleep of the patient, the author used observation, interview and a Richards-Campbell sleep questionnaire (RCSQ). It was observed that, before massage, the patient's sleep quality was poor, which wa why the protocol with back massage was proposed. The results after back massage was applied that heart beat, respiration. oxygen saturation and blood pressure were not significantly improved. This was probably related to the patient's worry about having his endotracheal tube removed. The patient's perception of sleep, indeed, was obviously improved, a result which may have been related to his/her perception of comfort and care from the nurse. Applying back massage to an ICU patient may therefore be regarded as helpful improving the patient's sleep quality. It is hoped that this case report may serve as a positive reference for health care providers so that it may help patients to recover fully through rest and sleep. Since this report concerned only one patient, however, to understand the real outcome of how back massage could improve the quality of sleep of ICU patients, research is planned on the use of back massage protocol on a large number os such patients.

Variation in critical care services across North America and Western Europe.

PubMed

Wunsch, Hannah; Angus, Derek C; Harrison, David A; Collange, Olivier; Fowler, Robert; Hoste, Eric A J; de Keizer, Nicolette F; Kersten, Alexander; Linde-Zwirble, Walter T; Sandiumenge, Alberto; Rowan, Kathryn M

2008-10-01

Critical care represents a large percentage of healthcare spending in developed countries. Yet, little is known regarding international variation in critical care services. We sought to understand differences in critical care delivery by comparing data on the distribution of services in eight countries. Retrospective review of existing national administrative data. We identified sources of data in each country to provide information on acute care hospitals and beds, intensive care units and beds, intensive care admissions, and definitions of intensive care beds. Data were all referenced and from as close to 2005 as possible. United States, France, United Kingdom, Canada, Belgium, Germany, The Netherlands, and Spain. Not available. None. No standard definition existed for acute care hospital or intensive care unit beds across countries. Hospital beds varied three-fold from 221/100,000 population in the United States to 593/100,000 in Germany. Adult intensive care unit beds also ranged seven-fold from 3.3/100,000 population in the United Kingdom to 24.0/100,000 in Germany. Volume of intensive care unit admissions per year varied ten-fold from 216/100,000 population in the United Kingdom to 2353/100,000 in Germany. The ratio of intensive care unit beds to hospital beds was highly correlated across all countries except the United States (r = .90). There was minimal correlation between the number of intensive care unit beds per capita and health care spending per capita (r = .45), but high inverse correlation between intensive care unit beds and hospital mortality for intensive care unit patients across countries (r = -.82). Absolute critical care services vary dramatically between countries with wide differences in both numbers of beds and volume of admissions. The number of intensive care unit beds per capita is not strongly correlated with overall health expenditure, but does correlate strongly with mortality. These findings demonstrate the need for critical care data from all countries, as they are essential for interpretation of studies, and policy decisions regarding critical care services.

[Phenylephrine dosing error in Intensive Care Unit. Case of the trimester].

PubMed

2013-01-01

A real clinical case reported to SENSAR is presented. A patient admitted to the surgical intensive care unit following a lung resection, suffered arterial hypotension. The nurse was asked to give the patient 1 mL of phenylephrine. A few seconds afterwards, the patient experienced a hypertensive crisis, which resolved spontaneously without damage. Thereafter, the nurse was interviewed and a dosing error was identified: she had mistakenly given the patient 1 mg of phenylephrine (1 mL) instead of 100 mcg (1 mL of the standard dilution, 1mg in 10 mL). The incident analysis revealed latent factors (event triggers) due to the lack of protocols and standard operating procedures, communication errors among team members (physician-nurse), suboptimal training, and underdeveloped safety culture. In order to preempt similar incidents in the future, the following actions were implemented in the surgical intensive care unit: a protocol for bolus and short lived infusions (<30 min) was developed and to close the communication gap through the adoption of communication techniques. The protocol was designed by physicians and nurses to standardize the administration of drugs with high potential for errors. To close the communication gap, repeated checks about saying and understanding was proposed ("closed loop"). Labeling syringes with the drug dilution was also recommended. Copyright © 2013 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

Risk and prognostic factors of ventilator-associated pneumonia in trauma patients.

PubMed

Cavalcanti, Manuela; Ferrer, Miquel; Ferrer, Ricard; Morforte, Ramon; Garnacho, Angel; Torres, Antoni

2006-04-01

To assess the risk and prognostic factors of ventilator-associated pneumonia in trauma patients, with an emphasis on the inflammatory response. Case-control study. Trauma intensive care unit. Of 190 consecutive mechanically ventilated patients, those with microbiologically confirmed pneumonia (n = 62) were matched with 62 controls without pneumonia. None. Clinical, microbiological, and outcome variables were recorded. Cytokines were measured in serum and blind bronchoalveolar lavage specimens at onset of pneumonia. Multivariate analyses of risk and prognostic factors for ventilator-associated pneumonia were done. Increased severity of head and neck injury (odds ratio, 11.9; p < .001) was the only independent predictor of pneumonia. Among patients with pneumonia, serum levels of interleukin-6 (p = .019) and interleukin-8 (p = .036) at onset of pneumonia were higher in nonresponders to treatment. Moreover, serum levels of tumor necrosis factor-alpha (p = .028) and interleukin-6 (p = .007) at onset of pneumonia were higher in nonsurvivors. Mortality in the intensive care unit was 23% in cases and controls. Nonresponse to antimicrobial treatment (odds ratio, 22.2; p = .001) and the use of hyperventilation (p = .021) were independent predictors of mortality in the intensive care unit for patients with pneumonia. Severe head and neck trauma is strongly associated with ventilator-associated pneumonia. A higher inflammatory response is associated with nonresponse to treatment and mortality among patients with pneumonia. Although pneumonia did not influence mortality, nonresponse to treatment independently predicted mortality among these patients.

Instituting parent education practices in the neonatal intensive care unit: an administrative case report of practice evaluation and statewide action.

PubMed

Dusing, Stacey C; Van Drew, Catherine M; Brown, Shaaron E

2012-07-01

Infants born preterm are at high risk of developmental disabilities and benefit from early developmental intervention programs. Physical therapists with neonatal expertise are ideally suited to educate parents about ways to support their infant's development in the first months of life. However, administrative policies are needed to support the therapist in providing adequate parent education in the neonatal intensive care unit (NICU). This administrative case report describes the process used by a team of neonatal therapists to evaluate clinical practice, determine the need for change, and develop and implement a new parent education program in the NICU. Physical therapy parent education practices were evaluated in an academic medical center with a 36-bed, level-3 NICU. Physical therapists with neonatal expertise covered multiple units within the hospital each day. A series of focus groups, a small descriptive study, and staff discussion were used to evaluate parent education practices in this academic medical center. A new parent education program was developed based on data collected and literature to improve clinical care. The new parent education model was implemented over the course of several months using overlapping initiatives. Administrative support for the change was developed through collaboration, open communication, and presentation of clinical data. In addition, this hospital-based program contributed to the development of a statewide initiative to educate parents of preterm infants about the importance of supporting development in the first months of life. A collaborative and data-driven approach to evaluating parent education practices supported the development of a new parent education practice while acknowledging the need to meet staff productivity standards and provide excellent care throughout the hospital.

Double jeopardy: the impact of neoliberalism on care workers in the United States and South Africa.

PubMed

Abramovitz, Mimi; Zelnick, Jennifer

2010-01-01

Many researchers have explored how neoliberal restructuring of the workplace has reduced the standard of living and increased workplace stress among private sector employees. However, few have focused on how neoliberal restructuring of public policy has had similar effects on the public sector workforce. Using original case study research, the authors examine how two iconic pieces of neoliberal policy--the 1996 welfare reform bill in the United States and the GEAR macroeconomic policy in South Africa--affected public/nonprofit human service workers in New York City, United States, and public sector nurses in KwaZulu-Natal, South Africa. The authors argue that in both situations, despite national differences, these policies created a "double jeopardy," in which patients/clients and care workers are adversely affected by neoliberal public policy. This "double jeopardy" creates significant hardship, but also the opportunity for new social movements.

The effectiveness of telemedicine for paediatric retrieval consultations: rationale and study design for a pragmatic multicentre randomised controlled trial.

PubMed

Armfield, Nigel R; Coulthard, Mark G; Slater, Anthony; McEniery, Julie; Elcock, Mark; Ware, Robert S; Scuffham, Paul A; Bensink, Mark E; Smith, Anthony C

2014-11-11

In many health systems, specialist services for critically ill children are typically regionalised or centralised. Studies have shown that high-risk paediatric patients have improved survival when managed in specialist centres and that volume of cases is a predictor of care quality. In acute cases where distance and time impede access to specialist care, clinical advice may be provided remotely by telephone. Emergency retrieval services, attended by medical and nursing staff may be used to transport patients to specialist centres. Even with the best quality retrieval services, stabilisation of the patient and transport logistics may delay evacuation to definitive care. Several studies have examined the use of telemedicine for providing specialist consultations for critically ill children. However, no studies have yet formally examined the clinical effectiveness and economic implications of using telemedicine in the context of paediatric patient retrieval. The study is a pragmatic, multicentre randomised controlled trial running over 24 months which will compare the use of telemedicine with the use of the telephone for paediatric retrieval consultations between four referring hospitals and a tertiary paediatric intensive care unit. We aim to recruit 160 children for whom a specialist retrieval consultation is required. The primary outcome measure is stabilisation time (time spent on site at the referring hospital by the retrieval team) adjusted for initial risk. Secondary outcome measures are change in patient's physiological status (repeated measure, two time points) scored using the Children's Emergency Warning Tool; change in diagnosis (repeated measure taken at three time points); change in destination of retrieved patients at the tertiary hospital (general ward or paediatric intensive care unit); retrieval decision, and length of stay in the Paediatric Intensive Care Unit for retrieved patients. The trial has been approved by the Human Research Ethics Committees of Children's Health Services Queensland and The University of Queensland, Australia. Health services are adopting telemedicine, however formal evidence to support its use in paediatric acute care is limited. Generalisable evidence is required to inform clinical use and health system policy relating to the effectiveness and economic implications of the use in telemedicine in paediatric retrieval. Australian and New Zealand Clinical Trials Registry ACTRN12612000156886 .

ICU telemedicine and critical care mortality: a national effectiveness study

PubMed Central

Kahn, Jeremy M; Le, Tri Q.; Barnato, Amber E.; Hravnak, Marilyn; Kuza, Courtney C.; Pike, Francis; Angus, Derek C.

2015-01-01

Background Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain. Objectives To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals. Research design We performed a multi-center retrospective case-control study using 2001–2010 Medicare claims data linked to a national survey identifying United States hospitals adopting ICU telemedicine. We matched each adopting hospital (cases) to up to 3 non-adopting hospitals (controls) based on size, case-mix and geographic proximity during the year of adoption. Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach. Results 132 adopting case hospitals were matched to 389 similar non-adopting control hospitals. The pre- and post-adoption unadjusted 90-day mortality was similar in both case hospitals (24.0% vs. 24.3%, p=0.07) and control hospitals (23.5% vs. 23.7%, p<0.01). In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality (ratio of odds ratios: 0.96, 95% CI = 0.95–0.98, p<0.001). However, there was wide variation in the ICU telemedicine effect across individual hospitals (median ratio of odds ratios: 1.01; interquartile range 0.85–1.12; range 0.45–2.54). Only 16 case hospitals (12.2%) experienced statistically significant mortality reductions post-adoption. Hospitals with a significant mortality reduction were more likely to have large annual admission volumes (p<0.001) and be located in urban areas (p=0.04) compared to other hospitals. Conclusions Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions. PMID:26765148

Using the UKROC dataset to make the case for resources to improve cost-efficiency in neurological rehabilitation

PubMed Central

2012-01-01

Purpose A key challenge for providers and commissioners of rehabilitation services is to find optimal balance between service costs and outcomes. This article presents a “real-lifeâ application of the UK Rehabilitation Outcomes Collaborative (UKROC) dataset. We undertook a comparative cohort analysis of case-episode data (n = 173) from two specialist neurological rehabilitation units (A and B), to compare the cost-efficiency of two service models. Key messages (i) Demographics, casemix and levels of functional dependency on admission and discharge were broadly similar for the two units. (ii) The mean length of stay for Unit A was 1.5 times longer than Unit B, which had 85% higher levels of therapy staffing in relation to occupied bed days so despite higher bed-day costs, Unit B was 20% more cost-efficient overall, for similar gain. (iii) Following analysis, engagement with service commissioners led to successful negotiation of a business plan for service reconfiguration with increased staffing levels for Unit A and further development of local community rehabilitation services. Conclusion (i) Lower front-end service costs do not always signify optimal cost-efficiency. (ii) Analysis of routinely collected clinical data can be used to engage commissioners and to make the case for resources to maximise efficiency and improve patient care. PMID:22506504

Using the UKROC dataset to make the case for resources to improve cost-efficiency in neurological rehabilitation.

PubMed

Turner-Stokes, Lynne; Poppleton, Rob; Williams, Heather; Schoewenaars, Katie; Badwan, Derar

2012-01-01

A key challenge for providers and commissioners of rehabilitation services is to find optimal balance between service costs and outcomes. This article presents a "real-life" application of the UK Rehabilitation Outcomes Collaborative (UKROC) dataset. We undertook a comparative cohort analysis of case-episode data (n = 173) from two specialist neurological rehabilitation units (A and B), to compare the cost-efficiency of two service models. (i) Demographics, casemix and levels of functional dependency on admission and discharge were broadly similar for the two units. (ii) The mean length of stay for Unit A was 1.5 times longer than Unit B, which had 85% higher levels of therapy staffing in relation to occupied bed days so despite higher bed-day costs, Unit B was 20% more cost-efficient overall, for similar gain. (iii) Following analysis, engagement with service commissioners led to successful negotiation of a business plan for service reconfiguration with increased staffing levels for Unit A and further development of local community rehabilitation services. (i) Lower front-end service costs do not always signify optimal cost-efficiency. (ii) Analysis of routinely collected clinical data can be used to engage commissioners and to make the case for resources to maximise efficiency and improve patient care.

Hospital-in-the-home treatment of surgical infectious diseases: an economic analysis.

PubMed

Mazo, Sara; Emparan, Carlos; Vallejo, Manuel; Soriano, Pablo

2007-12-01

A growing number of surgical infections can be treated safely and effectively with parenteral antimicrobial therapy in the patient's home. Our objective was to define the economic impact of a hospital-in-the-home unit (HITH) introduced into a surgical unit. Patients admitted to the HITH must be assessed thoroughly for suitability, including clinical stability and social circumstances, and both patient and caregiver consent must be obtained. The HITH received all stable surgical patients with complicated infections and an expected long-term stay. A total of 150 patients were enrolled during a 12-month period. Patients were reviewed daily to monitor the progress of therapy and check for possible complications. Antibiotic selection was based on appropriate prescribing principles rather than dosing convenience. Innovative dosing regimens were included, such as once-daily aminoglycosides, continuous-infusion beta-lactams, once- or twice-daily cephalosporins, and oral fluoroquinolones in order to provide effective therapy for a wide range of infections that previously would have required in-hospital care. Economic efficiency for both the surgical and the HITH unit was assessed by examining Diagnosis-Related Group (DRG)-based clinical processes, profits and losses of each clinical process, and a quantitative model for performance evaluation and benchmarking (data envelopment analysis; DEA). The mean stay in the surgical unit was decreased (3.95 days) while increasing the case mix (1.42). At the same time, HITH patients had a mean stay of 8.69 days with a stable case mix of 1.61. The economic benefit of both units increased in the surgical unit because of a shorter stay and in the HITH secondary to greater impact of the case mix while maintaining the mean stay. Appropriate use of HITH leads to greater patient and caregiver satisfaction, efficient in-hospital bed use, and financial efficiencies. Patients receiving intravenous antibiotics, wound care, parenteral nutrition, or transfusions do not always need to be in the hospital.

Reverse transport of children from a tertiary pediatric hospital.

PubMed

McPherson, Mona L; Jefferson, Larry S; Smith, E O'Brian; Sitler, Garry C; Graf, Jeanine M

2007-01-01

The purpose of this study was to determine the epidemiology and resources used and to study the potential savings of pediatric reverse transport patients. A case control study was performed with patients undergoing a reverse or outbound transport from a large, pediatric hospital. Twenty-five children undergoing reverse transport were compared with matched controls. Lengths of stay and costs were compared between the reverse transport and matched control patients. Fifty-two percent of the reverse transport patients returned home, whereas 32% went home for end-of-life care and 16% went to other facilities. The average reverse transport was more than 400 miles and cost $6,064. The reverse transport of these patients did not save pediatric intensive care unit (PICU) days but did result in a shorter hospital stay compared with the matched controls (10 vs. 19 days, P = .03). Decreased utilization of bed days came from less use of intermediate care unit resources. Pediatric patients undergo reverse transports for a variety of reasons, often for end-of-life care. The ability to reverse transport pediatric patients may not save PICU bed days but may offer pediatric tertiary care hospitals a means to provide more intermediate care bed availability.

Health Care Utilization and Cost Burden of Herpes Zoster in a Community Population

PubMed Central

Yawn, Barbara P.; Itzler, Robbin F.; Wollan, Peter C.; Pellissier, James M.; Sy, Lina S.; Saddier, Patricia

2009-01-01

OBJECTIVE: To conduct a population-based study to assess health care utilization (HCU) and costs associated with herpes zoster (HZ) and its complications, including postherpetic neuralgia (PHN) and nonpain complications, in adults aged 22 years and older. PATIENTS AND METHODS: Medical record data on HCU were abstracted for all confirmed new cases of HZ from January 1, 1996, through December 31, 2001, among residents of Olmsted County, Minnesota. Herpes zoster-related costs were estimated by applying the Medicare Payment Fee Schedule to health care encounters and mean wholesale prices to medications. All costs were adjusted to 2006 US dollars using the medical care component of the Consumer Price Index. RESULTS: The HCU and cost of the 1669 incident HZ cases varied, depending on the complications involved. From 3 weeks before to 1 year after initial diagnosis, there were a mean of 1.8 outpatient visits and 3.1 prescribed medications at a cost of $720 for cases without PHN or nonpain complications compared with 7.5 outpatient visits and 14.7 prescribed medications at a cost of $3998 when complications, PHN, or nonpain complications were present. CONCLUSION: The annual medical care cost of treating incident HZ cases in the United States, extrapolated from the results of this study in Olmsted County, is estimated at $1.1 billion. Most of the costs are for the care of immunocompetent adults with HZ, especially among those 50 years and older. PMID:19720776

The Many Faces of Language.

ERIC Educational Resources Information Center

Werdmann, Anne M.

In a sixth-grade unit, students learned about people's facial expressions through careful observation, recording, reporting, and generalizing. The students studied the faces of people of various ages; explored "masks" that people wear in different situations; learned about the use of ritual masks; made case studies of individuals to show…

Using system dynamics for collaborative design: a case study

PubMed Central

Elf, Marie; Putilova, Mariya; von Koch, Lena; Öhrn, Kerstin

2007-01-01

Background In order to facilitate the collaborative design, system dynamics (SD) with a group modelling approach was used in the early stages of planning a new stroke unit. During six workshops a SD model was created in a multiprofessional group. Aim To explore to which extent and how the use of system dynamics contributed to the collaborative design process. Method A case study was conducted using several data sources. Results SD supported a collaborative design, by facilitating an explicit description of stroke care process, a dialogue and a joint understanding. The construction of the model obliged the group to conceptualise the stroke care and experimentation with the model gave the opportunity to reflect on care. Conclusion SD facilitated the collaborative design process and should be integrated in the early stages of the design process as a quality improvement tool. PMID:17683519

Clinical Presentation and Care of Patients with Ebola Virus Disease in the China Ebola Treatment Unit, Liberia.

PubMed

Shao, Xiaoping; Ren, Weizheng; Zhou, Feihu

2017-01-24

In order to evaluate the clinical characteristics of confirmed Ebola Virus Disease (EVD) patients admitted to the China Ebola Treatment Unit (China ETU) between January 2015 and March 2015, we retrospectively analyzed clinical symptoms, treatment, and epidemiologic features of 5 patients with confirmed EVD, and reviewed the relevant medical literature. Of these, 3 patients survived, and 2 died. The time interval from the onset of symptoms to the negative PCR test for Ebola virus in the 3 survivors was 14-18 days. All survivors reported direct contact with confirmed EVD patients up to 21 days prior to admission. All patients developed a fever, fatigue, and anorexia. Fever was generally the first symptom to develop, followed by a gastrointestinal phase characterized by vomiting/nausea (3 cases, 60%), diarrhea (3 cases), and abdominal pain (4 cases, 80%). Three patients (60%) reported joint pain, muscle pain, and conjunctival hemorrhage, respectively, and 2 patients (40%) developed a headache. We concluded that strict isolation and interruption of the route of transmission were required for suspected or confirmed EVD patients. The main treatment strategies were supportive care, maintenance of blood volume and electrolyte balance, and the prevention of complications.

[Nutritional support in the home-based hospitalization setting].

PubMed

Chicharro, L; Planas, M; Pérez-Portabella, C; Vélez, C; San José, A

2009-01-01

The Hospital at Home (HAD) is a choice of care that enables own care in a hospital at home patient. Moreover, the nutritional support (NS) -enteral or parenteral nutrition- is usually indicated in patients with serious underlying disease, and/or frequently remain severely disabled. To analyze the characteristics of the patients, attended at home for specific questions of the NS that receive. descriptive and retrospective study of the patients attended by the Nutritional Support Unit (NSU), in the area of the HAD, from September 1, 2006 until August 31, 2007. At home, the realized procedure was: refill of gastrostomia or jejunostomia feeding tube in 158 cases; modification of the guideline of enteral nutrition (EN) or parenteral nutrition (PN) in 53 cases; training of the skill of artificial nutrition in 14 cases. 39 visits were realized by complications -by infection or lead throught the estoma and by obstruction of the feeding tube-. Only in 3 patients (7.7%) the domiciliary assistance indicated the movement of the patient to the Emergency Unit. In our center, the infrastructure of the HAD has allowed to give answer to the needs of the patients who receive NS at home in our area of influence.

Care coordination gaps due to lack of interoperability in the United States: a qualitative study and literature review.

PubMed

Samal, Lipika; Dykes, Patricia C; Greenberg, Jeffrey O; Hasan, Omar; Venkatesh, Arjun K; Volk, Lynn A; Bates, David W

2016-04-22

Health information technology (HIT) could improve care coordination by providing clinicians remote access to information, improving legibility, and allowing asynchronous communication, among other mechanisms. We sought to determine, from a clinician perspective, how care is coordinated and to what extent HIT is involved when transitioning patients between emergency departments, acute care hospitals, skilled nursing facilities, and home health agencies in settings across the United States. We performed a qualitative study with clinicians and information technology professionals from six regions of the U.S. which were chosen as national leaders in HIT. We analyzed data through a two person consensus approach, assigning responses to each of nine care coordination activities. We also conducted a literature review of MEDLINE®, CINAHL®, and Embase, analyzing results of studies that examined interventions to improve information transfer during transitions of care. We enrolled 29 respondents from 17 organizations and conducted six focus groups. Respondents reported how HIT is currently used for care coordination activities. HIT is currently used to monitor patients and to align systems-level resources with population needs. However, we identified multiple areas where the lack of interoperability leads to inefficient processes and missing data. Additionally, the literature review identified ten intervention studies that address information transfer, seven of which employed HIT and three of which utilized other communication methods such as telephone calls, faxed records, and nurse case management. Significant care coordination gaps exist due to the lack of interoperability across the United States. We must design, evaluate, and incentivize the use of HIT for care coordination. We should focus on the domains where we found the largest gaps: information transfer, systems to monitor patients, tools to support patients' self-management goals, and tools to link patients and their caregivers with community resources.

How to solve the cost crisis in health care.

PubMed

Kaplan, Robert S; Porter, Michael E

2011-09-01

U.S. health care costs currently exceed 17% of GDP and continue to rise. One fundamental reason that providers are unable to reverse the trend is that they don't understand what it costs to deliver patient care or how those costs compare with outcomes. To put it bluntly, few health care providers measure the actual costs for treating a given patient with a given medical condition over a full cycle of care, or compare the costs they incur with the outcomes they achieve. What isn't measured cannot be managed or improved, and this is all too true in health care, where poor costing systems mean that effective and efficient providers go unrewarded, and inefficient ones have little incentive to improve. But all this can be remedied by exploring the concept of value in health care and carefully measuring costs. This article describes a new way to analyze costs that uses patients and their conditions--not organizational units or narrow diagnostic treatment groups--as the fundamental unit of analysis for measuring costs and outcomes. The new approach, called time-driven activity-cased costing, is currently being implemented in pilots at the Head and Neck Center at MD Anderson, the Cleft Lip and Palate Program at Children's Hospital in Boston, and units performing knee replacements at Schön Klinik in Germany and Brigham & Women's Hospital in Boston. As providers and payors better understand costs, they will be positioned to achieve a true "bending of the cost curve" from within the system, not in response to top-down mandates. Accurate costing also unlocks a whole cascade of opportunities, such as process improvement, better organization of care, and new reimbursement approaches that will accelerate the pace of innovation and value creation.

The relationship between organizational culture and family satisfaction in critical care.

PubMed

Dodek, Peter M; Wong, Hubert; Heyland, Daren K; Cook, Deborah J; Rocker, Graeme M; Kutsogiannis, Demetrios J; Dale, Craig; Fowler, Robert; Robinson, Sandra; Ayas, Najib T

2012-05-01

Family satisfaction with critical care is influenced by a variety of factors. We investigated the relationship between measures of organizational and safety culture, and family satisfaction in critical care. We further explored differences in this relationship depending on intensive care unit survival status and length of intensive care unit stay of the patient. Cross-sectional surveys. Twenty-three tertiary and community intensive care units within three provinces in Canada. One thousand two-hundred eighty-five respondents from 2374 intensive care unit clinical staff, and 880 respondents from 1381 family members of intensive care unit patients. None. Intensive care unit staff completed the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture. Family members completed the Family Satisfaction in the Intensive Care Unit 24, a validated survey of family satisfaction. A priori, we analyzed adjusted relationships between each domain score from the culture surveys and either satisfaction with care or satisfaction with decision-making for each of four subgroups of family members according to patient descriptors: intensive care unit survivors who had length of intensive care unit stay <14 days or >14 days, and intensive care unit nonsurvivors who had length of stay <14 days or ≥14 days. We found strong positive relationships between most domains of organizational and safety culture, and satisfaction with care or decision-making for family members of intensive care unit nonsurvivors who spent at least 14 days in the intensive care unit. For the other three groups, there were only a few weak relationships between domains of organizational and safety culture and family satisfaction. Our findings suggest that the effect of organizational culture on care delivery is most easily detectable by family members of the most seriously ill patients who interact frequently with intensive care unit staff, who are intensive care unit nonsurvivors, and who spend a longer time in the intensive care unit. Positive relationships between measures of organizational and safety culture and family satisfaction suggest that by improving organizational culture, we may also improve family satisfaction.

Controlling the last known cluster of Ebola virus disease - Liberia, January-February 2015.

PubMed

Nyenswah, Tolbert; Fallah, Mosoka; Sieh, Sonpon; Kollie, Karsor; Badio, Moses; Gray, Alvin; Dilah, Priscilla; Shannon, Marnijina; Duwor, Stanley; Ihekweazu, Chikwe; Cordier-Lassalle, Thierry; Cordier-Lasalle, Thierry; Shinde, Shivam A; Hamblion, Esther; Davies-Wayne, Gloria; Ratnesh, Murugan; Dye, Christopher; Yoder, Jonathan S; McElroy, Peter; Hoots, Brooke; Christie, Athalia; Vertefeuille, John; Olsen, Sonja J; Laney, A Scott; Neal, Joyce J; Yaemsiri, Sirin; Navin, Thomas R; Coulter, Stewart; Pordell, Paran; Lo, Terrence; Kinkade, Carl; Mahoney, Frank

2015-05-15

As one of the three West African countries highly affected by the 2014-2015 Ebola virus disease (Ebola) epidemic, Liberia reported approximately 10,000 cases. The Ebola epidemic in Liberia was marked by intense urban transmission, multiple community outbreaks with source cases occurring in patients coming from the urban areas, and outbreaks in health care facilities (HCFs). This report, based on data from routine case investigations and contact tracing, describes efforts to stop the last known chain of Ebola transmission in Liberia. The index patient became ill on December 29, 2014, and the last of 21 associated cases was in a patient admitted into an Ebola treatment unit (ETU) on February 18, 2015. The chain of transmission was stopped because of early detection of new cases; identification, monitoring, and support of contacts in acceptable settings; effective triage within the health care system; and rapid isolation of symptomatic contacts. In addition, a "sector" approach, which divided Montserrado County into geographic units, facilitated the ability of response teams to rapidly respond to community needs. In the final stages of the outbreak, intensive coordination among partners and engagement of community leaders were needed to stop transmission in densely populated Montserrado County. A companion report describes the efforts to enhance infection prevention and control efforts in HCFs. After February 19, no additional clusters of Ebola cases have been detected in Liberia. On May 9, the World Health Organization declared the end of the Ebola outbreak in Liberia.

The contribution of viral hepatitis to the burden of chronic liver disease in the United States.

PubMed

Roberts, Henry W; Utuama, Ovie A; Klevens, Monina; Teshale, Eyasu; Hughes, Elizabeth; Jiles, Ruth

2014-03-01

Chronic liver disease (CLD) is increasingly recognized as a major public health problem. However, in the United States, there are few nationally representative data on the contribution of viral hepatitis as an etiology of CLD. We applied a previously used International Classification of Diseases, Ninth Revision, Clinical Modification-based definition of CLD cases to the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey databases for 2006-2010. We estimated the mean number of CLD visits per year, prevalence ratio of visits by patient characteristics, and the percentage of CLD visits attributed to viral hepatitis and other selected etiologies. An estimated 6.0 billion ambulatory care visits occurred in the United States from 2006 to 2010, of which an estimated 25.8 million (0.43%) were CLD-related. Among adults aged 45-64 years, Medicaid and Medicare recipients were 3.9 (prevalence ratio (PR)=3.9, 95% confidence limit (CL; 2.8, 5.4)) and 2.3 (PR=2.3, 95% CL (1.6, 3.4)) times more likely to have a CLD-related ambulatory visit than those with private insurance, respectively. In the United States, from 2006 to 2010, an estimated 49.6% of all CLD-related ambulatory visits were attributed solely to viral hepatitis B and C diagnoses. In this unique application of health-care utilization data, we confirm that viral hepatitis is an important etiology of CLD in the United States, with hepatitis B and C contributing approximately one-half of the CLD burden. CLD ambulatory visits in the United States disproportionately occur among adults, aged 45-64 years, who are primarily minorities, men, and Medicare or Medicaid recipients.

Developing a minimum dataset for nursing team leader handover in the intensive care unit: A focus group study.

PubMed

Spooner, Amy J; Aitken, Leanne M; Corley, Amanda; Chaboyer, Wendy

2018-01-01

Despite increasing demand for structured processes to guide clinical handover, nursing handover tools are limited in the intensive care unit. The study aim was to identify key items to include in a minimum dataset for intensive care nursing team leader shift-to-shift handover. This focus group study was conducted in a 21-bed medical/surgical intensive care unit in Australia. Senior registered nurses involved in team leader handovers were recruited. Focus groups were conducted using a nominal group technique to generate and prioritise minimum dataset items. Nurses were presented with content from previous team leader handovers and asked to select which content items to include in a minimum dataset. Participant responses were summarised as frequencies and percentages. Seventeen senior nurses participated in three focus groups. Participants agreed that ISBAR (Identify-Situation-Background-Assessment-Recommendations) was a useful tool to guide clinical handover. Items recommended to be included in the minimum dataset (≥65% agreement) included Identify (name, age, days in intensive care), Situation (diagnosis, surgical procedure), Background (significant event(s), management of significant event(s)) and Recommendations (patient plan for next shift, tasks to follow up for next shift). Overall, 30 of the 67 (45%) items in the Assessment category were considered important to include in the minimum dataset and focused on relevant observations and treatment within each body system. Other non-ISBAR items considered important to include related to the ICU (admissions to ICU, staffing/skill mix, theatre cases) and patients (infectious status, site of infection, end of life plan). Items were further categorised into those to include in all handovers and those to discuss only when relevant to the patient. The findings suggest a minimum dataset for intensive care nursing team leader shift-to-shift handover should contain items within ISBAR along with unit and patient specific information to maintain continuity of care and patient safety across shift changes. Copyright © 2017 Australian College of Critical Care Nurses Ltd. All rights reserved.

Fluids and sepsis: changing the paradigm of fluid therapy: a case report.

PubMed

Hariyanto, Hori; Yahya, Corry Quando; Widiastuti, Monika; Wibowo, Primartanto; Tampubolon, Oloan Eduard

2017-02-04

Over the past 16 years, sepsis management has been guided by large-volume fluid administration to achieve certain hemodynamic optimization as advocated in the Rivers protocol. However, the safety of such practice has been questioned because large-volume fluid administration is associated with fluid overload and carries the worst outcome in patients with sepsis. Researchers in multiple studies have declared that using less fluid leads to increased survival, but they did not describe how to administer fluids in a timely and appropriate manner. An 86-year-old previously healthy Sundanese man was admitted to the intensive care unit at our institution with septic shock, acute kidney injury, and respiratory distress. Standard care was implemented during his initial care in the high-care unit; nevertheless, his condition worsened, and he was transferred to the intensive care unit. We describe the timing of fluid administration and elaborate on the amount of fluids needed using a conservative fluid regimen in a continuum of resuscitated sepsis. Because fluid depletion in septic shock is caused by capillary leak and pathologic vasoplegia, continuation of fluid administration will drive intravascular fluid into the interstitial space, thereby producing marked tissue edema and disrupting vital oxygenation. Thus, fluids have the power to heal or kill. Therefore, management of patients with sepsis should entail early vasopressors with adequate fluid resuscitation followed by a conservative fluid regimen.

Critical Care Nurses' Suggestions to Improve End-of-Life Care Obstacles: Minimal Change Over 17 Years.

PubMed

Beckstrand, Renea L; Hadley, Kacie Hart; Luthy, Karlen E; Macintosh, Janelle L B

Critical-care nurses (CCNs) provide end-of-life (EOL) care on a daily basis as 1 in 5 patients dies while in intensive care units. Critical-care nurses overcome many obstacles to perform quality EOL care for dying patients. The purposes of this study were to collect CCNs' current suggestions for improving EOL care and determine if EOL care obstacles have changed by comparing results to data gathered in 1998. A 72-item questionnaire regarding EOL care perceptions was mailed to a national, geographically dispersed, random sample of 2000 members of the American Association of Critical-Care Nurses. One of 3 qualitative questions asked CCNs for suggestions to improve EOL care. Comparative obstacle size (quantitative) data were previously published. Of the 509 returned questionnaires, 322 (63.3%) had 385 written suggestions for improving EOL care. Major themes identified were ensuring characteristics of a good death, improving physician communication with patients and families, adjusting nurse-to-patient ratios to 1:1, recognizing and avoiding futile care, increasing EOL education, physicians who are present and "on the same page," not allowing families to override patients' wishes, and the need for more support staff. When compared with data gathered 17 years previously, major themes remained the same but in a few cases changed in order and possible causation. Critical-care nurses' suggestions were similar to those recommendations from 17 years ago. Although the order of importance changed minimally, the number of similar themes indicated that obstacles to providing EOL care to dying intensive care unit patients continue to exist over time.

Global case management: Scotland. Real-time monitoring of patient flow as an instrument to optimize quality of care in acute receiving units.

PubMed

Thuemmler, Christoph; Morris, Carole

2005-01-01

Recent audits within our hospital suggest that especially during peak phases the patient flow from our acute admission units downstream into hospital beds is not directed in the most efficient way and patients may be placed inappropriately. This inevitably causes time delays and potentially increases the risk of malpractice as patients have to spend an extended period of time in admission areas with a high workload and very busy staff. Using latest information technology, such as wireless local area networks and handheld devices, can improve the efficiency of patient management and can increase the quality of care by helping to avoid unnecessary treatment delays in overcrowded admission areas.

[Influenza infection in intensive cardiac care unit patients].

PubMed

Ciuraszkiewicz, Katrzyna; Sielski, Janusz; Janion-Sadowska, Agnieszka; Stern, Agnieszka; Zychowicz, Joanna; Kaziród-Wolski, Karol; Paluchowski, Marian

2014-03-01

Infection with influenza type A virus may cause serious cardiovascular complications, such as myocarditis, heart failure, acute myocardial infarction. Also infection with influenza type AH1N1 may contribute to aggravation of cardiac disorders, i.e. acute coronary syndrome, heart failure, cardiogenic shock, severe ventricular arrythmias. One of the most fatal complication of influenza is pneumonia leading to acute respiratory insufficiency requiring artifitial ventilation. Symptoms of respiratory tract infections durnig influenza epidemy should always be treated with a high index of suspicion. Early diagnosis and adequate antiviral treatment may prevent those complications. A series of four cases of patients hospitalised in intensive cardiac care unit due to suspected cardiac dyspnea and finally diagnosed as a cardiac disease complicated by influenza pneumonia is presented.

[Nursing diagnoses related to breastfeeding in a rooming-in unit].

PubMed

da Silva, Evilene Pinto; Alves, Albertisa Rodrigues; Macedo, Ana Ruth Monteiro; Bezerra, Regina Maria de Sá Barreto; de Almeida, Paulo César; Chaves, Edna Maria Camelo

2013-01-01

The study aimed to identify, in a Rooming-in unit, diagnoses related to the phenomenon of breastfeeding according to the NANDA-I Taxonomy II. It was conducted a descriptive exploratory study involving 83 mothers and their babies in the period of February to April 2011. Data were collected by means of an instrument based on the Theory of Basic Human Needs and, after statistical analysis, presented in tables. The results showed that the most frequent nursing diagnosis was Effective breastfeeding, identified in 65 (78.3%) cases. It is estimated that the nursing diagnoses related to breastfeeding can contribute to nursing care so that it can be more targeted, in order to promote a more qualified, effective and human care.

Measuring Outcomes of an Intensive Care Unit Family Diary Program.

PubMed

Huynh, Truong-Giang; Covalesky, Miranda; Sinclair, Samantha; Gunter, Heather; Norton, Tamara; Chen, Alice; Yi, Cassia

2017-01-01

Patients discharged from intensive care units are at risk of short- and long-term physical, cognitive, and emotional symptoms known as post-intensive care syndrome. Family members of intensive care unit patients are at risk of similar symptoms known as post-intensive care syndrome-family. Both syndromes are common, and strategies to reduce risk factors should be employed. An intensive care unit diary project to help reduce these syndromes was implemented in 2 intensive care units using an evidence-based framework. The effects of these diaries were studied using the Family Satisfaction with Care in the Intensive Care Unit survey. Rates of referrals to a postintensive care unit recovery clinic were also observed in relation to the diaries. Although preliminary data did not reveal a significant increase in family satisfaction, the surveys provided important staff feedback. The diaries fostered feelings of compassion and caring as well as built trust between staff and family members of intensive care unit patients. The diaries increased referrals to the postintensive care unit recovery clinic. ©2017 American Association of Critical-Care Nurses.

Acute care surgery: impact on practice and economics of elective surgeons.

PubMed

Miller, Preston R; Wildman, Elizabeth A; Chang, Michael C; Meredith, J Wayne

2012-04-01

The creation of an acute care surgery service provides a rich operative experience for acute care surgeons. Elective surgeons typically have concerns about whether their practice volume will be restored with elective cases. Acute care surgery has financial implications for both groups. The aim of this project is to examine the impact in terms of work relative value units (wRVUs), collections, and cases in both groups with creation of an acute care surgery service at our institution. Work RVUs, collections, and case volume were examined from departmental records for 2 groups before and after acute care surgery service creation. The service began on September 1, 2008. Before this time, emergency surgical consults went to the general surgeon on call. After this date, all emergency consults were seen by acute care surgeons. The number of operations performed by the acute care surgery group increased significantly when the mean of the 2 years after institution of acute care surgery were compared with the mean of the 2 years preceding the service creation (1,639 vs 790/year; p = 0.007). There was no change in total operations done by the elective surgery group (2,763 vs 2,496/year: p = 0.13). Elective caseload, however, did increase by 23% in the elective surgery group. In the acute care surgery group, wRVUs increased by 140% and elective surgery group wRVUs decreased by 8%. Collections increased in both groups (acute care surgery 129%, elective surgery 7%) and the combined collections of the groups increased by $2,138,00 in the year after service creation. Acute care surgery service creation took emergency business from the elective surgery group, but this was almost immediately replaced with elective cases. This resulted in higher collections for both groups and a resultant significant increase in collections in aggregate. Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Liability issues in managed care.

PubMed

Ellis, M S

1997-05-01

The explosive growth in Managed Care Organizations as a mechanism for providing health care in the United States has generated an equal explosion in litigation and new legislation related to problems within this delivery system. Abuses have included the "gagging" of physicians from providing full disclosure of medical options for their patients, inappropriate denial of care, denial of specialty referral, false claims data, insurer insolvency, economic credentialling, deselection, financial disincentives to render care, and lack of appeal or grievance mechanisms. These issues and others have resulted in injuries to patients and damage to the patient/physician relationship. This article discusses some of the more dramatic litigated cases and endeavors to alert both physicians and patients to potential legal matters that should be considered before becoming involved within this structure.

Hearing-loss-associated gene detection in neonatal intensive care unit.

PubMed

Yang, S M; Liu, Ying; Liu, C; Yin, A H; Wu, Y F; Zheng, X E; Yang, H M; Yang, J

2018-02-01

To investigate the frequency and mutation spectrum of hearing loss-associated gene mutation in Neonatal Intensive Care Unit (NICU). Neonates (n=2305) admitted to NICU were enrolled in this study. Nine prominent hearing loss-associated genes, GJB2 (35 del G, 176 del 16,235 del C, 299 del AT), GJB3 (538 C > T), SLC26A4 (IVS7-2A > G, 2168 A > G) and mtDNA 12S rRNA(1555 A > G, 1494 C > T), were detected. There were 73 cases hearing-loss-associated gene mutation among 2305 cases, the mutation frequency was 3.1%, with 40 cases GJB2 (235del C) mutation (54.8%), 6 cases GJB2 (299 del AT) mutation (8.2%), 21 cases SLC26A4 (IVS 7-2 A > G) mutation (28.7%), 4 cases SLC26A4 (2168 A > G) mutation (5.5%), 2 cases of GJB2 (235del C) combined SLC26A4 (IVS 7-2 A > G, 2168 A > G) mutation (2.8%). Among 73 gene mutation cases, preterm neonates presented in 18 cases, accounting for 24.7% (18/73); hyperbilirubinemia in 13 cases, accounting for 17.8% (13/73); Torch Syndrome in 15 cases, with 12 cases CMV, 2 cases rubella, 1 case toxoplasm, respectively, totally accounting for 20.54% (15/73); neonatal pneumonia in 12 cases, accounting for 16.4% (12/73); birth asphyxia in 5 cases, accounting for 6.9% (5/73); sepsis in 5 cases, accounting for 6.9% (5/73); others in 5 cases, accounting for 6.8% (5/73) . The frequency of hearing loss-associated gene mutation was higher in NICU.There were hearing loss-associated gene mutations in the NICU, suggesting this mutation may complicate with perinatal high-risk factors.

The Burns Registry of Australia and New Zealand: progressing the evidence base for burn care.

PubMed

Cleland, Heather; Greenwood, John E; Wood, Fiona M; Read, David J; Wong She, Richard; Maitz, Peter; Castley, Andrew; Vandervord, John G; Simcock, Jeremy; Adams, Christopher D; Gabbe, Belinda J

2016-03-21

Analysis of data from the Burns Registry of Australia and New Zealand (BRANZ) to determine the extent of variation between participating units in treatment and in specific outcomes during the first 4 years of its operation. BRANZ, an initiative of the Australian and New Zealand Burn Association, is a clinical quality registry developed in accordance with the Australian Commission on Safety and Quality in Healthcare national operating principles. Patients with burn injury who fulfil pre-defined criteria are transferred to and managed in designated burn units. There are 17 adult and paediatric units in Australia and New Zealand that manage almost all patients with significant burn injury. Twelve of these units treat adult patients. Data on 7184 adult cases were contributed by ten acute adult burn units to the registry between July 2010 and June 2014.Major outcomes: In-hospital mortality, hospital length of stay, skin grafting rates, and rates of admission to intensive care units. Considerable variations in unit profiles (including numbers of patients treated), in treatment and in outcomes were identified. Despite the highly centralised delivery of care to patients with severe or complex burn injury, and the relatively small number of specialist burn units, we found significant variation between units in clinical management and in outcomes. BRANZ data from its first 4 years of operation support its feasibility and the value of further development of the registry. Based on these results, the focus of ongoing research is to improve understanding of the reasons for variations in practice and of their effect on outcomes for patients, and to develop evidence-informed clinical guidelines for burn management in Australia and New Zealand.

Impact of consultant specialty on discharge decisions in patients admitted as medical emergencies to hospitals in the United Kingdom.

PubMed

Subbe, C P; Jeune, Ivan Le; Ward, D; Pradhan, S; Masterton-Smith, C

2017-02-01

The Society for Acute Medicine's Benchmarking Audit (SAMBA) annually examines Clinical Quality Indicators (CQIs) of the care of patients admitted to UK hospitals as medical emergencies. The aim of this study is to review the impact of consultant specialty on discharge decisions in the SAMBA data-set. Prospective audit of patients admitted to acute medical units (AMUs) on 25 June 2015 to participating hospitals throughout the UK with subgroup analysis. Eighty-three units submitted patient data from 3138 patients.Nearly 1845 (58%, IQR for units 50-69%) of patients were referrals from Emergency Medicine, 1072 (32%, IQR for units 24-44%) were referrals from Primary Care. The mean age was 65 (SD 20). One hundred and forty-one (4.5%) patients were admitted from care homes and 951 (30%) of patients were at least 'mildly frail' and 407 (13%) had signs of physiological instability. The median and the mean time to being seen by a doctor were 1 h 20 min and 2 h 3 min, respectively. The median and the mean time to being seen by senior specialist were 3 h 55 min and 5 h 56 min, respectively. By 72 h, 29 (1%) patients had died in the AMU, 73 were admitted to critical care units, 1297 (41%) had been discharged to their own home and 60 to nursing or residential homes. For every 100 patients seen specialists in acute medicine discharged 12 more patients than specialists from other disciplines of medicine ( P  < 0.001). The difference remained significant after adjustment for case mix. Specialist in acute care might facilitate discharge in a higher proportion of patients. © The Author 2016. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Patient stress in intensive care: comparison between a coronary care unit and a general postoperative unit

PubMed Central

Dias, Douglas de Sá; Resende, Mariane Vanessa; Diniz, Gisele do Carmo Leite Machado

2015-01-01

Objective To evaluate and compare stressors identified by patients of a coronary intensive care unit with those perceived by patients of a general postoperative intensive care unit. Methods This cross-sectional and descriptive study was conducted in the coronary intensive care and general postoperative intensive care units of a private hospital. In total, 60 patients participated in the study, 30 in each intensive care unit. The stressor scale was used in the intensive care units to identify the stressors. The mean score of each item of the scale was calculated followed by the total stress score. The differences between groups were considered significant when p < 0.05. Results The mean ages of patients were 55.63 ± 13.58 years in the coronary intensive care unit and 53.60 ± 17.47 years in the general postoperative intensive care unit. For patients in the coronary intensive care unit, the main stressors were “being in pain”, “being unable to fulfill family roles” and “being bored”. For patients in the general postoperative intensive care unit, the main stressors were “being in pain”, “being unable to fulfill family roles” and “not being able to communicate”. The mean total stress scores were 104.20 ± 30.95 in the coronary intensive care unit and 116.66 ± 23.72 (p = 0.085) in the general postoperative intensive care unit. When each stressor was compared separately, significant differences were noted only between three items. “Having nurses constantly doing things around your bed” was more stressful to the patients in the general postoperative intensive care unit than to those in the coronary intensive care unit (p = 0.013). Conversely, “hearing unfamiliar sounds and noises” and “hearing people talk about you” were the most stressful items for the patients in the coronary intensive care unit (p = 0.046 and 0.005, respectively). Conclusion The perception of major stressors and the total stress score were similar between patients in the coronary intensive care and general postoperative intensive care units. PMID:25909309

Descriptive epidemiology and natural history of idiopathic venous thromboembolism in U.S. active duty enlisted personnel, 1998-2007.

PubMed

Freeman, Randall J; Li, Yuanzhang; Niebuhr, David W

2011-05-01

The estimated incidence of idiopathic venous thromboembolism (IVTE) cases in the United States ranges from 24,000 to 282,000/year. This analysis explores the incidence and prevalence of IVTE in the military and if cases experience increased attrition. The Defense Medical Surveillance System was searched for incident IVTE cases from 1998 through 2007. Enlisted cases were each matched to 3 controls. Kaplan-Meier survival analysis and Cox proportional hazard modeling were performed. We matched 463 cases to 1,389 controls. Outpatient IVTE rates have increased markedly from 1998 through 2007. Cases of all-cause attrition risk (0.56 [95% CI = 0.44, 0.72]) and rates were significantly less than controls (p < 0.0001), and cases of medical attrition risk (1.64 [95% CI = 1.13, 2.37]) and rates were significantly higher (p < 0.01). Increasing rates with lower attrition suggests increasing case prevalence. Health care providers must maintain a high index of suspicion for venous thromboembolism to minimize adverse sequelae affecting health, unit readiness, and medical costs.

Organizational Factors Associated With Perceived Quality of Patient Care in Closed Intensive Care Units.

PubMed

McIntosh, Nathalie; Oppel, Eva; Mohr, David; Meterko, Mark

2017-09-01

Improving patient care quality in intensive care units is increasingly important as intensive care unit services account for a growing proportion of hospital services. Organizational factors associated with quality of patient care in such units have been identified; however, most were examined in isolation, making it difficult to assess the relative importance of each. Furthermore, though most intensive care units now use a closed model, little research has been done in this specific context. To examine the relative importance of organizational factors associated with patient care quality in closed intensive care units. In a national exploratory, cross-sectional study focused on intensive care units at US Veterans Health Administration acute care hospitals, unit directors were surveyed about nurse and physician staffing, work resources and training, patient care coordination, rounding, and perceptions of patient care quality. Administrative records yielded data on patient volume and facility teaching status. Descriptive statistics, bivariate analyses, and regression modeling were used for data analysis. Sixty-nine completed surveys from directors of closed intensive care units were returned. Regression model results showed that better patient care coordination (β = 0.43; P = .01) and having adequate work resources (β = 0.26; P = .02) were significantly associated with higher levels of patient care quality in such units ( R 2 = 0.22). Augmenting work resources and/or focusing limited hospital resources on improving patient care coordination may be the most productive ways to improve patient care quality in closed intensive care units. ©2017 American Association of Critical-Care Nurses.

Assessing Complex Emergency Management with Clinical Case-Vignettes: A Validation Study

PubMed Central

2015-01-01

Objective To evaluate whether responses to dynamic case-vignettes accurately reflect actual practices in complex emergency situations. We hypothesized that when obstetricians were faced with vignette of emergency situation identical to one they previously managed, they would report the management strategy they actually used. On the other hand, there is no reason to suppose that their response to a vignette based on a source case managed by another obstetrician would be the same as the actual management. Methods A multicenter vignette-based study was used in 7 French maternity units. We chose the example of severe postpartum hemorrhage (PPH) to study the use of case-vignettes for assessing the management of complex situations. We developed dynamic case-vignettes describing incidents of PPH in several steps, using documentation in patient files. Vignettes described the postpartum course and included multiple-choice questions detailing proposed clinical care. Each participating obstetrician was asked to evaluate 4 case-vignettes: 2 directly derived from cases they previously managed and 2 derived from other obstetricians’ cases. We compared the final treatment decision in vignette responses to those documented in the source-case by the overall agreement and the Kappa coefficient, both for the cases the obstetricians previously managed and the cases of others. Results Thirty obstetricians participated. Overall agreement between final treatment decisions in case-vignettes and documented care for cases obstetricians previously managed was 82% (Kappa coefficient: 0.75, 95% CI [0.62–0.88]). Overall agreement between final treatment decisions in case-vignettes and documented care in vignettes derived from other obstetricians’ cases was only 48% (Kappa coefficient: 0.30, 95% CI [0.12–0.48]). Final agreement with documented care was significantly better for cases based on their own previous cases than for others (p<0.001). Conclusions Dynamic case-vignettes accurately reflect actual practices in complex emergency situations. Therefore, they can be used to assess the quality of management in these situations. PMID:26383261

Tetanus in adult males, Bugando Medical Centre, United Republic of Tanzania.

PubMed

Aziz, Riaz; Peck, Robert N; Kalluvya, Samuel; Kenemo, Bernard; Chandika, Alphonce; Downs, Jennifer A

2017-11-01

In the United Republic of Tanzania, the incidence of non-neonatal circumcision-related tetanus is probably underreported. We analysed charts and extracted information on outcome and wound location for non-neonatal cases of tetanus admitted to the intensive care unit of Bugando Medical Centre between 2001 and 2016. Bugando Medical Centre, which is one of four teaching referral hospitals in the United Republic of Tanzania, has a 13-bed intensive care unit that manages all admitted patients with tetanus. Within the United Republic of Tanzania, formal programmes of tetanus immunization are targeted at infants or women. From our inpatient logs, we identified six patients with non-neonatal tetanus among male patients with a recent history of circumcision. Only one of these patients had been circumcised within a subnational programme of voluntary medical male circumcision. The other five had been circumcised outside of the programme - e.g. at small rural dispensaries or by a traditional provider with no formal medical training. The six patients were aged 11-55 years and five (83%) of them died in hospital - all of overwhelming sepsis. Within the Tanzanian programme of voluntary medical male circumcision, education on wound hygiene probably helps to reduce the incidence of non-neonatal circumcision-related tetanus. The corresponding incidence among the boys and men who are circumcised beyond this subnational programme is probably higher. The training of all circumcision providers in wound care and a vaccination programme to ensure that male Tanzanians receive tetanus immunization post-infancy are recommended.

Patterns of antibacterials use in intensive care units.

PubMed

Santos, Edilson Floriano Dos; Lauria-Pires, Liana

2010-06-01

To know and compare the patterns of antimicrobials use in intensive care units (ICUs) based on the Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) system. a prospective cohort study was conducted in three medical-surgical intensive care units, two of them in public hospitals and one in a private hospital. Simple random, independent samples of patients admitted from 10/2004 to 09/2005 to the selected intensive care units were used. The antibiotics use was assessed using the ATC/DDD system. The amount of antibacterials used in each intensive care unit, in grams, was transformed in daily defined dose (DDD). The number of DDDs was divided by the number of patient-days, multiplied by one thousand, to obtain the average density of consumption (DC) per thousand patient-days (DDD1000). 1,728 patients-days and 2,918.6 DDDs were examined in the three intensive care units, corresponding to an average density of consumption of 1,689.0 DDD1000. The median number of DDDs of antibiotics use in the public hospitals’ intensive care units was significantly higher (p=0.002) versus the private hospital’s intensive care unit. The consumption of antibiotics in the private hospital’s intensive care unit (DC=2,191.7 DDD1000) was significantly higher (p<0.001) versus the intensive care units of public hospitals (1,499.5 DDD1000). The most used antibiotics groups in the three intensive care units were 3rd generation cephalosporins, penicillins/betalactamases inhibitors, carbapenems and fluorquinolones. The pattern of antibiotics use in the three examined intensive care units was not uniform. The private hospital’s intensive care unit used a significantly larger amount versus the public hospitals’ intensive care units. Nevertheless, the most used antibiotics groups were similar in the three intensive care units.

Beyond counting cases: public health impacts of national Paediatric Surveillance Units

PubMed Central

Grenier, D; Elliott, E J; Zurynski, Y; Pereira, R Rodrigues; Preece, M; Lynn, R; von Kries, R; Zimmermann, H; Dickson, N P; Virella, D

2007-01-01

Paediatric Surveillance Units (PSUs) have been established in 14 countries and facilitate national, prospective, active surveillance for a range of conditions, with monthly reporting by child health specialists. The International Network of Paediatric Surveillance Units (INoPSU) was established in 1998 and facilitates international collaboration among member PSUs and allows for sharing of resources, simultaneous data collection and hence comparison of data from different geographical regions. The impact of data collected by PSUs, both individually and collectively as members of INoPSU, on public health outcomes, clinical care and research is described. PMID:17158859

Anesthesia Practice and Clinical Trends in Interventional Radiology: A European Survey

DOE Office of Scientific and Technical Information (OSTI.GOV)

Haslam, Philip J.; Yap, Bernard; Mueller, Peter R.

Purpose: To determine current European practice in interventional radiology regarding nursing care, anesthesia, and clinical care trends.Methods: A survey was sent to 977 European interventional radiologists to assess the use of sedoanalgesia, nursing care, monitoring equipment, pre- and postprocedural care, and clinical trends in interventional radiology. Patterns of sedoanalgesia were recorded for both vascular and visceral interventional procedures. Responders rated their preferred level of sedoanalgesia for each procedure as follows: (a) awake/alert, (b) drowsy/arousable, (c) asleep/arousable, (d) deep sedation, and (e) general anesthesia. Sedoanalgesic drugs and patient care trends were also recorded. A comparison was performed with data derived frommore » a similar survey of interventional practice in the United States.Results: Two hundred and forty-three of 977 radiologists responded (25%). The total number of procedures analyzed was 210,194. The majority (56%) of diagnostic and therapeutic vascular procedures were performed at the awake/alert level of sedation, 32% were performed at the drowsy/arousable level, and 12% at deeper levels of sedation. The majority of visceral interventional procedures were performed at the drowsy/arousable level of sedation (41%), 29% were performed at deeper levels of sedation, and 30% at the awake/alert level. In general, more sedoanalgesia is used in the United States. Eighty-three percent of respondents reported the use of a full-time radiology nurse, 67% used routine blood pressure/pulse oximetry monitoring, and 46% reported the presence of a dedicated recovery area. Forty-nine percent reported daily patient rounds, 30% had inpatient hospital beds, and 51% had day case beds.Conclusion: This survey shows clear differences in the use of sedation for vascular and visceral interventional procedures. Many, often complex, procedures are performed at the awake/alert level of sedation in Europe, whereas deeper levels of sedation are used in the United States. Trends toward making interventional radiology a clinical specialty are evident, with 51% of respondents having day case beds, and 30% having inpatient beds.« less

Welfare, law and ethics in the veterinary intensive care unit: (A discussion of the different types of suffering that patients may endure in the veterinary intensive care unit, the legal limits to that suffering, and the ethics underpinning at what point that suffering becomes 'un-necessary').

PubMed

Fordyce, Peter S

2017-03-01

In UK law, allowing an animal protected under the Animal Welfare Act 2006 (AWA 2006) (as devolved) to suffer 'unnecessarily' may render the person responsible for it to prosecution. The act does not define suffering, although 'case law' suggests that suffering encompasses more than pain. Clinicians responsible for animals under their care in the intensive care unit (ICU) are likely to also be responsible in law for the welfare of those animals, and may be called upon to justify why any suffering was necessary, or more likely, why they did not act to end any suffering when it became 'unnecessary'. As animals are considered to be 'property' in law, the legal requirement to prevent 'unnecessary suffering' may conflict with the owner's property rights. Additionally, professional conflict may arise between the clinicians whose opinion of where the border between 'heroic treatment' and 'futile treatment' lays. Different types of suffering that might be relevant to clinical and ethical decision making for patients in the ICU are discussed, with suggestions for how these might be categorised, measured and recorded, so that objective data is available on which discussions about the animal's actual and projected welfare can be held with the animal's owner, and other clinicians involved in the case. The development of 'welfare scoring systems' for the ICU may assist clarifying the point at which heroic treatment is becoming futile, and therefore suffering becoming unnecessary, and place veterinary anaesthetists in an even stronger position to act as 'advocate for the animal' in their care. Copyright © 2017 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.

Pacific Partnership 2007: The First Dedicated United States Ship Humanitarian and Civic Assistance Mission

DTIC Science & Technology

2010-10-25

surgical patients. Other eye surgeries corrected ptyergium and strabismus. Pediatric surgical cases were mainly hernia repair and cleft palate / cleft ... lip repair. Basic medical care, MEDCAP, was provided ashore at each location of the mission. PP07 MEDCAP mission data, consolidated from daily

Creating institutions of care: The case for democratic forest trusts

Treesearch

Gus diZerega

2007-01-01

Strong institutional and systemic barriers prevent traditional political and economic institutions from effectively managing national forests in the United States. Despite consistent support for ecological values by the public, Congress does not protect them, and existing political institutions are not designed to respond effectively to citizens with these concerns....

Identifying an Education Gap in Wound Care Training in United States Dermatology.

PubMed

Ruiz, Emily Stamell; Ingram, Amber; Landriscina, Angelo; Tian, Jiaying; Kirsner, Robert S; Friedman, Adam

2015-07-01

As restoration of the integument is paramount to wound healing, dermatologists should be central to managing wounds; yet this is often not the case. If a training gap exists during residency training, this may account for the observed discrepancy. To identify United States (US) dermatology residents' impressions regarding their preparedness to care for wounds, and to assess the amount and type of training devoted to wound care during residency. An online survey among current US dermatology residents enrolled in a residency training program. The primary goal was to determine whether dermatology residents believe more wound care education is needed, evaluate preparedness to care for wounds, and identify future plans to manage wounds. Responses were received from 175 of 517 (33.8%) US Dermatology residents contacted. The majority of residents did not feel prepared to manage acute (78.3%) and chronic (84.6%) wounds. Over three quarters (77.1%) felt that more education is needed. Fewer than half (49.1% and 35.4%) of residents planned to care for acute and chronic wounds, respectively, when in practice. There is a gap in wound care education in US dermatology residency training. This translates to a low percentage of dermatology residents planning to care for wounds in future practice. Dermatology residents need to receive focused wound care training in order to translate the underpinnings of wound healing biology and ultimately better serve patients.

Understanding the challenges to implementing case management for people with dementia in primary care in England: a qualitative study using Normalization Process Theory.

PubMed

Bamford, Claire; Poole, Marie; Brittain, Katie; Chew-Graham, Carolyn; Fox, Chris; Iliffe, Steve; Manthorpe, Jill; Robinson, Louise

2014-11-08

Case management has been suggested as a way of improving the quality and cost-effectiveness of support for people with dementia. In this study we adapted and implemented a successful United States' model of case management in primary care in England. The results are reported elsewhere, but a key finding was that little case management took place. This paper reports the findings of the process evaluation which used Normalization Process Theory to understand the barriers to implementation. Ethnographic methods were used to explore the views and experiences of case management. Interviews with 49 stakeholders (patients, carers, case managers, health and social care professionals) were supplemented with observation of case managers during meetings and initial assessments with patients. Transcripts and field notes were analysed initially using the constant comparative approach and emerging themes were then mapped onto the framework of Normalization Process Theory. The primary focus during implementation was on the case managers as isolated individuals, with little attention being paid to the social or organizational context within which they worked. Barriers relating to each of the four main constructs of Normalization Process Theory were identified, with a lack of clarity over the scope and boundaries of the intervention (coherence); variable investment in the intervention (cognitive participation); a lack of resources, skills and training to deliver case management (collective action); and limited reflection and feedback on the case manager role (reflexive monitoring). Despite the intuitive appeal of case management to all stakeholders, there were multiple barriers to implementation in primary care in England including: difficulties in embedding case managers within existing well-established community networks; the challenges of protecting time for case management; and case managers' inability to identify, and act on, emerging patient and carer needs (an essential, but previously unrecognised, training need). In the light of these barriers it is unclear whether primary care is the most appropriate setting for case management in England. The process evaluation highlights key aspects of implementation and training to be addressed in future studies of case management for dementia.

Using continuous sedation until death for cancer patients: A qualitative interview study of physicians’ and nurses’ practice in three European countries

PubMed Central

Rietjens, Judith; Bruinsma, Sophie; Deliens, Luc; Sterckx, Sigrid; Mortier, Freddy; Brown, Jayne; Mathers, Nigel; van der Heide, Agnes

2015-01-01

Background: Extensive debate surrounds the practice of continuous sedation until death to control refractory symptoms in terminal cancer care. We examined reported practice of United Kingdom, Belgian and Dutch physicians and nurses. Methods: Qualitative case studies using interviews. Setting: Hospitals, the domestic home and hospices or palliative care units. Participants: In all, 57 Physicians and 73 nurses involved in the care of 84 cancer patients. Results: UK respondents reported a continuum of practice from the provision of low doses of sedatives to control terminal restlessness to rarely encountered deep sedation. In contrast, Belgian respondents predominantly described the use of deep sedation, emphasizing the importance of responding to the patient’s request. Dutch respondents emphasized making an official medical decision informed by the patient’s wish and establishing that a refractory symptom was present. Respondents employed rationales that showed different stances towards four key issues: the preservation of consciousness, concerns about the potential hastening of death, whether they perceived continuous sedation until death as an ‘alternative’ to euthanasia and whether they sought to follow guidelines or frameworks for practice. Conclusion: This qualitative analysis suggests that there is systematic variation in end-of-life care sedation practice and its conceptualization in the United Kingdom, Belgium and the Netherlands. PMID:25062816

Regional health care planning: a methodology to cluster facilities using community utilization patterns

PubMed Central

2013-01-01

Background Community-based health care planning and regulation necessitates grouping facilities and areal units into regions of similar health care use. Limited research has explored the methodologies used in creating these regions. We offer a new methodology that clusters facilities based on similarities in patient utilization patterns and geographic location. Our case study focused on Hospital Groups in Michigan, the allocation units used for predicting future inpatient hospital bed demand in the state’s Bed Need Methodology. The scientific, practical, and political concerns that were considered throughout the formulation and development of the methodology are detailed. Methods The clustering methodology employs a 2-step K-means + Ward’s clustering algorithm to group hospitals. The final number of clusters is selected using a heuristic that integrates both a statistical-based measure of cluster fit and characteristics of the resulting Hospital Groups. Results Using recent hospital utilization data, the clustering methodology identified 33 Hospital Groups in Michigan. Conclusions Despite being developed within the politically charged climate of Certificate of Need regulation, we have provided an objective, replicable, and sustainable methodology to create Hospital Groups. Because the methodology is built upon theoretically sound principles of clustering analysis and health care service utilization, it is highly transferable across applications and suitable for grouping facilities or areal units. PMID:23964905

Regional health care planning: a methodology to cluster facilities using community utilization patterns.

PubMed

Delamater, Paul L; Shortridge, Ashton M; Messina, Joseph P

2013-08-22

Community-based health care planning and regulation necessitates grouping facilities and areal units into regions of similar health care use. Limited research has explored the methodologies used in creating these regions. We offer a new methodology that clusters facilities based on similarities in patient utilization patterns and geographic location. Our case study focused on Hospital Groups in Michigan, the allocation units used for predicting future inpatient hospital bed demand in the state's Bed Need Methodology. The scientific, practical, and political concerns that were considered throughout the formulation and development of the methodology are detailed. The clustering methodology employs a 2-step K-means + Ward's clustering algorithm to group hospitals. The final number of clusters is selected using a heuristic that integrates both a statistical-based measure of cluster fit and characteristics of the resulting Hospital Groups. Using recent hospital utilization data, the clustering methodology identified 33 Hospital Groups in Michigan. Despite being developed within the politically charged climate of Certificate of Need regulation, we have provided an objective, replicable, and sustainable methodology to create Hospital Groups. Because the methodology is built upon theoretically sound principles of clustering analysis and health care service utilization, it is highly transferable across applications and suitable for grouping facilities or areal units.

Making the case for a clinical information system: the chief information officer view.

PubMed

Cotter, Carole M

2007-03-01

Adequate decision support for clinicians and other caregivers requires accessible and reliable patient information. Powerful societal and economic forces are moving us toward an integrated, patient-centered health care information system that will allow caregivers to exchange up-to-date patient health information quickly and easily. These forces include patient safety, potential health care cost savings, empowerment of consumers (and their subsequent demands for quality), new federal policies, and growing regional health care initiatives. Underspending on health care information technologies has gone on for many years; and the creation and implementation of a comprehensive clinical information system will entail many difficulties, particularly in regard to patients' privacy and control of their information, standardization of electronic health records, cost of adopting information technology, unbalanced financial incentives, and the varying levels of preparation across caregivers. There will also be potential effects on the physician-patient relationship. Ultimately, an integrated system will require a concerted transformation of the health care industry that is akin to what the banking industry has accomplished with electronic automation. Critical care units provide a good starting point for how information system technologies can be used and electronic patient information collected, although the robust systems designed for intensive care units are not always used to their potential.

Severe maternal morbidity due to sepsis: The burden and preventability of disease in New Zealand.

PubMed

Lepine, Sam; Lawton, Beverley; Geller, Stacie; Abels, Peter; MacDonald, Evelyn J

2018-02-20

Sepsis is a life-threatening systemic condition that appears to be increasing in the obstetric population. Clinical detection can be difficult and may result in increased morbidity via delays in the continuum of patient care. To describe the burden of severe maternal morbidity (SMM) caused by sepsis in New Zealand and investigate the potential preventability. A multidisciplinary expert review panel was established to review cases of obstetric sepsis admitted to intensive care or high-dependency units over an 18 month span in New Zealand. Cases were then analysed for the characteristics of infection and their preventability. Fifty cases met the inclusion criteria, most commonly due to uterine, respiratory or kidney infection. Fifty per cent (25) of these cases were deemed potentially preventable, predominantly due to delays in diagnosis and treatment. A high index of suspicion, development of early recognition systems and multi-disciplinary training are recommended to decrease preventable cases of maternal sepsis. © 2018 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Invasive Group A Streptococcal Infection in Older Adults in Long-term Care Facilities and the Community, United States, 1998–20031

PubMed Central

Richards, Chesley L.; Lynfield, Ruth; Barrett, Nancy L.; Harrison, Lee H.; Arnold, Kathryn E.; Reingold, Arthur; Bennett, Nancy M.; Craig, Allen S.; Gershman, Ken; Cieslak, Paul R.; Lewis, Paige; Greene, Carolyn M.; Beall, Bernard; Van Beneden, Chris A.

2007-01-01

Limited information exists on the incidence and characteristics of invasive group A streptococcal (GAS) infections among residents of long-term care facilities (LTCFs). We reviewed cases of invasive GAS infections occurring among persons >65 years of age identified through active, population-based surveillance from 1998 through 2003. We identified 1,762 invasive GAS cases among persons >65 years, including 1,662 with known residence type (LTCF or community). Incidence of invasive GAS infection among LTCF residents compared to community-based elderly was 41.0 versus 6.9 cases per 100,000 population. LTCF case-patients were 1.5 times as likely to die from the infection as community-based case-patients (33% vs. 21%, p<0.01) but were less often hospitalized (90% vs. 95%, p<0.01). In multivariate logistic regression modeling, LTCF residence remained an independent predictor of death. Additional prevention strategies against GAS infection in this high-risk population are urgently needed. PMID:18258035

Neuromuscular disorders in the intensive care unit.

PubMed

Marinelli, William A; Leatherman, James W

2002-10-01

Neuromuscular disorders encountered in the ICU can be categorized as muscular diseases that lead to ICU admission and those that are acquired in the ICU. This article discusses three neuromuscular disorders can lead to ICU admission and have a putative immune-mediated pathogenesis: the Guillian-Barré syndrome, myasthenia gravis, and dermatomyositis/polymyositis. It also reviews critical care polyneuropathy and ICU acquired myopathy, two disorders that, alone or in combination, are responsible for nearly all cases of severe ICU acquired muscle weakness.

National surveillance of pandemic influenza A(H1N1) infection-related admissions to intensive care units during the 2009-10 winter peak in Denmark: two complementary approaches.

PubMed

Gubbels, S; Perner, A; Valentiner-Branth, P; Molbak, K

2010-12-09

Surveillance of 2009 pandemic influenza A(H1N1) in Denmark was enhanced during the 2009–10 winter season with a system monitoring the burden of the pandemic on intensive care units (ICUs), in order to inform policymakers and detect shortages in ICUs in a timely manner. Between week 46 of 2009 and week 11 of 2010, all 36 relevant Danish ICUs reported in two ways: aggregate data were reported online and case-based data on paper. Cases to be reported were defined as patients admitted to an ICU with laboratory-confirmed 2009 pandemic influenza A(H1N1) infection or clinically suspected illness after close contact with a laboratory-confirmed case. Aggregate numbers of cases were reported weekly: during weeks 48-51 (the peak), reporting was daily. The case-based reports contained demographic and clinical information. The aggregate surveillance registered 93 new cases, the case-based surveillance 61, of whom 53 were laboratory confirmed. The proportion of beds used for influenza patients did not exceed 4.5% of the national capacity. Hospitals with cases used a median of 11% of bed capacity (range: 3–40%). Of the patients for whom information was available, 15 of 48 patients developed renal insufficiency, 19 of 50 developed septic shock and 17 of 53 died. The number of patients with pandemic influenza could be managed within the national bed capacity, although the impact on some ICUs was substantial. The combination of both reporting methods (collecting aggregate and case-based data) proved to be useful for monitoring the burden of the pandemic on ICUs.

Prognostic factors in pediatric sepsis study, from the Spanish Society of Pediatric Intensive Care.

PubMed

Vila Pérez, David; Jordan, Iolanda; Esteban, Elisabeth; García-Soler, Patricia; Murga, Vega; Bonil, Vanesa; Ortiz, Irene; Flores, Carlos; Bustinza, Amaya; Cambra, Francisco Jose

2014-02-01

Sepsis and septic shock represent up to 30% of admitted patients in pediatric intensive care units, with a mortality that can exceed 10%. The objective of this study is to determine the prognostic factors for mortality in sepsis. Multicenter prospective descriptive study with patients (aged 7 days to 18 years) admitted to the pediatric intensive care units for sepsis, between January 2011 and April 2012. Data from 136 patients were collected. Eighty-seven were male (63.9%). The median age was a year and a half (P25-75 0.3-5.5 years). In 41 cases (30.1%), there were underlying diseases. The most common etiology was Neisseria meningitidis (31 cases, 22.8%) followed by Streptococcus pneumoniae (16 patients, 11.8%). Seventeen cases were fatal (12.5%). In the statistical analysis, the factors associated with mortality were nosocomial infection (P = 0.004), hypotension (P <0.001) and heart and kidney failure (P < 0.001 and P = 0.004, respectively). The numbers of leukocytes, neutrophils and platelets on admission were statistically lower in the group that died (P was 0.006, 0.013 and <0.001, respectively). Multivariate analysis showed that multiple organ failure, neutropenia, purpura or coagulopathy and nosocomial infection were independent risk factors for increased mortality (odds ratio: 17, 4.9, 9 and 9.2, respectively). Patients with sepsis and multiorgan failure, especially those with nosocomial infection or the presence of neutropenia or purpura, have a worse prognosis and should be monitored and treated early.

Trauma and emergency surgery: an evolutionary direction for trauma surgeons.

PubMed

Scherer, Lynette A; Battistella, Felix D

2004-01-01

The success of nonoperative management of injuries has diminished the operative experience of trauma surgeons. To enhance operative experience, our trauma surgeons began caring for all general surgery emergencies. Our objective was to characterize and compare the experience of our trauma surgeons with that of our general surgeons. We reviewed records to determine case diversity, complexity, time of operation, need for intensive care unit care, and payor mix for patients treated by the trauma and emergency surgery (TES) surgeons and elective practice general surgery (ELEC) surgeons over a 1-year period. TES and ELEC surgeons performed 253 +/- 83 and 234 +/- 40 operations per surgeon, respectively (p = 0.59). TES surgeons admitted more patients and performed more after-hours operations than their ELEC colleagues. Both groups had a mix of cases that was diverse and complex. Combining the care of patients with trauma and general surgery emergencies resulted in a breadth and scope of practice for TES surgeons that compared well with that of ELEC surgeons.

Vital signs: melanoma incidence and mortality trends and projections - United States, 1982-2030.

PubMed

Guy, Gery P; Thomas, Cheryll C; Thompson, Trevor; Watson, Meg; Massetti, Greta M; Richardson, Lisa C

2015-06-05

Melanoma incidence rates have continued to increase in the United States, and risk behaviors remain high. Melanoma is responsible for the most skin cancer deaths, with about 9,000 persons dying from it each year. CDC analyzed current (2011) melanoma incidence and mortality data, and projected melanoma incidence, mortality, and the cost of treating newly diagnosed melanomas through 2030. Finally, CDC estimated the potential melanoma cases and costs averted through 2030 if a comprehensive skin cancer prevention program was implemented in the United States. In 2011, the melanoma incidence rate was 19.7 per 100,000, and the death rate was 2.7 per 100,000. Incidence rates are projected to increase for white males and females through 2019. Death rates are projected to remain stable. The annual cost of treating newly diagnosed melanomas was estimated to increase from $457 million in 2011 to $1.6 billion in 2030. Implementation of a comprehensive skin cancer prevention program was estimated to avert 230,000 melanoma cases and $2.7 billion in initial year treatment costs from 2020 through 2030. If additional prevention efforts are not undertaken, the number of melanoma cases is projected to increase over the next 15 years, with accompanying increases in health care costs. Much of this morbidity, mortality, and health care cost can be prevented. Substantial reductions in melanoma incidence, mortality, and cost can be achieved if evidence-based comprehensive interventions that reduce ultraviolet (UV) radiation exposure and increase sun protection are fully implemented and sustained.

Risk factors and prevalence of newborn hearing loss in a private health care system of Porto Velho, Northern Brazil

PubMed Central

de Oliveira, Juliana Santos; Rodrigues, Liliane Barbosa; Aurélio, Fernanda Soares; da Silva, Virgínia Braz

2013-01-01

OBJECTIVE: To determine the prevalence of hearing loss and to analyze the results of newborn hearing screening and audiological diagnosis in private health care systems. METHODS Cross-sectional and retrospective study in a database of newborn hearing screening performed by a private clinic in neonates born in private hospitals of Porto Velho, Rondônia, Northern Brazil. The screening results, the risk for hearing loss, the risk indicators for hearing loss and the diagnosis were descriptively analyzed. Newborns cared in rooming in with their mothers were compared to those admitted to the Intensive Care Unit regarding risk factors for hearing loss. RESULTS: Among 1,146 (100%) enrolled newborns, 1,064 (92.8%) passed and 82 (7.2%) failed the hearing screening. Among all screened neonates, 1,063 (92.8%) were cared in rooming and 83 (7.2%) needed intensive care; 986 (86.0%) were considered at low risk and 160 (14.0%) at high risk for hearing problems. Of the 160 patients identified as having high risk for hearing loss, 83 (37.7%) were admitted to an hospitalized in the Intensive Care Unit, 76 (34.5%) used ototoxic drugs and 38 (17.2%) had a family history of hearing loss in childhood. Hearing loss was diagnosed in two patients (0.2% of the screened sample). CONCLUSIONS: The prevalence of hearing loss in newborns from private hospitals was two cases per 1,000 evaluated patients. The use of ototoxic drugs, admission to Intensive Care Unit and family history of hearing loss were the most common risk factors for hearing loss in the studied population. PMID:24142311

[Ethical case discussions in the intensive care unit : from testing to routine].

PubMed

Meyer-Zehnder, B; Barandun Schäfer, U; Albisser Schleger, H; Reiter-Theil, S; Pargger, H

2014-06-01

The daily work of many healthcare professionals has become more complex and demanding in recent years. Apart from purely medical issues, ethical questions and problems arise quite often. Managing these problems requires ethical knowledge. Questions about the usefulness of a therapy and treatment occur especially at the end of life. So-called medical futility, a useless futile therapy, is often perceived by nurses and physicians in intensive care units who themselves often develop symptoms of depression or burnout. The clinical ethical model METAP (acronym from module, ethics, therapy decision, allocation and process) provides methods and criteria that allow the clinical team to treat and solve ethical issues according to a solution-oriented approach. The ethical decision-making of this model addresses these issues according to a series of sequential stages in the form of a so-called escalation model. When it is not possible to tackle and solve an ethical problem or dilemma in one stage, one moves to the next. The implementation of this approach in everyday practice requires the commitment of all team members in addition to certain basic conditions. In a surgical intensive care unit a fixed date in the schedule is reserved for ethical case discussions (level 3 of the escalation model). At this level a team member who has been specified according to a quarterly plan is responsible for the organization and performance of the discussion. All protocols of the 44 ethical case discussions in 41 patients between January 2011 and July 2012 were collected and summarized. A short questionnaire to all participants recorded their assessment of the benefits for the patient and the team as well as their perception of personal stress reduction. Also queried was the impact of this method on the collaboration between nurses and physicians and the ethical competence. Ethical case discussions among the care team took place regularly (44 case discussions between January 2011 and June 2012). The duration of these discussions ranged from 30 to 60 min. On average 6.2 persons took part, including 2.7 nurses and 3.2 physicians. Of the 41 patients (16 female, 25 male) for whom a discussion was carried out, 23 died during the continued hospital stay. The respondents (response rate 52 %) assessed the benefit for patients and team as high (slightly higher benefit for physicians than nurses) and 55 % of physicians and 71 % of nurses perceived a reduction in the burden of decision-making in difficult cases due to the case discussions. All physicians and 66 % of the nurses reported an improvement in the cooperation between the professional groups and 80 % of the nurses and more than half of the physicians noticed an increase in their own ethical competence. A methodically structured ethical decision-making process can and should be integrated into the clinical routine. This process requires a fixed place in everyday practice and the defined responsibility for the actual organization and performance. Support by medical and nursing management personnel is also essential for the implementation. The regular occurrence of ethical case discussions among the care team relieves the participants and improves collaboration between nurses and physicians.

Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study.

PubMed

McCormack, Ruaidhri; Moriarty, John; Mellers, John D; Shotbolt, Paul; Pastena, Rosa; Landes, Nadine; Goldstein, Laura; Fleminger, Simon; David, Anthony S

2014-08-01

Gold standard protocols have yet to be established for the treatment of motor conversion disorder (MCD). There is limited evidence to support inpatient, multidisciplinary intervention in chronic, severe cases. To evaluate the characteristics and outcomes of MCD patients admitted to a specialist neuropsychiatric inpatient unit. All patients admitted to the Lishman Unit (years 2007-2011) with a diagnosis of MCD were included. Data relevant to characteristics and status with regard to mobility, activities of daily living (ADLs) and Modified Rankin Scale (MRS) score at admission and discharge were extracted. Thirty-three cases (78.8% female) were included; the median duration of illness was 48 months. In comparison with brain injury patients admitted to the same unit, more cases had histories of childhood sexual abuse (36.4%, n=12), premorbid non-dissociative mental illness (81.1%, n=27) and employment as a healthcare/social-care worker (45.5%, n=15). Cases showed significant improvements in MRS scores (p<0.001), mobility (p<0.001) and ADL (p=0.002) following inpatient treatment. Patients with severe, long-standing MCD can achieve significant improvements in functioning after admission to a neuropsychiatry unit. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Equine Botulinum Antitoxin for the Treatment of Infant Botulism ▿

PubMed Central

Vanella de Cuetos, Elida E.; Fernandez, Rafael A.; Bianco, María I.; Sartori, Omar J.; Piovano, María L.; Lúquez, Carolina; de Jong, Laura I. T.

2011-01-01

Infant botulism is the most common form of human botulism in Argentina and the United States. BabyBIG (botulism immune globulin intravenous [human]) is the antitoxin of choice for specific treatment of infant botulism in the United States. However, its high cost limits its use in many countries. We report here the effectiveness and safety of equine botulinum antitoxin (EqBA) as an alternative treatment. We conducted an analytical, observational, retrospective, and longitudinal study on cases of infant botulism registered in Mendoza, Argentina, from 1993 to 2007. We analyzed 92 medical records of laboratory-confirmed cases and evaluated the safety and efficacy of treatment with EqBA. Forty-nine laboratory-confirmed cases of infant botulism demanding admission in intensive care units and mechanical ventilation included 31 treated with EqBA within the 5 days after the onset of signs and 18 untreated with EqBA. EqBA-treated patients had a reduction in the mean length of hospital stay of 23.9 days (P = 0.0007). For infants treated with EqBA, the intensive care unit stay was shortened by 11.2 days (P = 0.0036), mechanical ventilation was reduced by 11.1 days (P = 0.0155), and tube feeding was reduced by 24.4 days (P = 0.0001). The incidence of sepsis in EqBA-treated patients was 47.3% lower (P = 0.0017) than in the untreated ones. Neither sequelae nor adverse effects attributable to EqBA were noticed, except for one infant who developed a transient erythematous rash. These results suggest that prompt treatment of infant botulism with EqBA is safe and effective and that EqBA could be considered an alternative specific treatment for infant botulism when BabyBIG is not available. PMID:21918119

Equine botulinum antitoxin for the treatment of infant botulism.

PubMed

Vanella de Cuetos, Elida E; Fernandez, Rafael A; Bianco, María I; Sartori, Omar J; Piovano, María L; Lúquez, Carolina; de Jong, Laura I T

2011-11-01

Infant botulism is the most common form of human botulism in Argentina and the United States. BabyBIG (botulism immune globulin intravenous [human]) is the antitoxin of choice for specific treatment of infant botulism in the United States. However, its high cost limits its use in many countries. We report here the effectiveness and safety of equine botulinum antitoxin (EqBA) as an alternative treatment. We conducted an analytical, observational, retrospective, and longitudinal study on cases of infant botulism registered in Mendoza, Argentina, from 1993 to 2007. We analyzed 92 medical records of laboratory-confirmed cases and evaluated the safety and efficacy of treatment with EqBA. Forty-nine laboratory-confirmed cases of infant botulism demanding admission in intensive care units and mechanical ventilation included 31 treated with EqBA within the 5 days after the onset of signs and 18 untreated with EqBA. EqBA-treated patients had a reduction in the mean length of hospital stay of 23.9 days (P = 0.0007). For infants treated with EqBA, the intensive care unit stay was shortened by 11.2 days (P = 0.0036), mechanical ventilation was reduced by 11.1 days (P = 0.0155), and tube feeding was reduced by 24.4 days (P = 0.0001). The incidence of sepsis in EqBA-treated patients was 47.3% lower (P = 0.0017) than in the untreated ones. Neither sequelae nor adverse effects attributable to EqBA were noticed, except for one infant who developed a transient erythematous rash. These results suggest that prompt treatment of infant botulism with EqBA is safe and effective and that EqBA could be considered an alternative specific treatment for infant botulism when BabyBIG is not available.

Predictors for Perioperative Outcomes following Total Laryngectomy: A University HealthSystem Consortium Discharge Database Study.

PubMed

Rutledge, Jonathan W; Spencer, Horace; Moreno, Mauricio A

2014-07-01

The University HealthSystem Consortium (UHC) database collects discharge information on patients treated at academic health centers throughout the United States. We sought to use this database to identify outcome predictors for patients undergoing total laryngectomy. A secondary end point was to assess the validity of the UHC's predictive risk mortality model in this cohort of patients. Retrospective review. Academic medical centers (tertiary referral centers) and their affiliate hospitals in the United States. Using the UHC discharge database, we retrieved and analyzed data for 4648 patients undergoing total laryngectomy who were discharged between October 2007 and January 2011 from all of the member institutions. Demographics, comorbidities, institutional data, and outcomes were retrieved. The length of stay and overall costs were significantly higher among female patients (P < .0001), while age was a predictor of intensive care unit stay (P = .014). The overall complication rate was higher among Asians (P = .019) and in patients with anemia and diabetes compared with other comorbidities. The average institutional case load was 1.92 cases/mo; we found an inverse correlation (R = -0.47) between the institutional case load and length of stay (P < .0001). The UHC admit mortality risk estimator was found to be an accurate predictor not only of mortality (P < .0002) but also of intensive care unit admission and complication rate (P < .0001). This study provides an overview of laryngectomy outcomes in a contemporary cohort of patients treated at academic health centers. UHC admit mortality risk is an excellent outcome predictor and a valuable tool for risk stratification in these patients. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.

Differences in case-mix can influence the comparison of standardised mortality ratios even with optimal risk adjustment: an analysis of data from paediatric intensive care.

PubMed

Manktelow, Bradley N; Evans, T Alun; Draper, Elizabeth S

2014-09-01

The publication of clinical outcomes for consultant surgeons in 10 specialties within the NHS has, along with national clinical audits, highlighted the importance of measuring and reporting outcomes with the aim of monitoring quality of care. Such information is vital to be able to identify good and poor practice and to inform patient choice. The need to adequately adjust outcomes for differences in case-mix has long been recognised as being necessary to provide 'like-for-like' comparisons between providers. However, directly comparing values of the standardised mortality ratio (SMR) between different healthcare providers can be misleading even when the risk-adjustment perfectly quantifies the risk of a poor outcome in the reference population. An example is shown from paediatric intensive care. Using observed case-mix differences for 33 paediatric intensive care units (PICUs) in the UK and Ireland for 2009-2011, SMRs were calculated under four different scenarios where, in each scenario, all of the PICUs were performing identically for each patient type. Each scenario represented a clinically plausible difference in outcome from the reference population. Despite the fact that the outcome for any patient was the same no matter which PICU they were to be admitted to, differences between the units were seen when compared using the SMR: scenario 1, 1.07-1.21; scenario 2, 1.00-1.14; scenario 3, 1.04-1.13; scenario 4, 1.00-1.09. Even if two healthcare providers are performing equally for each type of patient, if their patient populations differ in case-mix their SMRs will not necessarily take the same value. Clinical teams and commissioners must always keep in mind this weakness of the SMR when making decisions. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

In their own words: Patients and families define high-quality palliative care in the intensive care unit*

PubMed Central

Nelson, Judith E.; Puntillo, Kathleen A.; Pronovost, Peter J.; Walker, Amy S.; McAdam, Jennifer L.; Ilaoa, Debra; Penrod, Joan

2011-01-01

Objective Although the majority of hospital deaths occur in the intensive care unit and virtually all critically ill patients and their families have palliative needs, we know little about how patients and families, the most important “stakeholders,” define high-quality intensive care unit palliative care. We conducted this study to obtain their views on important domains of this care. Design Qualitative study using focus groups facilitated by a single physician. Setting A 20-bed general intensive care unit in a 382-bed community hospital in Oklahoma; 24-bed medical–surgical intensive care unit in a 377-bed tertiary, university hospital in urban California; and eight-bed medical intensive care unit in a 311-bed Veterans’ Affairs hospital in a northeastern city. Patients Randomly-selected patients with intensive care unit length of stay ≥5 days in 2007 to 2008 who survived the intensive care unit, families of survivors, and families of patients who died in the intensive care unit. Interventions None. Measurements and Main Results Focus group facilitator used open-ended questions and scripted probes from a written guide. Three investigators independently coded meeting transcripts, achieving consensus on themes. From 48 subjects (15 patients, 33 family members) in nine focus groups across three sites, a shared definition of high-quality intensive care unit palliative care emerged: timely, clear, and compassionate communication by clinicians; clinical decision-making focused on patients’ preferences, goals, and values; patient care maintaining comfort, dignity, and personhood; and family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Participants also endorsed specific processes to operationalize the care they considered important. Conclusions Efforts to improve intensive care unit palliative care quality should focus on domains and processes that are most valued by critically ill patients and their families, among whom we found broad agreement in a diverse sample. Measures of quality and effective interventions exist to improve care in domains that are important to intensive care unit patients and families. PMID:20198726

Frequency of placenta previa in previously scarred and non scarred uterus.

PubMed

Majeed, Tayyaba; Waheed, Fatima; Mahmood, Zahid; Saba, Kanwal; Mahmood, Hamis; Bukhari, Mulazim Hussain

2015-01-01

To determine the frequency of placenta Previa in patients coming to a tertiary care unit with previously scarred and non-scarred uterus. A descriptive cross sectional study was carried on 114 cases who underwent caesarean sections (37 cases out of 645 cases with non scarred uterus and 77 cases from 721 cases with scarred uterus) in the department of obstetrics and gynecology Lady Willingdon Hospital from January 2008- December 2011. Most patients (47.36%) were between 26-30 years age group, presented with gestational age between 36-40 weeks (70.17%), were mostly G2-4, while frequency of placenta Previa in non-scarred uterus was 32.45% (37 cases), and frequency in previously scarred uterus was 67.54% (77 cases). Major degree Previa was found in 88 cases (77.19%). There were 5.70% cases of placenta Previa from non-scarred uteruses and 10.67% cases of placenta Previa (10.67%) from already scarred uteruses. Stratification revealed a higher trend of the morbidity with the increase in number of previous caesarean sections. A significantly higher frequency of placenta Previa was found among patients coming to a tertiary care hospital with previously scarred uterus.

Frequency of placenta previa in previously scarred and non scarred uterus

PubMed Central

Majeed, Tayyaba; Waheed, Fatima; Mahmood, Zahid; Saba, Kanwal; Mahmood, Hamis; Bukhari, Mulazim Hussain

2015-01-01

Objective: To determine the frequency of placenta Previa in patients coming to a tertiary care unit with previously scarred and non-scarred uterus. Methods: A descriptive cross sectional study was carried on 114 cases who underwent caesarean sections (37 cases out of 645 cases with non scarred uterus and 77 cases from 721 cases with scarred uterus) in the department of obstetrics and gynecology Lady Willingdon Hospital from January 2008– December 2011. Results: Most patients (47.36%) were between 26-30 years age group, presented with gestational age between 36-40 weeks (70.17%), were mostly G2-4, while frequency of placenta Previa in non-scarred uterus was 32.45% (37 cases), and frequency in previously scarred uterus was 67.54% (77 cases). Major degree Previa was found in 88 cases (77.19%). There were 5.70% cases of placenta Previa from non-scarred uteruses and 10.67% cases of placenta Previa (10.67%) from already scarred uteruses. Stratification revealed a higher trend of the morbidity with the increase in number of previous caesarean sections. Conclusion: A significantly higher frequency of placenta Previa was found among patients coming to a tertiary care hospital with previously scarred uterus. PMID:26101491

Neonatal blood stream infections in tertiary referral hospitals in Kurdistan, Iran.

PubMed

Nikkhoo, Bahram; Lahurpur, Fariba; Delpisheh, Ali; Rasouli, Mohammad Aziz; Afkhamzadeh, Abdorrahim

2015-06-09

Bloodstream infection (BSI) is one of the most common causes of nosocomial infection in neonatal intensive care units (NICU). The aim of the present study was to determine bacterial agents and their susceptibility patterns to antibiotics and to investigate the risk factors associated with BSI. This was a nested case-control study carried out from September 2009 to June 2010 in the NICU wards in Sanandaj hospitals western Iran. Cases were patients with BSI and controls were other patients who had negative blood culture. Bacteriologic diagnosis and antibiotic susceptibility pattern was performed based on the Edward & Ewings and the National Committee of Clinical Laboratory (NCCL) Standards. Of 472 patients who hospitalized in NICU, 6.4% had BSI (n = 30) including 17girls (56.7%) and 13 boys (43.3%). Enterobacter SPP was the predominant isolated bacteria from blood culture (36.7%). The maximum antibiotic resistance and sensitivity were observed by Tetracycline and Ciprofloxacin respectively. Risk factors associated with BSI were age ≤ 7 days (p = 0.001), previous antibiotic consumption (p = 0.013), and low birth weight (LBW), (p = 0.001). Gram negative bacteria and Entrobacter in particular are the most common pathogens. Improving prenatal health care, standards of infection control and choosing accurate antibiotics are recommended to avoid BSI in neonatal intensive care units.

[A day in the busy obstetric unit from the anesthesiologist point of view, experience at the Cleveland clinic; Cleveland, Ohio].

PubMed

Ootaki, Chiyo; Barsoum, Sabri

2009-10-01

Cleveland Clinic Labor and Delivery Unit is a syntactical delivery facility and comprised of 16 delivery rooms, 3 operating rooms, 3 triage rooms, and 1 recovery room that has a capacity of 6 beds, 43 postpartum rooms, 2 nurseries, and 1 neonatal intensive care unit (NICU). Cleveland Clinic Labor and Delivery Unit (LDU) had 3,691 delivery cases in 2007. The ratio of neuraxial analgesia (NA) during labor is 84.2% (2,348/ 2,787), using epidural anesthesia or combined spinalepidural anesthesia (CSEA). This article introduces the obstetrical (OB) anesthesia practice at the Cleveland Clinic and our novel anesthetic regime as typical of one typical busy day.

The Union Health Center: a working model of clinical care linked to preventive occupational health services.

PubMed

Herbert, R; Plattus, B; Kellogg, L; Luo, J; Marcus, M; Mascolo, A; Landrigan, P J

1997-03-01

As health care provision in the United States shifts to primary care settings, it is vital that new models of occupational health services be developed that link clinical care to prevention. The model program described in this paper was developed at the Union Health Center (UHC), a comprehensive health care center supported by the International Ladies Garment Workers Union (now the Union of Needletrades, Industrial and Textile Employees) serving a population of approximately 50,000 primarily minority, female garment workers in New York City. The objective of this paper is to describe a model occupational medicine program in a union-based comprehensive health center linking accessible clinical care with primary and secondary disease prevention efforts. To assess the presence of symptoms suggestive of occupational disease, a health status questionnaire was administered to female workers attending the UHC for routine health maintenance. Based on the results of this survey, an occupational medicine clinic was developed that integrated direct clinical care with worker and employer education and workplace hazard abatement. To assess the success of this new approach, selected cases of sentinel health events were tracked and a chart review was conducted after 3 years of clinic operation. Prior to initiation of the occupational medicine clinic, 64% (648) of the workers surveyed reported symptoms indicative of occupational illnesses. However, only 42 (4%) reported having been told by a physician that they had an occupational illness and only 4 (.4%) reported having field a workers' compensation claim for an occupational disease. In the occupational medicine clinic established at the UHC, a health and safety specialist acts as a case manager, coordinating worker and employer education as well as workplace hazard abatement focused on disease prevention, ensuring that every case of occupational disease is treated as a potential sentinel health event. As examples of the success of this approach, index cases of rotator cuff tendonitis, lead poisoning, and formaldehyde overexposure in three patients and their preventative workplace follow-up, affecting approximately 150 workers at three worksites, are described. Work-related conditions diagnosed during the first 3 years of clinic operation included cumulative trauma disorders (141 cases), carpal tunnel syndrome (47 cases), low back disorders (33 cases), lead poisoning (20 cases), and respiratory disease (9 cases). This pilot project represents a new model for effective integration of clinical care and occupational disease prevention efforts within a primary care center. It could serve as a prototype for development of such services in other managed and primary care settings.

Specialist palliative care nurses' management of the needs of patients with depression.

PubMed

Hayes, Jessica Elizabeth; Hart, Bethne; Phillips, Jane

2017-06-02

Depression is an important condition to consider if we are to optimise the care outcomes for patients with palliative care needs. Depression has a high incidence in palliative patients, with up to 15% diagnosed with major depression and 37% expressing some form of depressive symptoms ( O'Connor et al, 2010 ). The challenge is to ensure that palliative care patients with depression are identified in a timely manner and that their depression is effectively managed. To examine how Australian specialist inpatient palliative care nurses perceive, assess and respond to depression in a patient case study. This descriptive pilot study is a replication of a United States study by Little et al (2005) , exploring contemporary Australian specialist palliative care nurses' screening, assessment and management of depression in people with a progressive life-limiting illness. A survey titled 'Specialist palliative care nurses managing patients with complex care needs' questioned the nursing assessment, knowledge and clinical care priorities related to a case vignette of a patient demonstrating signs of depression. A total of 33 nurses completed this survey. Less than half (39.4%) of the participants identified depression as a major issue arising from the case vignette. Depression screening tools were not widely known. Functionality assessments measuring activities of daily living were the most recognised and widely used tools by participants. This small sample pilot study demonstrated that specialist palliative care nurses are still not confident in their screening and responding to a patient with depression. The available evidenced based depression screening tools were unfamiliar to these nurses and not widely used which can result in depression remaining undetected and undermanaged. The connections between physical health and mental health need stronger recognition and response within nursing care of palliative patients.

Innovation and Technology: Electronic Intensive Care Unit Diaries.

PubMed

Scruth, Elizabeth A; Oveisi, Nazanin; Liu, Vincent

2017-01-01

Hospitalization in the intensive care unit can be a stressful time for patients and their family members. Patients' family members often have difficulty processing all of the information that is given to them. Therefore, an intensive care unit diary can serve as a conduit for synthesizing information, maintaining connection with patients, and maintaining a connection with family members outside the intensive care unit. Paper intensive care unit diaries have been used outside the United States for many years. This article explores the development of an electronic intensive care unit diary using a rapid prototyping model to accelerate the process. Initial results of design testing demonstrate that it is feasible, useful, and desirable to consider the implementation of electronic intensive care unit diaries for patients at risk for post-intensive care syndrome. ©2017 American Association of Critical-Care Nurses.

Risk factors and predictors for candidemia in pediatric intensive care unit patients: implications for prevention.

PubMed

Zaoutis, Theoklis E; Prasad, Priya A; Localio, A Russell; Coffin, Susan E; Bell, Louis M; Walsh, Thomas J; Gross, Robert

2010-09-01

Candida species are the leading cause of invasive fungal infections in hospitalized children and are the third most common isolates recovered from patients with healthcare-associated bloodstream infection in the United States. Few data exist on risk factors for candidemia in pediatric intensive care unit (PICU) patients. We conducted a population-based case-control study of PICU patients at Children's Hospital of Philadelphia during the period from 1997 through 2004. Case patients were identified using laboratory records, and control patients were selected from PICU rosters. Control patients were matched to case patients by incidence density sampling, adjusting for time at risk. Following conditional multivariate analysis, we performed weighted multivariate analysis to determine predicted probabilities for candidemia given certain risk factor combinations. We identified 101 case patients with candidemia (incidence, 3.5 cases per 1000 PICU admissions). Factors independently associated with candidemia included presence of a central venous catheter (odds ratio [OR], 30.4; 95% confidence interval [CI], 7.7-119.5), malignancy (OR, 4.0; 95% CI, 1.23-13.1), use of vancomycin for >3 days in the prior 2 weeks (OR, 6.2; 95% CI, 2.4-16), and receipt of agents with activity against anaerobic organisms for >3 days in the prior 2 weeks (OR, 3.5; 95% CI, 1.5-8.4). Predicted probability of having various combinations of the aforementioned factors ranged from 10.7% to 46%. The 30-day mortality rate was 44% among case patients and 14% among control patients (OR, 4.22; 95% CI, 2.35-7.60). To our knowledge, this is the first study to evaluate independent risk factors and to determine a population of children in PICUs at high risk for developing candidemia. Future efforts should focus on validation of these risk factors identified in a different PICU population and development of interventions for prevention of candidemia in critically ill children.

Implementing Information and Communication Technology to Support Community Aged Care Service Integration: Lessons from an Australian Aged Care Provider.

PubMed

Douglas, Heather E; Georgiou, Andrew; Tariq, Amina; Prgomet, Mirela; Warland, Andrew; Armour, Pauline; Westbrook, Johanna I

2017-04-10

There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services. We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration. Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange. Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system. There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients.

Implementing Information and Communication Technology to Support Community Aged Care Service Integration: Lessons from an Australian Aged Care Provider

PubMed Central

Georgiou, Andrew; Tariq, Amina; Prgomet, Mirela; Warland, Andrew; Armour, Pauline; Westbrook, Johanna I

2017-01-01

Introduction: There is limited evidence of the benefits of information and communication technology (ICT) to support integrated aged care services. Objectives: We undertook a case study to describe carelink+, a centralised client service management ICT system implemented by a large aged and community care service provider, Uniting. We sought to explicate the care-related information exchange processes associated with carelink+ and identify lessons for organisations attempting to use ICT to support service integration. Methods: Our case study included seventeen interviews and eleven observation sessions with a purposive sample of staff within the organisation. Inductive analysis was used to develop a model of ICT-supported information exchange. Results: Management staff described the integrated care model designed to underpin carelink+. Frontline staff described complex information exchange processes supporting coordination of client services. Mismatches between the data quality and the functions carelink+ was designed to support necessitated the evolution of new work processes associated with the system. Conclusions: There is value in explicitly modelling the work processes that emerge as a consequence of ICT. Continuous evaluation of the match between ICT and work processes will help aged care organisations to achieve higher levels of ICT maturity that support their efforts to provide integrated care to clients. PMID:29042851

Sedation at the end of life - a nation-wide study in palliative care units in Austria.

PubMed

Schur, Sophie; Weixler, Dietmar; Gabl, Christoph; Kreye, Gudrun; Likar, Rudolf; Masel, Eva Katharina; Mayrhofer, Michael; Reiner, Franz; Schmidmayr, Barbara; Kirchheiner, Kathrin; Watzke, Herbert Hans

2016-05-14

Sedation is used to an increasing extent in end-of-life care. Definitions and indications in this field are based on expert opinions and case series. Little is known about this practice at palliative care units in Austria. Patients who died in Austrian palliative care units between June 2012 and June 2013 were identified. A predefined set of baseline characteristics and information on sedation during the last two weeks before death were obtained by reviewing the patients' charts. The data of 2414 patients from 23 palliative care units were available for analysis. Five hundred two (21 %) patients received sedation in the last two weeks preceding their death, 356 (71 %) received continuous sedation until death, and 119 (24 %) received intermittent sedation. The median duration of sedation was 48 h (IQR 10-72 h); 168 patients (34 %) were sedated for less than 24 h. Indications for sedation were delirium (51 %), existential distress (32 %), dyspnea (30 %), and pain (20 %). Midazolam was the most frequently used drug (79 %), followed by lorazepam (13 %), and haloperidol (10 %). Sedated patients were significantly younger (median age 67 years vs. 74 years, p ≤ 0.001, r = 0.22), suffered more often from an oncological disease (92 % vs. 82 %, p ≤ 0.001, φ = 0.107), and were hospitalized more frequently (94 % vs. 76 %, p ≤ 0.001, φ = 0.175). The median number of days between admission to a palliative care ward/mobile palliative care team and death did not differ significantly in sedated versus non-sedated patients (10 vs. 9 days; p = 0.491). This study provides insights into the practice of end-of-life sedation in Austria. Critical appraisal of these data will serve as a starting point for the development of nation-wide guidelines for palliative sedation in Austria.

Communications and relationships between patient and nurse in Intensive Care Unit: knowledge, knowledge of the work, knowledge of the emotional state.

PubMed

Foà, Chiara; Cavalli, Lisa; Maltoni, Alessia; Tosello, Nicoletta; Sangilles, Chiara; Maron, Ilaria; Borghini, Marina; Artioli, Giovanna

2016-11-22

In an Intensive Care Unit (ICU) the communication between nurse and patient, the core of the care, is often hindered by patient's cognitive alterations and critical situation, by devices employed for the mechanical ventilation, and by the clinical and care-giving setting. How to overcome these barriers? How is the relational and communicative approach between nurse and patient unable to express him or herself to be managed? The available literature reveals that studies on communication with difficult patients, such as those treated in ICU are currently scarce. The present research offers a contribution in this respect, through fact-finding about the knowledge acquired by professional studies or work experiences, the personal and institutional techniques implemented in regards to communication (knowledge of the work), the relational behaviours and the emotional experience with patients (knowledge of the emotional state) of nurses working in the Intensive Care Units. A semi-structured interview have been designed and submitted to 30 nurses working in fourteen Highly Specialized Centres (HUB) in Emilia Romagna, Italy. Two nurses with different years of experience in the field have been chosen for each Operating Unit. According to the interviewees paraverbal communication is the most common way to communicate with patients: different strategies are employed such as facial expression or lip movement. In any case, the nurse has the task to choose the most suitable technique according to his or her experiences, his or her knowledge and the patient him or herself. The results claim that lack of specific training on communicative aspects of care, should be combined with an attitude of being prone to listening to and understanding the needs of the patient and of his or her family as well. The interviewees declare they have a solid preparation in the bio-clinical aspect of care, but both new hired nurses and experts affirm that they need a specific training in relational and communicative aspects, proving its importance.

Implementation of a quality management system according to 9001 standard in a hospital in the home unit: changes and achievements.

PubMed

Rodríguez-Cerrillo, Matilde; Fernández-Diaz, Eddita; Iñurrieta-Romero, Amaia; Poza-Montoro, Ana

2012-01-01

The purpose of this paper is to describe changes and results obtained after implementation of a quality management system (QMS) according to ISO standards in a Hospital in the Home (HIH) Unit. The paper describes changes made and outcomes achieved. This took part in the HiH Unit, Clinico Hospital, Madrid, Spain, and looked at admissions, mean stay, patient satisfaction, adverse events, returns to hospital, no admitted referrals, complaints, compliance to protocols, equipment failures and resolution of urgent consultations. In June 2008, HiH Unit, Clinico Hospital obtained ISO certification. The main results achieved are as follows. There was an increase in patients' satisfaction--in June 2008, assessment of the quality of care provided by staff was scored at 4.7 (on a scale of 1 to 5); in 2010 it has been scored at 4.96. Patient satisfaction rate has increased from 92 percent to 98.8 percent. No complaints from patients were received. Unscheduled returns to hospital have decreased from 7 percent to 3 percent. There were no medical equipment failures. External suppliers' performance has improved. Material and medication needed by staff was available when necessary. The number of admissions has increased. Compliance to protocols has reached 97 percent. Inappropriate referrals have decreased by 8 percent. Six medications-related incidents were detected; in two cases the incident was not due to an error. In the other four cases error could have been detected before reaching the patient. Implementations of an ISO quality management system allow improved quality of care and patient satisfaction in a HIH Unit.

The content and meaning of administrative work: a qualitative study of nursing practices.

PubMed

Michel, Lucie; Waelli, Mathias; Allen, Davina; Minvielle, Etienne

2017-09-01

To investigate the content and meaning of nurses' administrative work. Nurses often report that administrative work keeps them away from bedside care. The content and meaning of this work remains insufficiently explored. Comparative case studies. The investigation took place in 2014. It was based on 254 hours of observations and 27 interviews with nurses and staff in two contrasting units: intensive care and long-term care. A time and motion study was also performed over a period of 96 hours. Documentation and Organizational Activities is composed of six categories; documenting the patient record, coordination, management of patient flow, transmission of information, reporting quality indicators, ordering supplies- stock management Equal amounts of time were spent on these activities in each case. Nurses did not express complaints about documentation in intensive care, whereas they reported feeling frustrated by it in long-term care. These differences reflected the extent to which these activities could be integrated into nurses' clinical work and this is in turn was related to several factors: staff ratios, informatics, and relevance to nursing work. Documentation and Organizational Activities are a main component of care. The meaning nurses attribute to them is dependent on organizational context. These activities are often perceived as competing with bedside care, but this does not have to be the case. The challenge for managers is to fully integrate them into nursing practice. Results also suggest that nurses' Documentation and Organizational Activities should be incorporated into informatics strategies. © 2017 John Wiley & Sons Ltd.

Using a personal digital assistant to document clinical pharmacy services in an intensive care unit.

PubMed

Lau, A; Balen, R M; Lam, R; Malyuk, D L

2001-07-01

Management Case Studies describe approaches to real-life management problems in health systems. Each installment is a brief description of a problem and how it was dealt with. The cases are intended to help readers deal with similar experiences in their own work sites. Problem solving, not hypothesis testing, is emphasized. Successful resolution of the management issue is not a criterion for publication--important lessons can be learned from failures, too.

[Invasive meningococcal disease--management and treatment].

PubMed

Garlicki, Aleksander; Bociqga-Jasik, Monika; Kalinowska-Nowak, Anna

2008-01-01

Invasive meningococcal disease is life threatening disease and in fulminant cases mortality rate may be as high as 70%. Rapid introduction of treatment and monitoring on intensive care unit is crucial for prognosis. The understanding of patomechanism responsible for sepsis development allow to introduce supportive treatment including glicocorticoids and recombinant human activated protein C. Very important is suitable prophylaxis among risk groups with, additional considering vaccination in the case of infection caused by A, C, Y, W-135 serogroups.

Intensive care unit-acquired blood stream infections: a 5-year retrospective analysis of a single tertiary care hospital in Korea.

PubMed

Lim, S J; Choi, J Y; Lee, S J; Cho, Y J; Jeong, Y Y; Kim, H C; Lee, J D; Hwang, Y S

2014-10-01

Bloodstream infections (BSIs) are serious complications with high mortality and morbidity in patients with critical illness. This study was conducted to analyze the clinical and microbiological characteristics as well as outcomes in patients with intensive care unit (ICU)-acquired BSIs. Data from 1,545 patients admitted to the ICU were retrospectively collected from January 2005 to December 2010. ICU-acquired BSI was defined as a positive blood culture for a clinically significant bacterial or fungal pathogen obtained >72 h after admission to the ICU. Data on clinical and demographic characteristics, comorbid illness, causes of infections, causative pathogens, and clinical outcomes were analyzed. Among the 1,545 ICU patients analyzed, 129 ICU-acquired BSIs occurred in 124 patients. Catheter-related BSIs (CR-BSIs) and ventilator-associated pneumonia (VAP) were the most common causes (29.4 and 20.9%, respectively). The most common isolates were Staphylococcus aureus in 35 (25.7%) and Candida species in 32 (24.8%) cases. Ninety-eight patients died (overall hospital mortality rate, 75.9%). ICU-acquired BSI-related mortality occurred in 23 (63.8%) and 7 (19.4%) of the VAP and CR-BSIs cases, respectively. The most commonly isolated microorganisms from these fatalities were S. aureus (12, 25.7%) and Acinetobacter species (12, 25.7%). In 99 ICU-acquired BSI cases, patients did not receive adequate empirical antimicrobial treatment at the onset of BSIs, whereas the patients in 30 cases did. ICU-acquired BSIs may be associated with high mortality in patients with critical illness. Meticulous infection control and adequate treatment may reduce ICU-acquired BSI-related mortality.

Incidence, risk factors, management, and outcomes of stroke in pregnancy.

PubMed

Scott, Catherine A; Bewley, Susan; Rudd, Anthony; Spark, Patsy; Kurinczuk, Jennifer J; Brocklehurst, Peter; Knight, Marian

2012-08-01

To estimate the incidence of antenatal stroke in the United Kingdom and to describe risk factors associated with stroke during pregnancy, management, and outcomes. A population-based (nationwide) cohort and nested case-control study was conducted using the UK Obstetric Surveillance System between October 2007 and March 2010. We investigated the potential factors associated with antenatal stroke using a logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Thirty cases of antenatal stroke were reported giving an estimated incidence of 1.5 cases per 100,000 women delivering (95% CI 1.0-2.1). The incidences of nonhemorrhagic and hemorrhagic stroke were 0.9 (95% CI 0.5-1.3) and 0.6 (95% CI 0.3-1.0) per 100,000 women delivering. Factors associated with increased risk of antenatal stroke were history of migraine (adjusted OR 8.5, 95% CI 1.5-62.1), gestational diabetes (adjusted OR 26.8, 95% CI 3.2-∞), and preeclampsia or eclampsia (adjusted OR 7.7, 95% CI 1.3-55.7). There was wide variation in the use of pharmacologic, surgical, and organized stroke unit care. There were six stroke-related maternal deaths giving a case-fatality rate of 20% of all strokes, 50% of hemorrhagic strokes, and a mortality rate of 0.3 (95% CI 0.1-0.6) per 100,000 women delivering. The risk of a stroke during pregnancy is low; however, the poor outcomes in terms of morbidity and mortality and variations in care highlight the importance of such women receiving specialist stroke care. Clinicians should be aware of an association with a history of migraine, gestational diabetes, and preeclampsia or eclampsia. II.

Legionnaires' disease caused by Legionella longbeachae: Clinical features and outcomes of 107 cases from an endemic area.

PubMed

Isenman, Heather L; Chambers, Stephen T; Pithie, Alan D; MacDonald, Sharyn L S; Hegarty, Justin M; Fenwick, Joanna L; Maze, Michael J; Metcalf, Sarah C L; Murdoch, David R

2016-10-01

Legionella longbeachae is a predominant cause of Legionnaires' disease in some parts of the world, particularly in Australasia. Clinical reports of L. longbeachae infection are limited to case reports or small case series, and culture-confirmed cases. We reviewed the clinical characteristics and outcomes of L. longbeachae pneumonia in a large case series from Christchurch, New Zealand during a 4-year period when both PCR and cultures were used as routine diagnostic tools for Legionnaires' disease. Cases of Legionella pneumophila pneumonia were reviewed for comparison. A total of 107 cases of L. longbeachae infection were identified by PCR and/or culture. The median age was 65 years (range 25-90 years), 63% were male, and most became unwell during spring or summer. Presenting clinical features were similar to those reported for community-acquired pneumonia, with headache, myalgia and diarrhoea being common. Elevated C-reactive protein, hyponatraemia and abnormal liver function tests were also common. History of productive cough, involvement of both lungs, and high bacterial load were independently associated with culture of Legionella from lower respiratory samples. One quarter required intensive care unit admission, and 5% died. Among patients given antimicrobial therapy before admission, those given agents without anti-Legionella activity were more likely to be admitted to the intensive care unit. Limited comparisons were made with the 19 L. pneumophila cases over the same time period. Characteristics of L. longbeachae pneumonia are broadly similar to those reported for community-acquired pneumonia from a variety of other populations, except for the spring/summer seasonality. © 2016 Asian Pacific Society of Respirology.

Sensitivity and specificity of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) for detecting post-cardiac surgery delirium: A single-center study in Japan.

PubMed

Nishimura, Katsuji; Yokoyama, Kanako; Yamauchi, Noriko; Koizumi, Masako; Harasawa, Nozomi; Yasuda, Taeko; Mimura, Chizuru; Igita, Hazuki; Suzuki, Eriko; Uchiide, Yoko; Seino, Yusuke; Nomura, Minoru; Yamazaki, Kenji; Ishigooka, Jun

2016-01-01

To compare the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) for detecting post-cardiac surgery delirium. These tools have not been tested in a specialized cardio-surgical ICU. Sensitivities and specificities of each tool were assessed in a cardio-surgical ICU in Japan by two trained nurses independently. Results were compared with delirium diagnosed by psychiatrists using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. There were 110 daily, paired assessments in 31 patients. The CAM-ICU showed 38% sensitivity and 100% specificity for both nurses. All 20 false-negative cases resulted from high scores in the auditory attention screening in CAM-ICU. The ICDSC showed 97% and 94% sensitivity, and 97% and 91% specificity for the two nurses (cutoff ≥4). In a Japanese cardio-surgical ICU, the ICDSC had a higher sensitivity than the CAM-ICU. Copyright © 2016 Elsevier Inc. All rights reserved.

Cytomegalovirus Infection among Infants in California Neonatal Intensive Care Units, 2005–2010

PubMed Central

Lanzieri, Tatiana M.; Bialek, Stephanie R.; Bennett, Mihoko V.; Gould, Jeffrey B.

2016-01-01

Aim Assess the burden of congenital and perinatal cytomegalovirus (CMV) disease among infants hospitalized in neonatal intensive care units (NICUs). Methods CMV infection was defined as a report of positive CMV viral culture or PCR at any time since birth in an infant hospitalized in a NICU reporting to California Perinatal Quality Care Collaborative during 2005–2010. Results 156 (1.7 per 1000) infants were reported with CMV infection, representing an estimated 5% of the expected number of live births with symptomatic CMV disease. Prevalence was higher among infants with younger gestational ages and lower birth weights. Infants with CMV infection had significantly longer hospital stays; 14 (9%) died. Conclusions Reported prevalence of CMV infection in NICUs represents a fraction of total expected disease burden from CMV in the newborn period, likely resulting from underdiagnosis and milder symptomatic cases that do not require NICU care. More complete ascertainment of infants with congenital CMV infection that would benefit from antiviral treatment may reduce the burden of CMV disease in this population. PMID:24334425

Early rehabilitation for severe acquired brain injury in intensive care unit: multicenter observational study.

PubMed

Bartolo, Michelangelo; Bargellesi, Stefano; Castioni, Carlo A; Bonaiuti, Donatella; Antenucci, Roberto; Benedetti, Angelo; Capuzzo, Valeria; Gamna, Federica; Radeschi, Giulio; Citerio, Giuseppe; Colombo, Carolina; Del Casale, Laura; Recubini, Elena; Toska, Saimir; Zanello, Marco; D'Aurizio, Carlo; Spina, Tullio; Del Gaudio, Alredo; Di Rienzo, Filomena; Intiso, Domenico; Dallocchio, Giulia; Felisatti, Giovanna; Lavezzi, Susanna; Zoppellari, Roberto; Gariboldi, Valentina; Lorini, Luca; Melizza, Giovanni; Molinero, Guido; Mandalà, Giorgio; Pignataro, Amedeo; Montis, Andrea; Napoleone, Alessandro; Pilia, Felicita; Pisu, Marina; Semerjian, Monica; Pagliaro, Giuseppina; Nardin, Lorella; Scarponi, Federico; Zampolini, Mauro; Zava, Raffaele; Massetti, Maria A; Piccolini, Carlo; Aloj, Fulvio; Antonelli, Sergio; Zucchella, Chiara

2016-02-01

The increased survival after a severe acquired brain injury (sABI) raise the problem of making most effective the treatments in Intensive Care Unit (ICU)/Neurointensive Care Unit (NICU), also integrating rehabilitation care. Despite previous studies reported that early mobilization in ICU was effective in preventing complications and reducing hospital stay, few studies addressed the rehabilitative management of sABI patients in ICU/NICU. To collect clinical and functional data about the early rehabilitative management of sABI patients during ICU/NICU stay. Prospective, observational, multicenter study. Fourteen facilities supplied by intensive neurorehabilitation units and ICU/NICUs. Consecutive sABI patients admitted to ICU/NICU. Patients were evaluated at admission and then every 3-5 days. Clinical, functional and rehabilitative data, including Glasgow Coma Scale (GCS), Disability Rating Scale (DRS), The Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), Early Rehabilitation Barthel Index (ERBI), Glasgow Outcome scale (GOS) and Functional Independence Measure (FIM) were collected. One hundred and two patients (F/M 44/58) were enrolled. The mean duration of ICU stay was 24.7±13.9 days and the first rehabilitative evaluation occurred after 8.7±8.8 days. Regular postural changes and multijoint mobilization were prescribed in 63.7% and 64.7% cases, respectively. The mean session duration was 38±11.5 minutes. Swallowing evaluation was performed in 14.7% patients, psychological support was provided to 12.7% of patients' caregivers, while 17.6% received a psycho-educational intervention, and 28.4% were involved in interdisciplinary team meetings. The main discharge destinations were Severe Acquired Brain Injury rehabilitation units for 43.7%, intensive neurorehabilitation units for 20.7%. Data showed that early rehabilitation was not diffusely performed in sABI subjects in ICU/NICU and rehabilitative interventions were variable; one-third of subjects were not referred to dedicated rehabilitation unit at discharge. The study stresses the need to spread and implement a rehabilitative culture also for critical ill patients due to neurological diseases.

Health professionals' perceptions about their clinical performance and the influence of audit and feedback on their intentions to improve practice: a theory-based study in Dutch intensive care units.

PubMed

Gude, Wouter T; Roos-Blom, Marie-José; van der Veer, Sabine N; Dongelmans, Dave A; de Jonge, Evert; Francis, Jill J; Peek, Niels; de Keizer, Nicolette F

2018-02-17

Audit and feedback aims to guide health professionals in improving aspects of their practice that need it most. Evidence suggests that feedback fails to increase accuracy of professional perceptions about clinical performance, which likely reduces audit and feedback effectiveness. This study investigates health professionals' perceptions about their clinical performance and the influence of feedback on their intentions to change practice. We conducted an online laboratory experiment guided by Control Theory with 72 intensive care professionals from 21 units. For each of four new pain management indicators, we collected professionals' perceptions about their clinical performance; peer performance; targets; and improvement intentions before and after receiving first-time feedback. An electronic audit and feedback dashboard provided ICU's own performance, median and top 10% peer performance, and improvement recommendations. The experiment took place approximately 1 month before units enrolled into a cluster-randomised trial assessing the impact of adding a toolbox with suggested actions and materials to improve intensive care pain management. During the experiment, the toolbox was inaccessible; all participants accessed the same version of the dashboard. We analysed 288 observations. In 53.8%, intensive care professionals overestimated their clinical performance; but in only 13.5%, they underestimated it. On average, performance was overestimated by 22.9% (on a 0-100% scale). Professionals similarly overestimated peer performance, and set targets 20.3% higher than the top performance benchmarks. In 68.4% of cases, intentions to improve practice were consistent with actual gaps in performance, even before professionals had received feedback; which increased to 79.9% after receiving feedback (odds ratio, 2.41; 95% CI, 1.53 to 3.78). However, in 56.3% of cases, professionals still wanted to improve care aspects at which they were already top performers. Alternatively, in 8.3% of cases, they lacked improvement intentions because they did not consider indicators important; did not trust the data; or deemed benchmarks unrealistic. Audit and feedback helps health professionals to work on aspects for which improvement is recommended. Given the abundance of professionals' prior good improvement intentions, the limited effects typically found by audit and feedback studies are likely predominantly caused by barriers to translation of intentions into actual change in clinical practice. ClinicalTrials.gov NCT02922101 . Registered 26 September 2016.

Strange and scary memories of the intensive care unit: a qualitative, longitudinal study inspired by Ricoeur's interpretation theory.

PubMed

Svenningsen, Helle; Egerod, Ingrid; Dreyer, Pia

2016-10-01

To describe the content of former intensive care unit patients' memories of delusions. Intensive care unit patients often have strange and frightening experiences during the critical stage of illness. Earlier studies have provided small-sample in-depth descriptions of patient experiences in intensive care unit, but large-scale studies are also needed to inform intensive care unit follow-up. The study had a qualitative design using phenomenological hermeneutic analysis inspired by Ricoeur's interpretive theory. Patients were assessed with Confusion Assessment Method of the Intensive Care Unit for delirium in intensive care unit, and after discharge, memories of delusions were described by 114 of 325 patients in face-to-face (after two weeks) and telephone interviews (after two and six months) using the Intensive Care Unit Memory Tool. Four themes emerged: the ever-present family, dynamic spaces, surviving challenges and constant motion. Memories of delusions were a vivid mix of fact and fiction, demonstrating dynamic shifts in time, place and motion, but not dependent on the presence of delirium assessed by Confusion Assessment Method of the Intensive Care Unit. Analysis based on Ricoeurian phenomenological hermeneutics provided insights into themes in intensive care unit patients' memories of delusions. More studies are needed to understand the meaning of memories of delusions, the commonality of themes and the association between delusions and delirium after an intensive care unit stay. Understanding patients' memories of delusions is beneficial to nurses caring for patients that are anxious, upset or agitated. It opens a window to the world of the patient who is unable to communicate due to intubation and general weakness. We recommend the provision of nurse-led intensive care unit follow-up enabling patients to describe and discuss their intensive care unit experiences. © 2016 John Wiley & Sons Ltd.

Reason-Giving and Medical Futility: Contrasting Legal and Social Discourse in the United States With the United Kingdom and Ontario, Canada.

PubMed

Bosslet, Gabriel T; Baker, Mary; Pope, Thaddeus M

2016-09-01

Disputes regarding life-prolonging treatments are stressful for all parties involved. These disagreements are appropriately almost always resolved with intensive communication and negotiation. Those rare cases that are not require a resolution process that ensures fairness and due process. We describe three recent cases from different countries (the United States, United Kingdom, and Ontario, Canada) to qualitatively contrast the legal responses to intractable, policy-level disputes regarding end-of-life care in each of these countries. In so doing, we define the continuum of clinical and social utility among different types of dispute resolution processes and emphasize the importance of public reason-giving in the societal discussion regarding policy-level solutions to end-of-life treatment disputes. We argue that precedential, publicly available, written rulings for these decisions most effectively help to move the social debate forward in a way that is beneficial to clinicians, patients, and citizens. This analysis highlights the lack of such rulings within the United States. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

Teaching psychosocial aspects of coronary care.

PubMed

Egnew, T R; Jones, J M

1984-01-01

For the past two years, Tacoma Family Medicine, Tacoma, Washington. has integrated a curriculum in psychosocial aspects of coronary care with the Coronary Care Unit rotation taken by third-year residents. Goals of the curriculum are to provide information, to foster the development of psychosocial strategies for patient and family care, and to develop greater insight and awareness on the part of residents regarding the psychosocial aspects of coronary care. Attempts are made to meet these goals in a context as closely tied to the clinical management of patients and families as possible. Topics addressed include the biopsychosocial medical model, patient and family responses to cardiac illness, sexual concerns of the coronary patient and spouse, and issues related to cardiac rehabilitation. The format for the curriculum involves didactic presentations, group discussions, and case consultations.

The Most Common Detected Bacteria in Sputum of Patients with the Acute Exacerbation of COPD

PubMed Central

Cukic, Vesna

2013-01-01

Introduction: Acute exacerbation of COPD (AECOPD) may be triggered by infection with bacteria or viruses or by environmental pollutants; the cause of about one-third of exacerbations cannot be identified. Objective: To determine the most common bacteria in sputum culture of patients with AECOPD hospitalized in Intensive care unit of Clinic for pulmonary disease and TB “Podhrastovi” in the 2012. Material and methods: This is a retrospective analysis of sputum bacterial cultures of patients with AECOPD treated in the Intensive care unit of Clinic for pulmonary disease and TB “Podhrastovi” during 2012 .year. Each patient was required to give two sputum for bacterial examination. Each patient was treated with antibiotics prior to admission in Clinic “Podhrastovi”. The results of sputum bacterial culture findings are expressed in absolute number and percentage of examined patients. Results: In 2012, 75 patients with AECOPD were treated in Intensive care unit of Clinic for pulmonary disease and TB“Podhrastovi”. 44 (58.66%) of patients had normal –nonpathogenic – usual bacterial flora isolated in sputum cultures, 31 (41.34%) had a pathogen bacteria in sputum culture as follows: 7 had Streptoccocus pneumoniae, 8 had Klebsiella pneumoniae (2 with Streptococcus pneumoniae, one with Acinetobacter baumani) ,4 Escherichia colli, others are one or two cases with other bacteria. Conclusion: Bacterial airway infections play a great role in many, but not in all, of cases of AECOPD. So there is the need to do a sputum bacterial culture examination in each patient with AECOPD and with appropriate antibiotics to contribute to curing of them. PMID:24511262

Isolated transient loss of consciousness is an indicator of significant injury.

PubMed

Owings, J T; Wisner, D H; Battistella, F D; Perlstein, J; Walby, W F; Tharratt, R S

1998-09-01

To determine if isolated transient loss of consciousness is an indicator of significant injury. University-based level I trauma center. Phase 1 retrospective case series of all patients with trauma admitted directly from the emergency department to the operating room or an intensive care unit who had transient loss of consciousness as their only trauma triage criterion. Phase 2 prospective case series of all trauma patients transported by emergency medical system personnel with transient loss of consciousness as their only trauma triage criterion. Emergency operation and intensive care unit admission. Phase 1: From January 1, 1992, to March 31, 1995, we admitted 10255 patients with trauma. Three hundred seven (3%) met the enrollment criteria and were admitted to the operating room (n = 168) or intensive care unit (n = 139). Of these, 58 (18.9%) were taken to the operating room emergently to manage life-threatening injuries: 11 (4%) had craniotomies and 47 (15%) had non-neurosurgical operations. Phase 2: From July 1 to December 31, 1996, 2770 trauma patients were transported to our facility; 135 (4.9%) met the enrollment criteria. Forty-one (30.4%) of these required admission, and 6 (4.4%) were taken emergently to the operating room from the emergency department (1 [1%] for a craniotomy, 3 [2.2%] for intra-abdominal bleeding, and 2 [1.5%] for other procedures). Two (1.5%) of the 135 patients died. Patients with isolated transient loss of consciousness are at significant risk of critical surgical and neurosurgical injuries. These patients should be triaged to trauma centers or hospitals with adequate imaging, surgical, and neurosurgical resources.

Medication issues experienced by patients and carers after discharge from the intensive care unit.

PubMed

Eijsbroek, Heleen; Howell, David C J; Smith, Felicity; Shulman, Rob

2013-02-01

Medication-related problems (MRPs) frequently occur at the interfaces of care settings. We examined this further because little has been published about MRPs experienced by patients/carers after discharge from the intensive care unit (ICU). Medication history data were collected before, during, and after ICU admission and by face-to-face semistructured interviews with 21 patients and 13 carers attending the ICU Follow-up Clinic (FC) of our 35-bed adult ICU. A total of 122 drugs were prescribed regularly before ICU admission, 168 on ICU discharge, 132 at hospital discharge, and 128 at the FC. Medication-related problems were identified with hypnotics/anxiolytics, antidepressants, proton pump inhibitors, and analgesics. Good follow-up was observed in all 4 cases where the antidysrhythmic agent amiodarone was initiated on ICU. Patients/carers described 20 cases of difficulty in obtaining appropriate and timely supplies and 19 of insufficient information. These results show that our incidence of MRPs after ICU discharge was encouragingly infrequent, in which we attribute it to targeted medicine reconciliation and the availability of our FC. However, MRPs were perceived to stem from inadequate communication at the interfaces of care and the lack of opportunity for patients/carers to obtain relevant information. We recommend that FC should focus on MRPs during their consultation and that further research in this area should be performed to examine our observations further. Copyright © 2013 Elsevier Inc. All rights reserved.

Lead poisoning in pregnant women who used Ayurvedic medications from India--New York City, 2011-2012.

PubMed

2012-08-24

Lead poisoning still occurs in the United States despite extensive prevention efforts and strict regulations. Exposure to lead can damage the brain, kidneys, and nervous and reproductive systems. Fetal exposure to lead can adversely affect neurodevelopment, decrease fetal growth, and increase the risk for premature birth and miscarriage. During 2011-2012, the New York City Department of Health and Mental Hygiene (DOHMH) investigated six cases of lead poisoning associated with the use of 10 oral Ayurvedic medications made in India. All six cases were in foreign-born pregnant women assessed for lead exposure risk by health-care providers during prenatal visits, as required by New York state law. Their blood lead levels (BLLs) ranged from 16 to 64 µg/dL. Lead concentrations of the medications were as high as 2.4%; several medications also contained mercury or arsenic, which also can have adverse health effects. DOHMH distributed information about the medications to health-care providers, product manufacturers, and government agencies in the United States and abroad, via postal and electronic mail. DOHMH also ordered a local business selling contaminated products to cease sales. Health-care providers should ask patients, especially foreign-born or pregnant patients, about any use of foreign health products, supplements, and remedies such as Ayurvedic medications. Public health professionals should consider these types of products when investigating heavy metal exposures and raise awareness among health-care providers and the public regarding the health risks posed by such products.

Discovering Innovation at the Intersection of Undergraduate Medical Education, Human Factors, and Collaboration: The Development of a Nasogastric Tube Safety Pack.

PubMed

Taylor, Natalie; Bamford, Thomas; Haindl, Cornelia; Cracknell, Alison

2016-04-01

Significant deficiencies exist in the knowledge and skills of medical students and residents around health care quality and safety. The theory and practice of quality and safety should be embedded into undergraduate medical practice so that health care professionals are capable of developing interventions and innovations to effectively anticipate and mitigate errors. Since 2011, Leeds Medical School in the United Kingdom has used case study examples of nasogastric (NG) tube patient safety incidents within the undergraduate patient safety curriculum. In 2012, a medical undergraduate student approached a clinician with an innovative idea after undertaking an NG tubes root cause analysis case study. Simultaneously, a separate local project demonstrated low compliance (11.6%) with the United Kingdom's National Patient Safety Agency NG tubes guideline for use of the correct method to check tube position. These separate endeavors led to interdisciplinary collaboration between a medical student, health care professionals, researchers, and industry to develop the Initial Placement Nasogastric Tube Safety Pack. Human factors engineering was used to inform pack design to allow guideline recommendations to be accessible and easy to follow. A timeline of product development, mapped against key human factors and medical device design principles used throughout the process, is presented. The safety pack has since been launched in five UK National Health Service (NHS) hospitals, and the pack has been introduced into health care professional staff training for NG tubes. A mixed-methods evaluation is currently under way in five NHS organizations.

[Depression in adolescence treated at primary care centres: size of a hidden problem of general health].

PubMed

dos Santos Palazzo, L; Humberto Béria, J; Alonso-Fernández, F; Tomasi, E

2001-11-15

To investigate the prevalence of depression and its relationship to the reason for the consultation and to the medical diagnosis. Descriptive, cross-sectional design. Primary care units of a community in Brazil. Individuals between 13 and 19 years old, who attended 10 primary care units to consult with a non-psychiatric doctor between October 1997 and January 1998 (n = 463). The CET-DE (Alonso-Fernández, 1986) was used to measure depression, jointly with a questionnaire for evaluating social and demographic details and data pertinent to the consultation. Prevalence ran at 26.5% (95% CI: 22.6-30.4%). 99.2% cases of depression had not been identified. Complaints were spread over the somatic field (61.1%), or were sex-related (49.5%), mainly pregnancy (31.7%), especially among the cases of depression (p < 0.001). There were few psychiatric-social complaints (1.5%). Diagnoses often coincided with complaints: 59.9% somatic, 38.4% sex-related (pregnancy = 21.6%) and 1.7% psychiatric-social. Adolescent depression is common in primary care, but is not usually identified. The reason for this may be the kind of depression, which is usually light or focused on just one dimension of human vitality; the doctors tendency to centre his/her attention on the complaint without broadening the clinical spectrum; or even because the adolescent expresses his/her emotional problems poorly, which often contributes to the depression not being diagnosed.

Patient safety challenges in a case study hospital--of relevance for transfusion processes?

PubMed

Aase, Karina; Høyland, Sindre; Olsen, Espen; Wiig, Siri; Nilsen, Stein Tore

2008-10-01

The paper reports results from a research project with the objective of studying patient safety, and relates the finding to safety issues within transfusion medicine. The background is an increased focus on undesired events related to diagnosis, medication, and patient treatment in general in the healthcare sector. The study is designed as a case study within a regional Norwegian hospital conducting specialised health care services. The study includes multiple methods such as interviews, document analysis, analysis of error reports, and a questionnaire survey. Results show that the challenges for improved patient safety, based on employees' perceptions, are hospital management support, reporting of accidents/incidents, and collaboration across hospital units. Several of these generic safety challenges are also found to be of relevance for a hospital's transfusion service. Positive patient safety factors are identified as teamwork within hospital units, a non-punitive response to errors, and unit manager's actions promoting safety.

Advancing nursing enterprises: A cross-country comparison.

PubMed

Pittman, Patricia; Salmon, Marla E

2016-01-01

Health system transformations in the United States are creating new opportunities for nursing innovation, although financial sustainability has limited the expansion of nurse managed clinics. We explore case studies of nursing enterprises in the developing world and discuss their potential for informing related work in the United States. Cases were selected from the Center for Health Market Innovations. We describe a professional association network of clinics in Tanzania, a social franchise in Kenya, and a cooperative in the Philippines. All programs empowered nurses to own, lead, and advance their professional influence. They had a social mission of improving access to care for disadvantaged populations, while increasing employment and autonomy of women. They also provided a shared platform for branding, purchasing, and quality assurance. Organization sponsors in these models may be relevant to different actors in the United States. Each demonstrates the importance of a collective approach to advancing nursing enterprises. Copyright © 2016 Elsevier Inc. All rights reserved.

Kangaroo care for adoptive parents and their critically ill preterm infant.

PubMed

Parker, Leslie; Anderson, Gene Cranston

2002-01-01

In this case study kangaroo care (KC) was facilitated for an adoptive mother and father who were planning to attend the birth of the infant they had arranged to adopt. Unexpectedly, the birth mother delivered at 27 weeks gestation. The infant was critically ill and required mechanical ventilation. However, in this neonatal intensive care unit where all adoptive parents and parents of mechanically ventilated infants are offered KC, these adoptive parents began KC on Day 3 while their infant daughter was still mechanically ventilated. She thrived thereafter and the entire experience was profoundly beneficial for this beginning family both at the hospital and after discharge home.

Aromatherapy massage for joint pain and constipation in a patient with Guillian Barré.

PubMed

Shirreffs, C M

2001-05-01

The following case study will look at the efficacy of aromatherapy massage in a patient diagnosed with Guillian Barré Syndrome admitted to an IntensiveTherapy Unit. The pathophysiology of this disorder will be discussed, medical treatment will be outlined and adjuncts to conventional nursing care will be presented. Aromatherapy massage was used to complement the conventional nursing and medical treatment of joint pain and constipation. The Mead Model for nursing care was used for assessment and the plan of care devised from this. Evaluation of outcomes were incorporated into the implementation protocol to ensure positive outcomes were achieved.

Positive peritoneal fluid fungal cultures in postoperative peritonitis after bariatric surgery.

PubMed

Zappella, N; Desmard, M; Chochillon, C; Ribeiro-Parenti, L; Houze, S; Marmuse, J-P; Montravers, P

2015-09-01

Postoperative peritonitis (POP) is a common surgical complication after bariatric surgery (BS). We assessed the importance of positive fungal cultures in these cases of POP admitted to the intensive care unit. Clinical features and outcome were compared in 25 (41%) Candida-positive patients (6 (22%) fluconazole-resistant Candida glabrata) and 36 patients without Candida infection. Candida infections were more commonly isolated in late-onset peritonitis and were often associated with multidrug-resistant bacteria. Risk factors for intensive care unit mortality (19.6%) were diabetes and superobesity. Candida infections, including fluconazole-resistant strains, are common in POP after BS. These data encourage the empirical use of a broad-spectrum antifungal agent. Copyright © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Prospective study of symptom control in 133 cases of palliative care inpatients in Shatin Hospital.

PubMed

Lo, R S; Ding, A; Chung, T K; Woo, J

1999-07-01

We report a prospective study assessing the prevalence and severity of physical and nonphysical symptoms, and the benefits from treatment and intervention, in advanced cancer patients presenting to a local palliative care unit in Hong Kong. Patients were assessed by a modified version of the support team assessment schedule (STAS). The study highlighted some symptoms which needed better control, and also reinforced the team morale by demonstrating aspects where there was definite improvement. In general, the STAS was found to be practicable and acceptable by our patients and staff. The most important benefit gained from the study was the successful dissemination of the concept of audit and quality assurance throughout the unit, which is essential for continuous improvement in the future.

Frequency, Etiology and Several Sociodemographic Characteristics of Acute Poisoning in Children Treated in the Intensive Care Unit

PubMed Central

Azemi, Mehmedali; Berisha, Majlinda; Kolgeci, Selim; Bejiqi, Ramush

2012-01-01

Aim: The aim of this work has been to present the frequency, etiology and several other socio-demographic characteristics of acute poisoning in children. The treated patients and methods of work: The treated patients were children of all age groups hospitalized in the Pediatric Clinic of Prishtina during year 2009. The study was done retrospectively. The diagnosis was done on the basis of heteroanamnesis and in several cases on the basis of the anamnesis data of a child, routine laboratory tests and toxicologic analysis. Results: 66 (9.4%) poisoned children were treated in the Intensive Care Unit. The biggest number of patients, 37 (56.06%) of them, were male, and out of that number 36 (54.55%) cases were coming from rural areas. The biggest number of them 49 (74.98%) were over 2-6 years old. The poisoning was mostly caused through the digestive tract (ingestion), it happened with 55 cases (83.33%), 56 cases (84,80%) suffered from severe poisoning, whereas 59 cases (89,50%) suffered from accidental poisoning. Regarding the type of the substances that caused poisoning, the most frequent were drugs in 34 (51.50%) cases and pesticides in 20 (30.30%) cases. Among drugs, the most dominant were those belonging to a group of benzodiazepines (10 cases) and metoclopramide (4 cases). Among pesticides the most dominant one that caused poisoning was malation (5 cases), then paration and cipermetrina appeared in 3 cases each. The biggest number of cases, 64 (96.96%) of them, were treated, whereas 2 cases (3.40%) passed away. Conclusion: The practice proved that that our people are not well informed about the poisoning in general, therefore it is necessary that they be educated by the use of all media, written and electronic, as well as other methods of medical education. PMID:23678312

A Statewide Case Management, Surveillance, and Outcome Evaluation System for Children with Special Health Care Needs

PubMed Central

Monsen, Karen A.; Elsbernd, Scott A.; Barnhart, Linda; Stock, Jacquie; Prock, Carla E.; Looman, Wendy S.; Nardella, Maria

2013-01-01

Objectives. To evaluate the feasibility of implementing a statewide children with special health care needs (CSHCN) program evaluation, case management, and surveillance system using a standardized instrument and protocol that operationalized the United States Health and Human Services CSHCN National Performance Measures. Methods. Public health nurses in local public health agencies in Washington State jointly developed and implemented the standardized system. The instrument was the Omaha System. Descriptive statistics were used for the analysis of standardized data. Results. From the sample of CSHCN visit reports (n = 127), 314 problems and 853 interventions were documented. The most common problem identified was growth and development followed by health care supervision, communication with community resources, caretaking/parenting, income, neglect, and abuse. The most common intervention category was surveillance (60%), followed by case management (24%) and teaching, guidance, and counseling (16%). On average, there were 2.7 interventions per problem and 6.7 interventions per visit. Conclusions. This study demonstrates the feasibility of an approach for statewide CSHCN program evaluation, case management, and surveillance system. Knowledge, behavior, and status ratings suggest that there are critical unmet needs in the Washington State CSHCN population for six major problems. PMID:23533804

[Duties of institutions and heads of health care centers in the area of infection control, information, assessment, registration and financing of benefits provided to TB patients].

PubMed

Zielonka, Tadeusz M

2015-01-01

The Act on preventing and counteracting infections and infectious diseases in humans effective in Poland requires the heads of health care outlets and institutions to counteract spreading of TB in units under their management. They are, by all means, responsible for monitoring infections in their respective units, including development, implementation and monitoring of the implementation of procedures into practice, aiming at limiting the dissemination of TB in hospitals and outpatient clinics. Medical service unit managers are also responsible for providing members of their staff with means of individual protection against infection with Mycobacterium tuberculosis bacillus. Their duties also include reporting all of the recognized TB cases in their respective units. TB is an infectious diseases included in the occupational disease list. Assessment of TB as an occupational disease is the responsibility of provincial TB prevention clinics. The Act also provides principles of financing of individual benefits available for the insured TB patients as well as those not insured.

Neonatal extravasation injury: prevention and management in Australia and New Zealand-a survey of current practice.

PubMed

Restieaux, Matthew; Maw, Andrew; Broadbent, Roland; Jackson, Pam; Barker, David; Wheeler, Ben

2013-03-11

Extravasation injury remains an important cause of iatrogenic injury in neonatal intensive care. This study aims to describe the current approach to extravasation injury (EI) prevention and management in Neonatal Intensive Care Units (NICUs) in Australia and New Zealand. A literature review regarding extravasation injury in the newborn was carried out to inform questionnaire design. An internet-based survey was then conducted with the clinical directors of the 27 tertiary NICUs in Australia and New Zealand. The survey received a 96% response rate. Approximately two thirds of Australian and New Zealand NICUs have written protocols for prevention and management of extravasation injury. Considerable practice variation was seen for both prevention and treatment of EI. 92% of units had experienced cases of significant EI. Australian and New Zealand tertiary neonatal units clearly recognise EI as an important cause of iatrogenic morbidity and mortality. Significant variation still exists among units with regards to guidelines for both prevention and management of EI. We recommend that neonatal staff should remain vigilant, ensuring that guidelines for the prevention and treatment of EI are available, and rigorously followed.

Evidence-based guidelines for supportive care of patients with Ebola virus disease.

PubMed

Lamontagne, François; Fowler, Robert A; Adhikari, Neill K; Murthy, Srinivas; Brett-Major, David M; Jacobs, Michael; Uyeki, Timothy M; Vallenas, Constanza; Norris, Susan L; Fischer, William A; Fletcher, Thomas E; Levine, Adam C; Reed, Paul; Bausch, Daniel G; Gove, Sandy; Hall, Andrew; Shepherd, Susan; Siemieniuk, Reed A; Lamah, Marie-Claude; Kamara, Rashida; Nakyeyune, Phiona; Soka, Moses J; Edwin, Ama; Hazzan, Afeez A; Jacob, Shevin T; Elkarsany, Mubarak Mustafa; Adachi, Takuya; Benhadj, Lynda; Clément, Christophe; Crozier, Ian; Garcia, Armando; Hoffman, Steven J; Guyatt, Gordon H

2018-02-17

The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief. Copyright © 2018 Elsevier Ltd. All rights reserved.

A Case Study of Partnerships in International Service Learning: Exploring Reciprocity and Bi-Directional Benefits

ERIC Educational Resources Information Center

Healey-Walsh, Judith

2016-01-01

Based on demographic shifts toward more diversity and increasing health care disparities in the United States, nursing educators have been called upon to find innovative pedagogies to teach cultural competence and social justice concepts. International service-learning programs (ISL) are proliferating, as there is evidence that these experiences…

Teaching Pediatric Nursing Concepts to Non-Pediatric Nurses Using an Advance Organizer

ERIC Educational Resources Information Center

Bell, Julie Ann

2013-01-01

Non-pediatric nurses in rural areas often care for children in adult units, emergency departments, and procedural areas. A half-day program about pediatric nursing using constructivist teaching strategies including an advance organizer, case studies, and simulation was offered at a community hospital in Western North Carolina. Nurses reported a…

45 CFR 146.136 - Parity in mental health and substance use disorder benefits.

Code of Federal Regulations, 2010 CFR

2010-10-01

..., coverage unit refers to the way in which a plan (or health insurance coverage) groups individuals for... the case of an employer residing in a State that permits small groups to include a single individual... RELATING TO HEALTH CARE ACCESS REQUIREMENTS FOR THE GROUP HEALTH INSURANCE MARKET Requirements Related to...

Metabolite profiling of foodborne disease significance – case study Escherichia coli O157

USDA-ARS?s Scientific Manuscript database

In the United States, Escherichia coli (E. coli) O157 infection, associated with the consumption of contaminated ground beef, has resulted in an unnecessary burden for both the meat industry and the health care system, with meat recalls and often fatal human disease. Cattle, the primary reservoirs f...

Neonatal Pressure Ulcer Prevention.

PubMed

Scheans, Patricia

2015-01-01

The incidence of pressure ulcers in acutely ill infants and children ranges up to 27 percent in intensive care units, with a range of 16-19 percent in NICUs. Anatomic, physiologic, and developmental factors place ill and preterm newborns at risk for skin breakdown. Two case studies illustrate these factors, and best practices for pressure ulcer prevention are described.

Improper tube fixation causing a leaky cuff.

PubMed

Gupta, Babita; Farooque, Kamran; Jain, Divya; Kapoor, Rakesh

2010-04-01

Leaking endotracheal tube cuffs are common problems in intensive care units. We report a case wherein the inflation tube was damaged by the adhesive plaster used for tube fixation and resulted in leaking endotracheal tube cuff. We also give some suggestions regarding the tube fixation and some remedial measures for damaged inflation system.

Evaluation of a new silicone adhesive tape among clinicians caring for patients with fragile or at-risk skin.

PubMed

Manriquez, Sonia; Loperfido, Bonnie; Smith, Graham

2014-04-01

To evaluate performance of a new silicone tape among clinicians caring for patients with fragile skin. An international, multisite, 2-week-use evaluation. Caregivers (n = 217) from acute care hospitals in the United States, United Kingdom, and France who regularly use tapes on patients with fragile skin. The silicone tape was substituted for current-use gentle tapes for a 2-week trial period. Preuse and postuse questionnaires were collected. The main outcome measure was tape preference. Secondary outcomes included (1) satisfaction with current-use tapes, (2) willingness to replace current-use tapes with silicone tape, (3) performance comparisons between tapes, (4) clinician-reported problems with the silicone tape, and (5) case study information. The sample group consisted of nurses (98.1%), assistants (1.4%), and physicians (0.5%). Hospital units (n = 100) included oncology (31%), medical-surgical (14%), dialysis (12%), infusion/intravenous therapy (16%), critical care (10%), wound care (10%), and other units (7%). Overall preference was 92.0% for the silicone tape, 7.5% for current-use tapes, and 0.5% no preference. Dissatisfaction was 61.2% for current-use tapes, and most clinicians (90.2%) would change to the silicone tape. Evaluators favored (≥71.5%) the silicone tape on 10 performance attributes and on overall performance (91.6%). Most evaluators (75.1%) did not experience problems with the silicone tape, and those who did found problems related to adhesion (77.8%), gentleness (16.0%), and residue (6.2%). These results indicate that the silicone tape fills a performance-expectation gap of current acrylic tapes among users of tapes on patients with fragile or at-risk skin.

Treatment of toxic epidermal necrolysis with moisture-retentive ointment: a case report and review of the literature.

PubMed

Atiyeh, Bishara S; Dham, Ruwayda; Yassin, M Fayez; El-Musa, Kusai A

2003-02-01

Toxic epidermal necrolysis (TEN) is a rare condition that was described by Lyell in 1956. It is a severe, acute, adverse, primarily drug-induced, potentially fatal, cutaneous reaction that is characterized by large areas of skin desquamation and sloughing, similar in many aspects to second-degree burns. The treatment of cutaneous drug reactions rests essentially on immediate diagnosis and recognition of the disease process, accurate history, thorough physical examination, prompt discontinuation of the offending drug, and supportive care. TEN patients are best managed in specialized burn units. Nevertheless, the management remains very much individualized, based on the clinical setting. Topical wound care remains an essential factor in the treatment of burn-like syndromes and is a main determining parameter for morbidity and mortality. As the value of moist environment in wound healing is being fully appreciated, we report on the use of a newly introduced ointment, the Moist Exposed Burn Ointment (Julphar; Gulf Pharmaceutical industries, Ras El-Khaymah, United Arab of Emirutes), a moisture-retentive ointment, in the successful management of a case of TEN.

Paediatric electrical burn injuries: experience from a tertiary care burns unit in North India

PubMed Central

Srivastava, S.; Patil, A.N.; Bedi, M.; Tawar, R.S.

2017-01-01

Summary Electrical burn injuries in the paediatric age group constitute a small proportion of all burn cases and cause significant morbidity and long-term psychosocial impact. The objective of this study was to evaluate various aspects of electrical burn injuries in the paediatric age group in our region. A retrospective review was done of all paediatric electrical burns admitted to a tertiary care burns unit over a period of 12 months (January 2016 to December 2016). There were 77 cases of electrical burns under the age of 16 years. High voltage burns predominated and older age groups were more frequently affected. Male:female ratio was 4.1:1. Amputations were required in 18 (23%), skin grafting in 52 (67%) and flap cover in 29 (37%) patients. There were unfavourable outcomes in 32% patients with a mortality rate of 7.8%. Significant association was found between unfavourable outcomes and high voltage burn injuries and length of hospital stay. The impact of electrical burn injuries is substantial and can be reduced by simple preventive measures such as educating parents, improving health infrastructure and adherence to safety regulations.